Sie sind auf Seite 1von 133

Biyani's Think Tank

Concept based notes

Mental Health & Psychiatric


Nursing-I
(GNM)

Subita Fageria
Lecturer
Deptt. of B. Sc. (Nursing
Biyani Nursing College, Jaipur
2

Published by :
Think Tanks
Biyani Group of Colleges

Concept & Copyright :


Biyani Shikshan Samiti
Sector-3, Vidhyadhar Nagar,
Jaipur-302 023 (Rajasthan)
Ph : 0141-2338371, 2338591-95 Fax : 0141-2338007
E-mail : acad@biyanicolleges.org
Website :www.gurukpo.com; www.biyanicolleges.org

First Edition : 2011

While every effort is taken to avoid errors or omissions in this Publication, any
mistake or omission that may have crept in is not intentional. It may be taken note of
that neither the publisher nor the author will be responsible for any damage or loss of
any kind arising to anyone in any manner on account of such errors and omissions.

Leaser Type Setted by :


Biyani College Printing Department
Mental Health & Psychiatric Nursing 3

Preface
I am glad to present this book, especially designed to serve the needs of
the students. The book has been written keeping in mind the general weakness
in understanding the fundamental concepts of the topics. The book is self-
explanatory and adopts the “Teach Yourself” style. It is based on question-
answer pattern. The language of book is quite easy and understandable based
on scientific approach.
This is to help the students for clearing their doubts and for guidance and to
understand the subject why easily in a settled manner. This book covers the
diagnosis and management of both medical & nursing including the
psychopharmacology & general therapies of psychiatric disorders.
Any further improvement in the contents of the book by making corrections,
omission and inclusion is keen to be achieved based on suggestions from the
readers for which the author shall be obliged.
I acknowledge special thanks to Mr. Rajeev Biyani, Chairman & Dr. Sanjay
Biyani, Director (Acad.) Biyani Group of Colleges, who are the backbones and
main concept provider and also have been constant source of motivation
throughout this Endeavour. They played an active role in coordinating the various
stages of this Endeavour and spearheaded the publishing work.
I look forward to receiving valuable suggestions from professors of various
educational institutions, other faculty members and students for improvement of
the quality of the book. The reader may feel free to send in their comments and
suggestions to the under mentioned address.
Author
4

Mental Health/
Psychiatric Nursing
Course Description
This course is designed to help students develop the concept of mental health and mental
illness, symptoms, prevention, treatment modalities and nursing management of mentally
ill.
General Objectives:-
Upon completion of this course, the students will be able to:
1. Describe the concept of mental health and mental illness and the emerging trends
is psychiatric nursing.
2. Explain the causes and factors of mental illness, its prevention and control.
3. Identify the symptoms and dynamics and abnormal human behavior in
comparison with normal human behavior.
4. Demonstrate a desirable attitude and skills in rendering comprehensive nursing
care to the mentally ill.
Course Content
Unit I Introduction
 Meaning of mental health and mental illness
 Definition of terms used in psychiatry.
 Review of mental mechanisms (ego mechanisms)
 Review of personality and types of personality.

Unit II History of Psychiatry


 Contributors to psychiatry
 History of psychiatric nursing
 Trends in psychiatric nursing
Mental Health & Psychiatric Nursing 5

Unit III Mental Health Assessment


 Psychiatric history taking
 Interview technique and mental status examination.

Unit IV community Mental Health


 Concept, importance and scope
 Attitude and misconceptions towards mentally ill.
 Prevention of mental illness (preventive Psychiatry) during childhood,
adolescence, adulthood and old age.
 Community mental and old age.
 Community mental health services.
 Role of nurses in community mental health services.

Unit V Psychiatric Nursing Management


 Definition of psychiatric nursing
 Principles of psychiatric nursing
 Nursing process
 Role of nurses in providing psychiatric nursing care.
 Therapeutic nurse-patient relationship
 Communication skills

Unit VI Mental disorders and nursing interventions


 Etiology – various etiological theories (genetics, biochemical, psychological, etc)
 Classification of mental disorders.
 Organic mental disorder-Acute brain syndrome
 Chronic brain syndrome
 Functional mental disorder
6

 Prevalence, etiology, signs and symptoms, prognosis, medical nursing


management
 Schizophrenic disorders.
 Mood (affective ) disorders.
 Manic Depressive Psychosis
 Anxiety Status.

Definition, etiology, signs, symptoms, medical and nursing management of:


Phoebic disorders, obsessive compulsive disorders, depressive neurosis, conversion
disorders, dissociative reaction, hypochondriasis, Psychoactive disorders, alcohol, drugs
and other psychoactive substance abuse.

Unit-VII Bio-Psychosocial
 Psychopharmacology
 Definition, classification of drugs, antipsychotic, antidepressant, antimanic,
antianxiety agents.
 Role of nurses in psychopharmacology
 Psychosocial therapies
 Definition of psychosocial therapies.
 Types of therapies; individual and group therapy, behavior therapy, occupational
therapy.
 Role of nurse in these therapies.
 Somatic therapy
 History, technique of electro convulsive therapy (ECT) indications,
contraindications.
 Role of nurses before, during and after electroconvulsive therapy.
Mental Health & Psychiatric Nursing 7

Unit VIII Forensic Psychiatry/Legal Aspects


 Legal responsibilities in care of mentally sick patients.
 Procedure for admission and discharge from mental hospital, leave of absence.
 Indian Lunatic Act 1912
 Mental Health Act 1987
 Narcotic Drugs and Psychotropic Act 1985

Unit IX Psychiatric Emergencies and Crisis Intervention


 Over active patient
 Destructive patient
 Suicidal patient
8

Unit I
Introduction

Q.1 What do you mean by mental health?


Ans: According to WHO " Health is define as a state of complete physical, mental,
social and spiritual well being not merely an absence of disease or infirmity?
Mental Health means a Healthy mind in a healthy body. Mental Health is a part of
general health. It requires a balance between body, mind spirit and the
environment in which a person lines.
Mental Health

Environment Body, mind & spirit

According to Kerl Malinger: The adjustment of human beings to the world and
to each other with a maximum of effectiveness and happiness."
According to WHO: "The capacity of an individual to form harmonious
relationships with other and to participate in or contribute constructively to
change in social environment".
Thus, Mental Health is positive state in which the person is responsible, self-
directive and displays self-awareness.

Q.2 Define Mental illness ;


Ans.: It is an opposition of mental illness. Mental illness occurs when a state of
physical, mental, social and spiritual well being is disturbed.
It is explained in 3 ways:
1. Absence of Health: It defines illness is an absence of health. It emphasize
problem but does not solve it.
Mental Health & Psychiatric Nursing 9

2. Biology Approach : According to scadding – "Mental illness is result of


biological disturbance".
3. Pathological Approach: According to szusz – "Mental illness only is term of
physical pathology".
According to American Psychiatric Association defines "mental illness or
mental disorder is an illness or syndrome with psychological or behavioural
manifestations and/or impairment in functioning due to social, psychological,
genetic, physical/chemical or biological disturbance. The disorder is not limited
to relation between the person and society. The illness is characterized by
symptoms and/or impairment in functioning".

Q.3 How will you differentiate the mentally healthy people from mentally ill
people?
Ans.:
S.No. Mental Health Mental illness
1 Positive attitudes towards self Negative attitude towards self
acceptance and self awareness acceptance & self awareness
(Optimistic) (pessimistic)
2 Able to solve problems by self with Avoid problems than solve
creativity
3 Positive self concept relate well to - Poor self concept
people and their environment - Feels inadequate
4 Able to cope up stress and reality Not able to cope thus stressful
perception situations
5 Able to make decision and sound Poor decision making & judgments
judgment. power
6 Able to establish and maintain healthy Relationship with friends & family
relationship are disturbed.
7 Accepts the authority and Unable to assume authority &
responsibility responsibility
8 Able to work effectively and Mostly dependent work
independently
9 Differentiate and analyze the Unable to analyze
situations
10 Has good sense of humar Easily get irritated
10

11 Behavioural that is generally Maladaptive behavior


acceptable to others
12 Able to solve conflict very easily Always confused and unable to solve
conflict
13 Deeper insight Poor insight.

Q.4 What is mental (Defense) mechanism? How many types of mental


mechanism ?
Ans.: Sigmund freud the father of modern psychiatry coined the term, " Defense
mechanism". He described defense mechanism are unconscious processes that d
defined a person against anxiety.
It is often used by all people to feel free or relieved from the emotional stir,
internal conflict or anxiety. It gives ego satisfaction. Very commonly it is used :-
 To solve mental conflict
 To reduce fear or anxiety
 Protect one's self esteem
 Protect one's sense of security

Definition of mental mechanism :-


1. According to Bhatia & Craig : The individual has mental capacities or devices
for protecting himself against psychological danger & stress"
A defense mechanism is a coping mechanism used in an effort to protect the
individual from feelings of anxiety.
Types of mental mechanism and their origin
Mental Health & Psychiatric Nursing 11

Origin in oral period (0-2 yrs)  Compensation


 Displacement, denial
 Fixation & substitution

 Conversation
 Identification
Defense Origin in habit training  Introjections
mechanism (1-3 yrs)  Reaction formation
and their  Transference
origin.  Sublimation

 Repression
Origin in later period of child-  Suppression
hood (13-6)  Regression
 Rationalization

Origin in latency period  Projection


(6-12 yrs age)  Isolation
 Fantasy

 Incorporation
Other commonly use defense  Intellectualization
mechanism  Symbolization
 Undoing

 Psychotic patient use defense mechanism:- Projection, denial, fantasy, regression,


symbolization and fixation.
12

 Neurotic patient use following defense mechanism:- Repression, isolation,


reaction formation, displacement and dissociation.

Q.5 How mental mechanism help the person to react appropriately to the
situation?
Ans. It is one of the coping mechanism used to reduce anxiety & fear.
 It assist the client to identify the source of anxiety and explore the methods to
reduce anxiety.
 It also keeps an individual temporarily free or away from the problem.
 They protect the individual against psychological threats related to ego.
 Helps the people to other people's behaviour and the factors associated with
their nature.
 It helps the people to lead a satisfactory & productive life which prevents
mental illness, promote mental health of individual in specific family &
community in general.
For example:-
A graduate nurse is expected to do comprehensive nursing care, if
she fails to do so and the tutor identifies it and scolds, she cries like a child to overcome
her failure instead of putting more efforts and succeeding in it. Here, the nurse uses
regression mental mechanism.

Q.6 Define personality?


Ans: According to Allport: Personality is the dynamic organization within the
individual of those psychophysical systems that determine his unique adjustment to his
environment.
Mental Health & Psychiatric Nursing 13

According to Taylor : Personality refers to "the Aggregate of the physical & mental
qualities of the individual as these interact & function in characteristic fashion with his
environment.
 Personality is expressed through the behaviour of a person. The characteristic
behaviour which is a combination of physical and mental characteristics of an
individual, differentiate one individual from another with his/her unique ident.

Q.7 Mention the factors affecting development of personality?


Ans. Factors affecting development of personality :-

 Heredity
 Embryonic factors
I. Biological Factors  Fetal factor
 Antenatal factor

II. Physiological factors  Nervous system


 Endocrine glands

III. Social Factor  Family


 Scholastic Environment
 Social-economic influences
 Society

IV. Emotional / Psychological Factor


V. Biochemical Factor
VI. Physique –
14

Q.8 Explain Freud's psychodynamic theory:


Ans.: Freud explained psychodynamic theory as :
1. Conscious Level: It is awareness part certain thought which are pleasurable and
remembered
2. Unconscious level: Some thought are completely repressed which the person
doesn't like is painful for ethical standard or self image. All ID are unconscious.
3. Preconscious level: The memories/thought are easily available with a moment
reflection.
Mental Health & Psychiatric Nursing 15

Unit II

History of Psychiatry

Q.1 Brief the historical development of psychiatry nursing?


Ans.: History of psychiatry: History is meaningful record of human achievement. The
term, 'History' is derived from a Roman word "Historics" which means
knowledge through" enquiry. The whole series & record of past events that
occurred chronologically in relation to psychiatry were described.
The following categories of periods are identified historically :
1. The period of persecution : 1550 BC – 1400 AD
2. The period of Segregation : 1545 AD -1800 AD
3. The humanitarian period – 1745 – 1826 AD
4. Beginning of scientific attitude : 1796 AD – 1878 AD
5. The period of prevention : 1885 AD – 1960 AD

1. Past history:- In first century "CHARAK SAMHINTHA" has referred to psychiatric


as " Bhut vidhya" and personality was basically divided into 3 categories :
A. Satveek (Moral level)
B. Rajasse (Emotional level)
C. Tamsie (Said as mentally retard)

 Mental disorders was known as " UNMADA" & fainting was known as " Murkh"
16

 Psychotherapy process was present in form of "DAIUAIY APARYA


CHIKITSHA"
 About 4th century method of treatment are :
- Tortures
- Burning
- Jail
- Asylum
- 1st Mental asylum established in India in "DHAR" (MP)
- Philippe pinel (father of modern psychiatry) raise his voice against asylum.
II. Present History:
1. First psychiatric nurse" Linda Richards" from America start training of
nurses for care of psychiatric patient in 1873.
2. In 1953, national, legue of nursing (USA) publish a study's brought out
function's and qualification of a psychiatric nurse.
3. In 1956 DPN (Diploma in psychiatric nursing) was started in
NIMHANS (National Institute of Mental Health Neurological
Science), Banglore, 1 year course.
4. 1960, psychiatric nursing was made a compulsory course in America.
5. 1973, standard of psychiatric nursing was established.

Past Situation :
1. In 1946, bhore committee report recommend preparation of psychiatry
nurses.
2. In 1965, INC - Psychiatric Nursing or a compulsory course in BSc. (N)
3. In 1975, MSc. (Psychiatric Nursing) started in RAK New Delhi
4. In 1983, DPN in Ranchi
5. In 1986, Psychiatric Nursing In GNM
Mental Health & Psychiatric Nursing 17

6. In 1990, started in MG university Kottayam.

Present situation:
1. 22000 bed in 42 mental hospital
2. 2000-3000 bed in general hospital
3. I bed for 32,000 population
4. No. meaningful available for rural population
5. 1000-1500 psychiatrist in India.
6. Every year 150 are being trained.
7. All the same time number of psychiatric nurses only 900-950
8. About 60 seat are available for DPN & may not be filled each year.
9. 1 Nurse for every 1,00,000 population.
18

Unit III

Mental Health Assessment

Q.1 What is mental health assessment?


Ans.: Mental Health Assessment is the first step of nursing process that includes
analysis of data collected from the patient and his family and identification of
nursing needs.
The data can be collected from primary source, that is from the clients his family
members (subjective data) or from secondary source e.g. Clients care record,
nurse notes or notes from health team members.

Q.2 How many types of basic techniques included in Mental Health Assessment?
Ans. Three types of basic techniques included in mental health assessment:
1. History taking
2. Mental status examination
3. Psychological tests

Q.3 Describe the steps for taking psychiatric history?


Ans.: History taking and mental status examination are important measure for
diagnosis & treatment outline preparation of mental illness.
Psychiatric history included the following steps:

I. Identification data:
Name of the patient …………………….
age………..
Sex…………………
Bed no. …………………….
Mental Health & Psychiatric Nursing 19

Hospital Reg. No. …………………….


Education ………………………..
occupation …………………………
Marital status ……………………..
religion …………………………..
Language…………………………..
nationality ………………………………….
Income …………………………….
Address …………………………………
Data of Admission ………………………
Final diagnosis ……………………………
Identification mark…………………………….
II. a) Informant ………………………..
b) reliability of informant ……………………
III. Present chief complain
According to patient ………………………….
According to relatives :
 Onset of present complains ……………………..
 Duration of present complains……………….
 Nature of present complains ………………………
 Precipitating factors …………………………..
IV. History of present illness :
a. Time of onset of present episode of illness
b. Chronological arrangement of the symptoms
V. Past history of illness:
a. Medical illness
b. Psychiatric illness
VI. Personal history
1. Developmental History
a) Infancy history
20

b) Childhood history
c) Adolescence
d) Adulthood
e) Late maturity
2. Educational history
3. Play history
4. Occupational history
5. Sexual & menstrual history

VII. Family history :


 Family structure
 Family history of mental illness
 Current social condition of family

VIII Premorbid personality

Q.4 Define MSE (Mental Status Examination).


Ans.: According to K. Lalitha: MSE is defined as systematic evaluation of
Behaviour, emotion, cognitive functions of an individual.
 MSE in a standardized format is which the clinician records the mental sign &
symptoms present at the time of interview

Q.5. What are the aspects of MSE?


Ans. The aspects included in this examination are:-
1. General appearance & behavior:-
 Consciousness
 Physique
Mental Health & Psychiatric Nursing 21

 Personal hygiene
 Posture
 Facial expression
 Gestures
2. Talk or speech :
a) Speech activity :-
i. Unusual pattern
ii. Unusual words
b) Tone and volume of speech
c) Speech pattern
d) Coherence

3. Mood or affect :-
A. objective mood
a) Appearance
b) Intensity of happiness
c) Consistency of word
d) Emotional Expression
B. Subjective mood
4. Thought process :
1. Thought at formation level
2. Stream of Thought
3. Thought at content level.
5. Perception :
a) Illusion
b) Hallucination
6. Cognitive function:
22

1. Level of consciousness
2. Attention
3. Concentration
4. Memory – immediate/Recent memory/remote memory
7. Orientation: time, place, person
8. Intelligence: average/confused
9. Insight: Present/Partial/Present/Absent
10. Judgment: Personal/social
11. Abstract ability:
12 General Information
13 Psychosocial factor
 Stressor
 Coping skills
 Relationship
 Socio-cultural aspects
 Adaptability
 Spiritual areas

Q.6 Define interview technique?


Ans. Interview is an oral questionnaire where the interviewee gives the needed
information verbally in a face-to-face relationship.
Interviewer– The person who conduct interview
Interviewer – the person that interviewed
According to oxford English dictionary: - interview is a private meeting
between people where questions are asked & answered
According to Webster: Interview is a meeting at which information is obtaining
from a person.

Q.7 Mention the types of interview techniques :


Ans.: Interview Techniques:-
1. Observing
Mental Health & Psychiatric Nursing 23

2. listening
3. Validating
4. Providing information
5. Restating
6. Clarifying
7. Paraphrasing
8. Pin pointing
9. Linking
10. Questioning
11. Focusing
12. Sharing summarizing
13. Reflecting
14. Confronting
24

Unit-IV
Community Mental Health

Q.1 What are common misconceptions regarding mental illness?


Ans. Some of the misconceptions of community towards mental illness are:
1. Abnormal behavioural is bizarre.
2. Normal person will never be abnormal.
3. Mental illness is heredity.
4. Mental illnesses are not related to physical health.
5. Mental disorders are incurable.
6. Mental illness is caused by supernatural power.
7. Mental illness is life long
8. Mental illness is contagious
9. Marriage can cure mental illness
10. Mentally ill person should only be treated in asylums.
11. Mentally ill patients are dangerous.
12. Mental illness sometimes to be ashamed.
13. Prevalence of mental illness is low in India
14. Professionals who works with psychiatric patients are likely to become disturb
themselves.
15. Mental hospitals are place where only dangerous mental ill individual are
treated with restraint as a major approach.

Q.2 Define community mental health nursing


Mental Health & Psychiatric Nursing 25

Ans.: Community mental health nursing is the application of knowledge of psychiatric


nursing in preventing, promoting and maintaining mental health of people to help
in early diagnosis and to rehabilitate the client after mental illness.
It is also defined as to promote, maintain and conserve the health of population
aggregates in the community with emphasis on mental health.

Q.3 What are the facilities (Services) available in the community to strengthen
their mental Health ?
Ans.: varied community facilities are available to provide mental health care for total
population and self involvement for their future life.
1. Day hospital centre: Patient receives a full range of treatment, services during
day time and return home at the end of day. Patients develop routine &
discipline in life.
2. Half way house: These are for those who no longer need full services of a
hospital but are not yet ready for a completely independent living, still he may
require supervision for medication & carrying domestic activities
3. Quarter way house:-
 Chronically ill patients are kept in quarter way homes.
 These patients are enough improved to live in family but their family
members reject them
 This home try to make these patients self dependent. It reduces gap
between hospital life & community life.
Ex. 13 & 14 ward at NIMHANS, Banglore.
4. Group homes:-
 15-20 recovered mentally ill patients (client) will be placed in this
home.
 They stay together & provides moral, emotional, & social support to
each other.
5. Foster homes
26

 It is a social agency sponsored programme in which recovering


patients are placed for family care.
 This voluntary family is paid by social agency
 This placement may be for short time or permanent.
6. Sheltered workshop
 It is a work oriented rehabilitation facilities with a controlled working
environment to fulfill the individual vocational goals.
 Appropriate for those patient who find difficult to complete for
employment.
7. Mental Health Emergency Care :-
 Hotline : Telephone link
 Walk-in-clinic – psychiatric emergency room (24 hrs.)
 Home visits
 Crisis intervention centre
8. Self help Groups
 Group of patients having same mental illness
Eg. Alcohol anonymous
Group of MR patient
9. Evening/Night Hospital:
 Evening hospital – provide mental health facilities on 5 evening of a
week
 Night hospital – for those patients who are unable to attend clinic due
to job in day time.

Q.4 What are the role of nurse in community mental health services?
Ans. Nurse can play an important role in linking the community services to the
hospital. The following roles of nurse in community mental health services:-
Mental Health & Psychiatric Nursing 27

1. Consultative role
2. Clinician role/Practitioner role
3. Therapeutic role
4. Researcher role
5. Educator role
6. Liason role
7. Coordinator role
8. Domiciliary role
9. Manpower facilitator
10. Social skill training
11. Manger/administration role
12. Preventive role
13. Other role :
 Assertiveness training to improve self confidence
 Conducts groups meeting.
 Carryout community outreach services.
 Provide crisis intervention services.

Q.5 What is preventive psychiatry?


Ans.: Preventive psychiatry includes preventive measures at three levels.

1. Primary Prevention:
 Means reducing incidence of mental illness by controlling the factors
which cause mental illness.
 It includes two component:
Health promotion
Specific protection
2. Secondary prevention :
28

 Aims at early diagnosis and treatment of mental illness


 It Includes following components :
Screening of population
Crisis intervention services
Mental health education
3. Tertiary prevention:
Aims at reduce the recurrence of mental illness & prevalence of residual defects
or disability due to mental illness.
It includes following components:
 Intensive patient care
 Rehabilitation services.
 Follow up care of patient.
 Interactional skill training
 Recreational therapy
 Individual & behaviour therapy
Preventive psychiatry includes different preventive measures according to age of
mental ill patient:-
1. Prevention during child hood
2. Prevention during adolescence
3. Prevention during Adulthood
4. Prevention during Old age
Mental Health & Psychiatric Nursing 29

Unit V
Psychiatric Nursing Management

Q.1 Define psychiatric nursing. Write the branches of Psychiatric Nursing.


Ans. Psychiatric nursing :
Mental health nursing or psychiatric nursing can be defined as a part of nursing
where nurse uses herself, her knowledge of social and behaviour sciences and
communication skills for the purpose of :
 Promotion of mental health
 Prevention of mental illness
 Helping individual family and community to cope with mental disorders.
 It is a branch of medicine deal with diagnosis and treatment of mental illness.
BRANCHES OF PSYCHIATRIC NURSING:
1. Community psychiatry
2. Forensic psychiatry
3. Cultural psychiatry
4. Geriatric psychiatry
5. Child psychiatry
6. Industrial psychiatry

Q.2 What are the principles of psychiatric nursing?


Ans.: Basic principles of MHN (Mental Health Nursing) are:
1. To Provide a sense of individuality, safety & comfort to the patient.
2. Economise her time & energy judiciously while nursing the patient.
3. Maximum therapeutic intervention
30

General principles are:


1. Accept the client exactly as he is :
a) Being non-judgmental & Non punitive
b) Sincerity & positive interest
c) Recognizes & reflects on clients feelings, which he expresses.
d) Be an active listener
e) Purposeful conversation.
2. Self understanding will be used as a therapeutic tool
3. Be consistent while working with patient with behavioural problem
4. Give reassurance to the client in an acceptable and realistic manner
5. Modify client's behaviour through emotional experience.
6. Avoid unnecessary increase in patient's anxiety.
7. Maintain therapeutic nurse patient relationship (T-NPR).
8. Be maintained objectivity in understanding client's behavioural.
9. Avoid physical & verbal restrains
10. Continuous close observation.
11. Explained ward routines & procedures at the level of pt's understanding.
12. Use appropriate language.
13. Treat and respect the client as an individual & specificity in nature.

Q.3 Describe the role of Mental Health nurse in various setting?


Ans. Mental Health nursing practice encompasses various roles in different settings
like community hospital, varied agencies, therapies, etc.

A. Role of nurse in mental hospital:-


1. Direct patient care
2. Education
3. Communication of interpersonal relationship
Mental Health & Psychiatric Nursing 31

4. Ward management
5. Role of nurse in psychotropic drugs
6. Role of nurse in psychotherapy :-
a. Nurse as a Psychotherapist
b. Nurse as a parent substitute
c. Nurse as a role model
d. Nurse as a resource person
e. Nurse as a supporter
f. Nurse as a socializing agent
g. Nurse as a communication
h. Nurse as a counselor
i. Nurse as a catalyst
j. Nurse as a Occupational Therapist
k. Nurse as a administrator
l. Nurse as a interpreter
m. Nurse as a teacher or technician
n. Role of nurse before during and after electro convulsive therapy (ECT)

B. Role of nurse in community setting :


Main function of nurse in community setting are :-
1. Case finding
2. Assessment of individual needs
3. Consultation with other professionals
4. Involvement in individual, family and group therapy'
5. Co ordination of health services for individual and family
6. Establishment of therapeutic milieu
7. Function as client advocate
32

8. Prevention of mental illness


9. Nurses' role in primary prevention, secondary prevention, tertiary
prevention.

Q.4 Define Therapeutic - Nurse Patient Relationship (T-NPR)?


Ans. T-NPR :- Interaction occurs between two persons, the nurse who possesses the
skills, abilities and resources to relieve the clients discomfort and assisting him to
alleviate his existing problems.
According to Webster new collegiate dictionary defines – "Relationship as
character of being related or interrelated".

Q.5 What is the difference between therapeutic relationship and professional


(social) relationship?
Ans.
S.No. Character Therapeutic Relationship Professional
Relationship
1 Technique Planned It just happen with
mutual interest
2 Interaction time Planned for specific time & place May be planned &
unplanned & by
chance two people
meet
3 Objective Helping the patient Satisfying needs of
each other
4 Duration  Depends on goal This varies & may
 time is limited last for years
5 Accountability Nurse focus on goal during Both are
relationship responsible in this
relationship
6 Acceptance Nurse accept the patient as "Here Based on shared
and Now" without attaching values and belief
judgment & interest
7 Termination Planned and discuss with patient Relationship exist
life long.

Q.6 What are essential qualities of T-NPR?


Ans. Essential qualities of T-NPR:-
Mental Health & Psychiatric Nursing 33

1. Genuineness
2. Respecting the client
3. Empathy
4. Self-discipline
5. Sincerity
6. Role model
7. Good communication skills
8. Good observer
9. Show love & affection
10. Active listeners
11. Good speaker
12. Exploration of the problem (catharsis)
13. Immediacy
14. Trustful
15. Professionalism
16. Caring

Q.7 Why T-NPR is essential?


Ans. T-NPR is essential:
I.
1. Self realization, self acceptance and self respect.
2. Sense of personal identity and personal integration
3. An intimate interdependent and interpersonal relationship
4. Satisfying needs
5. Development goals.
II. Nurse helps the patient to –
 Cope with problems
 Understand the problem
34

 Face problem realistically


 Find out alternate solution to problem
 Tryout new pattern of behaviour
 Communication freely
 Socialize effectively
 Find meaning in his/her illness.

Q.8 What are phase involved in establishing and maintaining the therapeutic
relationship?
Ans. T-NPR involves series of phases:-
T-NPR Phases

I. Pre-Interaction II. Introductory or III. Working phase IV.Termination phase


phase Orientation phase

Phases of T-NPR :-
Quality Pre- Introductory/ Working phase Termination phase
Interaction Orientation (Resolution/End phase)
phase phase
Definition Begins when a Begin when It starts when nurse and Begins during orientation
nurse assigned nurse goes to patient are able to phase.
a patient before patient, overcome barrier of In this nurse develop pact
the nurse first introduce herself orientation phase. Nurse with patient
contact with & get & patient actively works
client. introduction on meeting the goals.
about him.

1. Nurse collect data and


Task : 1. Nurse identifying nursing 1. Bring a therapeutic end
explore her 1. Establishme needs of patient. of T-NPR.
fear & anxiety. nt of contact 2. Assist the patient to 2. Establish reality of
2. Set objective 2. Developmen identify his problem. separation by attaining
for t of an 3. Help the patient to specific goals.
introductory agreement or socialize & 3. Feeling of rejection,
Mental Health & Psychiatric Nursing 35

phase. pact communicate. loss of sadness & anger


3. Take help of 3. Talking with 4. Help the patient to are expressed &
clinical the patient find out alternate explore.
supervisory to solution to problem, 4. Decrease patient
overcome 5. Encourage the patient dependency and
anxiety and to use new pattern of increases with
fear. behaviour. independency in his
6. Set goals for relation environment
ship
7. Assist the patient to
achieve his goal.
8. Encourage the pt.
towards independency
decision making
ability.
III) 1. Improper 1. Client
Barriers self display 1. Patient test the nurse 1. Develop termination
awareness manipulative in various situations. 2. Develop sense of
and self behavior 2. Nurse think that disappointment &
analysis 2. Social class patient's progress is feeling of sadness
2. Anxiety & of patient slow. 3. Gift giving
fear towards 3. Status of 3. Resistance to explore 4. Patient may like to
the client patient & to develop telephone the nurse.
3. Unplanned 4. Anxiety independency 5. Develops negative self
goals level of 4. Fear of closeness concept.
4. Uncertainty nurse/patient with patient.
about her 5. Transference
ability 6. Counter
transference

Q.9 Define communication, therapeutic communication and communication


skills?
Ans.
Communication: Communication refers to the reciprocal exchange of information,
ideas, belief, feeling and attitudes between persons or among a group of persons.
It is goal directed process in which people use a system of symbols & signs to
convey a message.
Therapeutic Communication: The therapeutic interaction between the nurse and the
client will be helpful to develop mutual understanding between two individuals.
It occurs when the nurse exhibits empathy, utilize effective communication skills
and responds to the client's thought, needs and concerns.
Communication Skills:-
It is the ability or efficiency of the nurse to utilize their knowledge systematically
and effectively
36

a) General ability: Ability to listen, interpret speak & express through writing.
b) Special ability:
 Ability to observe or interpret observation
 Ability to ascertain
 Ability to recognize when to speak, silent smile, interact
 Ability to wait, proceed, speed
 Ability to maintain T-NPR

Q.10 What is communication process?


Ans.: Communication Process: Communication is two way process (sender &
receiver), multidisciplinary process, multistage process & goal directed process.
Communication between two or more persons involves a series of steps &
element this is known as communication process.

In communication process, we will discuss:


1. Stages of communication process
2. Steps of communication process
3. Elements of communication process
a) Stages of communication process (Multistage process)
1. Attention
2. Comprehension
3. Acceptance of the information
4. Retention & Action

B) Steps of communication process:


1. Clear perception of the ideas, information or problems
2. Participation of other in the decision
3. Transmission of ideas or message
4. Ensuring that the receiver of the message acts & behave as derived by the sender.
5. Ascertaining the effectiveness of communication
Mental Health & Psychiatric Nursing 37

C) Element:

Stimulus
Need for information, comfort, advice etc.

Source / Sender Ideas, Encoding


Message filter Can be : - symbols
Through personal – Suggestion
Factors – Order Channels
– Request Speech, written
– Instruction Message, gesture

Feed back Decoding Receiver


Receiver agree with Message
Message evaluated
Disagree with message through
Needs classification personal
Provides information Factor
38

Q. 11 Classify the communication?

Ans.
Communication

On the basis of relationship On the basis of flow On the basis of expression

Formal Informal
Communication Communication Verbal Nonverbal
Communication Communication

Upward Downward Lateral/Horizontal


communication Communication communication

Spoken/oral Written
Mental Health & Psychiatric Nursing 39

Unit IV

Mental Disorders and nursing


interventions

Q.1 What are common causes of mental illness or mental disorder?


Ans: As there are many causes for single effect (Mental Retardation caused by gentio, birth
injury etc) and single cause for several effects (Parental neglect leads to behaviour
disorder, Suicide, depression etc.)
Many causes are responsible for mental disorders which are classified as:
Causes of mental Disorder

Predisposing Precipitating Perpetuating Abnormal


Factor Factor Factor Behaviour

1. Genetic factor 1. Physical Factor 1. Isolation 1. Biological factor


2. Obstetric 2. Psychological 2. Social withdrawal 2. psychosocial factor
Complication 3. Social Factor 3. Socio-cultural factor
a. Antenatal 4. Neuro biological factors
b. Intra natal
c. Postnatal
3. Personality
40

Diagrammatic presentation of causes of abnormal behaviour :-

i. Neuro - ii. Biological Genetic factor


Mono Factors Constitutional factor
Amines biological
factors Physical handicap
Amino
Physical deprivation
Acids
Emotional factors
Peptides

CAUSES OF
ABNORMAL
BEHAVIOR

iii.Social iv. Psycho-Social


cultural factor factor

War & violence Maternal deprivation


group prejudice Pathogenic family
economic and Pattern
employment problem Pathogenic IPR
technological Stress
& social changes
Mental Health & Psychiatric Nursing 41

Q.2 Write the Classification of mental disorder?


Ans. Major classification of mental disorder are :
1. International classification of diseases by WHO (ICD-10)
2. Diagnostic and statistical manual of mental classification (DSM-IV-TR)
3. Research diagnostic criteria (RDC)
4. ICMI – Indian classification of mental illness.

1. International classification of diseases:


 Organic, including sympathetic, mental disorders. (F00-F09)
 Mental & behavioural disorder due to psychoactive substance use (f10-f19)
 Schizophrenia, schizotypal & delusional disorders (F20-F29)
 Mood (affective) disorder (F30-F39)
 Neurotic, stress related & somatoform disorders (F40-F49)
 Behavioural syndromes associated with psychological disturbances and physical
factors (F50-59)
 Disorder of adult personality & behaviour (F60-F69)
 Mental retardation (F70-F79)
 Disorder of psychological development (F80–F89)
 Behaviour & emotional disorders with onset usually occurring in childhood and
adolescence (F90-F98)
 Unspecified mental disorder (F99)
2. Diagnostic & Statistical manual of mental classification: (DSM-IV)
 Clinical psychiatric diagnosis
 Personality disorders and mental retardation
 General medical condition
 Psychosocial & environment problems.
 Global Assessment of functioning
42

3. Research diagnostic criteria: (R&C)


According to this, at least two of following symptoms for schizophrenic are
essential :-
I.
a. Withdrawal
b. Delusions of being controlled
c. Delusion other than persecution lasting at least one month
d. Delusion accompanying hallucination of any type for at least one week.
e. Current auditory hallucination
II. Period of illness lasing for at least 2 weeks.
III. No manic or depressive symptoms

4. Indian classification of mental illness :


Mental Health & Psychiatric Nursing 43

Mental Illness

Organic disorder Non-organic disorders

I. Dementia II. Delirium


(Chronic brain syndrome) (Acute brain syndrome) I. Psychosis II. Neurosis

A. Psychotic (Adult) B. Childhood


Disorder Disorder
1. Schizophrenia 1. Mental disorder
2. Mood or Affective disorder ,
. Mania
. Depression
3. Psychosexual 2. Developmental
. Disorder Disorders
4. Substance abuse disorder 3. Adolescence
a. Alcohol abuse disorder
b. Drug abuse
5. Personality disorder Disorders
6. Psychosomatic disorder
44

Neuropsychiatric disorder Functional disorder Anxiety Disorder


(Hysteria)

Panic dis.
Dissociative disorder Conversion disorder
Dissociative Amnesia Somatoforms disorder  Panic disorder
Dissociative Fugue Body dimorphic disorder  Phobia

Somnambulism Hypochondriasis  Post Traumatic Disorder

Depersonalization Somatoform pain disorder  Obsessive Compulsive

Multiple personality Conversion Disorder Neurosis


 Hypochondriasis
 Neurasthenia
 Depersonalization

Q.3 What is the different between the organic psychosis and functional psychosis?
Ans.

S.No. Organic Psychosis Functional Psychosis


1 Impairment of brain tissue function Caused by :
due to head injury, toxic condition, Biological factor
encephalitis, brain tumour. Psychological factor
Systemic infection etc. Socio Culture factor
2 Disturbance Of consciousness Very rare
3 Disturbance Of Memory, Orientation Markedly affected
& Intelligence Present
4 Visual hallucination Auditory hallucination
5 Emotional incontinence Rare
6 Deterioration of personal & social It is uncommon.
7 Physical examination reveals clinical Physical examination of patient
features of systemic disease. usually reveal no abnormality which
can explain mental illness
Mental Health & Psychiatric Nursing 45

8 Psychological test – BGT Negative


BGT – Bender Gestalt test positive.
9 Laboratory & Radiological diagnosis These reveals no specific abnormality
as EEG help in determining the
etiological factor responsible for
psychosis

Q.4 What is the difference between the psychosis and neurosis?


S.No. Psychosis Neurosis
1 Definition: Definition :
Very severe illness of personality – Mild to moderate illness of
- Impairment of ego function personality
46
- reality besting is highly impaired – Ego function & reality testing is
- Grave maladjustment to life not affected much.
– maladjustment to life is limited
2 Etiology: Etiology :
– Biological factor – Mainly due to psychological
– Psychosocial factor factor
– Socio culture factor
3 Personality disintegration–total Personality disintegration–partial
4 Defense mechanism: Defense mechanism:
– Denial (Run from reality) – Repression
– Regression – Suppression
– Identification – Conversion
– Introjections (Self analysis) – Substitution
– Reaction formation
– Displacement
– Undoing
5 Clinical Features : Clinical Features
- Impaired ego function - Ego function affected much
- Loss of reality testing - Not much affected
- Loss of insight - Insight present
- Loss of judgment - Not lost
- Presence of illusion & - Absent illusion &
hallucination hallucination
- Memory marked affected - Memory present
- Impaired attention - Attention present
- Intelligence absent - Not affected intelligence
- Orientation absent - Present Orientation
- Disturbance in consciousness - Consciousness
- Disturbance of thinking - No disturbance in thinking
- More behavioural change - Minor behavioural change
- Social relationship affected - Not affected
- Vocational, Social, Sexual, - Not markedly Impaired
Adjustment markedly
impaired
6 Treatment: Treatment :
- Hospitalization present - No need hospitalization
- ECT - No ECT
- Psychotherapy - Psychotherapy useful
- Psychotropic drugs - Psychotropic drug

7 Prognosis: Prognosis :
- Bad prognosis - Good prognosis
- Recurrence common - Recurrence less
Mental Health & Psychiatric Nursing 47

Q.5 What is the difference between the delirium and dementia?


Ans.:
48
S.No. Delirium Dementia
1 Etiology
Etiology
Intracranial : Tumour, Injury, Epilepsy i. De-generative brain diseases :
- Alzheimer’s disease
- Pick's disease
- Huntington chorea
- Parkinson's disease
(ii) Metabolic : Acidosis/alkalosis Cerebral Arteriosclerosis
(iii) Endocrinal causes Drugs
(iv) Nutritional deficiency Example Vitamin B Brain pathology
(v) Drugs – Alcohol use, digitalis, bromide
Other
- Co-poisoning
- Vitamin deficiency
- Hypercholesterolemia
- diabetes
- Koraskoff disease
[Delirium + thiamine
deficiency]
- Wernick disease
(vi) Systemic deficiency example TB,
Septicemia
(vii) Others – post operative care
– circulatory disturbance
2 Course – reversible course – irreversible
3 Onset – Acute onset – chronic
4 Duration – few days Duration – Months
5 Clinical features:- Clinical features:-
(i) Clouded of consciousness No clouded of consciousness
(ii) Impaired memory Recent memory impairment is
greater than remote memory
(iii) Orientation present Orientation absent (First involve
time)
(iv) Illusion, hallucination & delusion present Very rarely
(v) Emotions – labile mood Loss of emotional control
(vi) Inappropriate or violent behaviour Indecent behaviour
(vii) Intelligence deterioration Present Intelligence
(viii) Other – reasoning ability & judgment Other : Neglect personal hygiene,
impaired Anxiety, depression, loss of
learning, reasoning.
Mental Health & Psychiatric Nursing 49

Q.6 Define personality disorder?


Ans.: Personality disorders is defined as any deviation in personality traits from the normal that
they interfere with his well being or adjustment to society and require psychiatric
attention.
Personality disorders is different from mental illness. The symptoms of mental illness are
mostly episodic & not continuous and starts from adolescence or even before. It is
commonly found in 18-40 years age.

Q.7 Mention the different types of personality disorders?


Ans. Personality disorders can be classified into four groups.

Personality disorder

Withdrawn Dependent Inhibited Anti-Social


Personality disorder Personality personality Personality
Disorder disorder disorder

1. Schizotypal 1. Anxious 1. Hypochondrial 1. Histrionic


2. Schizoid 2. Dependent 2. Depressive 2. Impulsive
3. Paranoid 3. Aggressive 3. Obsessive 3. Borderline
Compulsive 4. Narcissitic

Other types of personality disorder :


1. Cyclothymic Personality disorder
2. Hypomanic
3. Melancholic
4. Expolsive
5. Inadequate Personality
50

Q.8 What is the sign and symptoms of psychiatric illness?


OR
What are types of deviation from normal behaviour?
Ans.
Deviation from normal behaviour

Disturbance Disorders Disorder Disorders Disorder Disorder of memory Disorder of


Of conscio- of motor of of of or intelligence orientation
-usness Activity Perception Through Affecter or
Mood

Confusion Illusion Hyper Amnesia


Clouding of consciousness Hallucination Amnesia
Stupor Paramnesia
Coma Dejavu
Delirium Dementia
Dream State Jamisvu
Somnolence
II. Disorder of motor activity

Increased activity (Over Activity) Dysactivity Decreased activity

Repetitious Negativism Automatic Compulsion Violence Suicide Agitation Tics


Behaviour behaviour

Stereotype 1 Echoprexia
Activity 2. Echolalia

Stereotype Stereotype Stereotype


Position Movement Speech

Waxy Mannerism Verbigeration


flexibility
Catalepsy
Mental Health & Psychiatric Nursing 51

III. Disorder of perception

Illusion Hallucination

Auditory visual Gustatory Olfactory Tactile Kinesthetic Hypnogogic Hypnosomatic

IV. Disorder of Thought

At Formation level At progression (Association) level At content level

1. Autistic thinking
2. Derestic Thinking Structure Speed of association Type of Association
of Association
1. Magical
Thinking
1. Neologism Flight of ideas Motor aphasia 2. Poverty of
2. Word salad Clang association Sensory aphasia content
3. Circumstantiality Blocking of through Nominal aphasia of speech
4. Tangentiality Thought retardation Syntactical 3. Overvalued
5. Perseveration Poverty of speech aphasia ideas
6. Irrelevant answer 4 Delusion
7. Lossening of association 5. Obsession
8. Derailment 6. Phobia
7. Hypochondriasis
52

V. Disorder of affect

Pleasurable affect Unpleasurable affect Other affect

Euphoria Depression – Anxiety


Elation Grief and Mourning – Apathy
Exhaltation – Panic
Ecstasy – Inappropriate affect
– Ambivalence
– Depersonalization
– Mood swing

Q.9 Define delusion. Mention the types of delusion?


Ans. Delusion is defined as false, fixed unshakable belief, not in accordance with one's
intelligence socio cultural and educational back ground.
For example : Sitting in a classroom as a student, thinking that he is the prime minister of the county
or he is supreme or god.

Types of Delusion :
1. Bizarre delusion
2. Delusion of grandeur
3. Delusion of self accusation
4. Delusion of control
5. Delusion of persecution
6. Delusion of reference
7. Delusion of jealousy/infidelity
8. Encapsulated delusion
9. Nihilistic delusion
10. Delusion of worthlessness and property
Mental Health & Psychiatric Nursing 53

11. Delusion of thought possession


12. Hypochondrial delusion
13. Sexual delusion
14. Religious delusion
15. Delusion of loving
16. Delusion of influence
17. Delusion of dysmorphophobia
18. Erotic delusion
19. Somatic delusion

Q.10 What do you mean by phobia?


Ans. Phobia is an exaggerated pathological fear of a specific type of stimulus or situation
The fear that a person feels in the presence of particular object or experience.
An irritational fear of an object/situation that persist, although the person may recognize it as
unreasonable
Types of phobia :
1. Acrophobia –– Fear of heights
2. Agoraphobia –– Fear of Open spaces
3. Astraphobia –– Fear of Electrical Storms
4. Claustrophobia –– Fear of Closed Spaces
5. Haematophobia –– Fear of blood
6. Hydrophobia –– Fear of water
7. Monophobia –– Fear of being alone
8. Mysophobia –– Fear of dirt/germ
9. Nyctophobia –– Fear of darkness
10. Pyrophobia –– Fear of fires
11. Social phobia –– Fear of situation in which one might be criticized; fear of making a fool of
one self;
12. Xenophobia – Fear of Strangers
54

13. Zoophobia – Fear of animals

Q.11 Define Schizophrenia?


Ans.: In 1911, Eugene Bleuler, a Swiss psychiatrist explain the schizophrenia, which is
combination of two Greek words schizo means split and phrenic means mind.
In other words schizophrenia means splitting of mind. Split occurred between the
cognitive and emotional aspect of the personality.
According to ICD 10 & DSM-IV
Schizophrenia is a group of disorders manifested by fundamental disturbances in
thinking, mood (affect), behavior (BAT) last for at least a month of active phase
symptoms.
– Disturbance in thinking is marked by alteration of concept formation which may
lead to misinterpretation of reality hallucinations and delusions.
– Mood changes includes ambivalent constricted and inappropriate responsiveness
or blunted affect and lack of empathy with other.
– Behaviour may be withdrawn regressive and bizarre.

Q.12 How schizophrenia is classified?


Ans. No accurate classification is possible because symptoms of one type of
schizophrenia may be observed in another type.
Schizophrenia

Typical Schizophrenia Atypical Schizophrenia

Simple Hebephrenic Catatonic Paranoid Undifferentiated


or mixed Juvenile Late Schizoaffective Latent Residual
Simple Psychosis
Classification according to ICD-10 (F20-29)
F 20 – Paranoid
F 21 – Hebephrenic
F 22 – Catatonic
F 23 – Undifferentiated
Mental Health & Psychiatric Nursing 55

F 24 – Post Schizophrenic depression


F 25 – Residual Schizophrenia
F 26 – Simple Schizophrenia
F 28 – Other Schizophrenia
F 29 – Unspecified Schizophrenia

Q.13 State the clinical features of schizophrenia?


Ans. Bleuler has explained :
– Primary/Fundamental symptoms
– Secondary/Accessory symptoms
According to recent concept :
– Positive symptoms
– Negative symptoms
Positive Symptoms :
 Aggression
 Agitation
 Delusion
 Excitement
 Grandiosity
 Bizarre behaiour
 Conceptual disorganization
 Hallucination
 Hostility
 Suspiciousness

Negative symptoms :
 Apathy
 Blunted affect
 Diminished Emotional Responsiveness
 Stereotype thinking
56

 Social withdrawal
 Lack of spontanity
 Avolition
 Detachment
Primary/Fundamental Symptoms (Bleuler 4 A's)

Associative Autism Affective Ambivalence


disturbance Incongruity
or
Inappropriate
Mood

Secondary/accessory symptoms

Disorder Disorder Disorder Deterio Disturbance Disturbance Insight disturbances


Or of of rated in in will
Perception activity thought Appearance Attention behavior
Manner

1 Hallucination Negativism Delusion Self-care Client is Agitation Severly Blunting of


(Auditory automatism (Grandiosity & grooming unable to bizarre affected will power
Visual or Echolalia persecution become held attention Suicidal (anergia)
Gustatory) Echopraxia reference) minimum for long and homicidal Aloofness
2 Illusion Mannerism Depersonalization time tendencies (avoiding
Mutism Incoherence Sexual over activity mixing
Stupor Neologism criminal behaviour with
Waxy Clang violent friend
flexibility association Assaultive & destructive & family)
Catatonic Perseveration behavior Inability
Excitement to take
decisions

Q.14 How schizophrenic patients are managed?


Ans. Treatment of schizophrenia depends upon the type of schizophrenia:-
1. Prevention of schizophrenia : by reducing etiological factors
2. Chemotherapy drugs
 Sedative is indicated when patient is excited and restless
 Hypnotics when patient is sleepless
Mental Health & Psychiatric Nursing 57

 Neuroleptics antipsychotics such as :


– Clozapine
– Sulpride
– Risperidone
– Phenothiazines
– Antiparkinsonian drugs
3. Electro – conclusive therapy : (ECT)
 Indicated when patient with severe schizophrenia
 About 10-12 ECT in 4-6 weels
4. Intense Psychotherapy : Indicated in
 Early schizophrenia
 Maintenance & rehabilitation of recovered patient
 Psychotherapy are given follows:-
i. Individual psychotherapy
ii. Supportive psychotherapy
iii. Group psychotherapy
iv. Behavioural psychotherapy
v. Occupational psychotherapy
vi. Recreational psychotherapy
vii. Social psychotherapy
viii. Milieu therapy
ix. Family therapy
5. Psycho education
6. Rehabilitation

Q.15 Define Manic-Depressive Psychosis (MDP)


Ans.: MDP is characterized by recurrent episodes of mania and depression in the same
patient at different times.
58

MDP is a mood disorder that is characterized by a severe disturbance of mood


manifested as elation and depression.

Q.16 What are the criteria to define mania and depression?


Ans.: Criteria to define mania (Triad Symptoms) :-
1. Elevation of mood
 Euphoria
 Elation
 Exaltation
 Ecstasy
2. Increase pressure of speech :
 Flight of ideas
 Increase tone of speech
 More talkative
 Delusion of grandeur
 Increase self esteem
3. Increase psychomotor activity
 Over activeness
 Restlessness
 Person wants to keep himself busy
 Unusually alert
 Try to do many things at a time
Criteria to define depression (Triad symptoms):-
1. Sadness of mood (Depressive mood)
A. Mild depression
– sensitivity to criticism,
– Lack of confidence
B. Acute/severe depression
 Head fixed face immobile
 Look fixedly downwards
Mental Health & Psychiatric Nursing 59

 Social withdrawal
 Persistent sadness
 Hypochondrial ideas
C. Depressive stupor :
 Intense form of depression
 Clouding of consciousness
 Marked ideas of death
2. Poverty of ideas :
 Retarded thinking
 Difficulty in thinking
 Death of thought
 Delusion of nihilism
 Suicidal of ideas
 Feeling of hopelessness
3. Decrease Psychomotor activity :
 Reduce energy level
 Negativism
 Delusion of guilt
 Frustration in day to day activity

Q.17 How will you classify the mood disorder ?


60

Ans.: I. Classification
Mood disorder

Manic-depressive psychosis (MDP) Involution psychotic reaction

Manic type depressive type circular type

II. Classification of Mood disorder

Unipolar disorder Bipolor disorder

Only attack of depression

Bipolar I Bipolar II Bipolar III

Episode of severe Episode of depression Episode of major


Mania and & Hypomania depression
depression
Mental Health & Psychiatric Nursing 61

III. According to ICD10 classification of mood disorder – (F30-F39)

F 30 – Manic episode
F 31 – Bipolar affective disorder
F 32 – Depressive episode
F 33 – Recurrent depressive disorder
F 34 – Persistent mood disorder
F 38 – Other mood disorder
F 39 – Unspecified mood disorder

Q.18 What are the treatment modalities available for depression?


Ans.: 1. Hospitalization : indicated in
Severe attack of depression
Suicidal & homicidal tendencies
Stupor condition of patient
Psychotic & delusional depression
2. Electro convulsive therapy :
Total 6-8 Ect
3 in Ist Week
2 in IInd Week
1 in IIIrd Week

3. Drugs :
a) Sedatives –– if patient agitated
b) Hypnotics - if insomnia present
62

c) Tranquillizers:
– Meprobamate 200-400 mg
– Chlordizepoxide 10-20 mg
– Diazepam 5-10 mg T.D.S. If patient is anxious
d) Neuroleptics - if patient agitated and anxious
– Chlorpromazine hydrochloride
e) Antidepressant drugs :
– Tricycle & Tetracyclic compounds
Such as immipremine, hydrochloride
– amitryptiline Hydrochloride
– Trimipramine
– Mianserin
 MAO (Mono amino oxide) inhibitors like phenelezine. It is more powerful anti
depressant drug
 Recently more specific drugs are :
– Aminiptine
– Fluoxetine
– Amoxopine
– Tradozone
Psychotherapy :
 Cognitive & behaviour therapy
 Analytical psychotherapy
 Occupational psychotherapy
 Work therapy
 Art therapy
 Music therapy
 Interpersonal therapy
Mental Health & Psychiatric Nursing 63

 Family therapy

Q.19 Define anxiety disorders ?


Ans. Anxiety disorder are psychological disturbance where anxiety is the essential
symptoms anxiety is a normal phenomena. Every normal person experience
anxiety.
But when it cause excessive tension out of proportion & interfere with physical &
mental activities is known as pathological anxiety.
Anxiety reaction is a neurotic state of chronic apprehension with recurrence of
acute anxiety symptoms.

Q.20 Define obsessive compulsive neurosis (OCN) ?


Ans.: It is a psychiatric neurotic disorder in which obsession & compulsion are a
significant source of distress and interfere with an individual ability to function.
Obsession:- Recurrent & persistent unwelcome ideas & impulses or images. They
interfere with individual mind again and again in a stereotype from. Patient does
not enjoy getting those ideas.
Thoughts, images or impulses are not simply excessive worries about real life
problems.
They appear senseless to the individual. He actually feel miserable and guilty.
Compulsion:- Repetitive stereotype behavioural or mental acts that person feels driven
to perform in response to an obsession to relive tention even though they are
recognized senseless by the individual.
Eg. Hand washing, checking, counting.

Q.21 What do you mean by Hysteria?


Ans. It is a neurotic disorder characterized by :
64

 Hysterionic behaviour
 Suggestibility (susceptible against any suggestion)
 Transformation of an unconscious conflict into physical symptoms
 Emotional outbursts
 Repressed anxiety
It is of two types:-
Hysteria

Somatoform disorder Dissociative disorder


1. Body dysmorphic disorder 1. Dissociative amnesia
2. Hypochondriasis a. Circumscribed amnesia
3. Somatoform pair disorder b. Selective amnesia
4. Conversion disorder c. Continuous Amnesia
d. Generalized
2. Dissociative fugue
3. Somnambulism
4. Depersonalization
5. Multiple personality
Q.22. What is psychosomatic disorder ?
Ans: It is also called psycho physiological disorder :
It is characterized by physical symptoms resulting from psychological factor
(emotional stress) usually involving one system of body under voluntary control:
Types – 1. GIT – Peptic ulcer, Anorexia nervosa
2. CVS : Hypertension, Ischemic heart disease
3. Endocrine system – Diabetes, thyrotoxicosis
4. Genito urinary system – Impotence, menstrual disorder
5. Respiratory system – Asthma
6. Integumentary - Psoriasis
7. Musculoskeletan System – Arthritis, backache
8. Others – headache, migraine

Q.23 Define alcoholism?


Ans.: Alcohol has been used for countries to obtain relief from discomfort & tention.
Alcoholisms or alcohol abuse disorder is defined as chronic dependence of alcohol
characterized by excessive and compulsive drinking that produces disturbances in mental
or cognitive level of functioning which interferes with social and economic functioning :
Alcoholism results due to
Mental Health & Psychiatric Nursing 65

– Excessive consumption
– Alcohol related disability
– Problem drinking
– Alcohol dependence

Q.24 Mention the certain special alcohol withdrawal syndrome?


Ans.:
1. Simple withdrawal syndrome :
 Mild tremors
 Nausea & vomiting
 Weakness
 Irritability
 Insomnia
 Anxiety
 Tachycardia
 Hypertension
 Impaired attention
2. Delirium tremens
3. Pathological darkness (Acute Alcoholic Psychosis)
4. Delirium
5. Alcoholic seizures
6. Alcoholic Hallucination
7. Dipsomania
8. Alcoholic paranoia
9. Dementia
10. Wernick's syndrome
11. korsakow's syndrome
66

Q.25 How the psychoactive substances are classified?


Ans.:
Psychoactive substances

Narcotics Sedative Stimulants Hallucinogens Minor Tranquilizers


& Depressant

–Ethyl
– Opium &
alohol – Amphetamines –Cannabis eg ganja, –Maprobamate
its
–sedative/ – Cocaine charas, bhang, –Diazepain
derivatives
hypnotics hashish –Chlordiazepoxide
Eg. Opium,
Eg. –other
heroin,
Barbiturates LSD: -
morphine,
Nindral Lysergic
Codeine
Dalmane Acid
– Synthetic
Doriden Diethylemide
Narcotics
Such as
methadone

Q.26 Define substance abuse/drug dependent?


Ans. Drug abuse/psychoactive substance abuse:
It is a term applied to pathological use of persistent or sporadic drugs with impairment
social & occupational functioning and a minimum duration of disturbance of at least one
month.
The substance abuse leads to many psychological dependence :-
1. Psychological dependence results in drug seeking behaviour
2. An inability to stop using the drug to physical dependence on the drug & tolerance
to its effect.
3. Continuous substance use results in physical & mental deterioration.
Drug Dependence: a maladaptive pattern of substance use leading to significant
impairment or distress as manifested by :-
Tolerance
withdrawal symptoms
Mental Health & Psychiatric Nursing 67

Frequent pre-occupation with seeking or taking the substance


Often takes the substance in larger amount or over a longer period
Often takes the substances to relieve or avoid withdrawal symptoms.
Q.27 Define childhood disorder?
Ans.: Childhood Disorder:-
Nursing personnel find various childhood & adolescent problems while working in
a hospital as well as in a community setting.
Disorders of psychological development & behaviour & emotional disorders with
onset usually occurring in childhood & adolescence.
The development phase from infancy to childhood is a significant period to
prevent a number of behavioural and other problems.
Childhood Disorders

Developme Disruptive Anxiety Eating General To disorder Elimination Speech Other disorder
ntal Behavioural Disorder disorders Identity disorder disorder
Disorders Disorder of disorder of
Childhood childhood

1. Mental retardation
2. Pervasive disorders-
a. autistic disorder 1. Attention 1. Separation 1.Anorexia 1.Trans 1.Eneuresi Stuttering
b. childhood autism deficit anxiety nervosa Sexuliasn s
c. childhood psychosis hyperactive disorder 2.bulimia 2. Gender 2.Encopre
d. pseudo defective psychosis disorder 2. avoidant nervosa identity sis
3. Specific development (ADHD) Disorder 3. pica disorder of
disorders- 2. conduct 3. Overanxious 4. rumination childhood
a. Specific reading disorder disorder disorder disorder of
b. Specific arithmetic infancy
disorder
c. specific development
disorder of speech &
language
d. Specific developmental
disorder of motor function.

Autistic Childhood Temper tantrum


disorder Schizophrenia

Q.28 Mention the sleep disorders?


Ans.: Sleep can be regarded as a physiological reversible reduction of conscious
awareness.
Sleep deprivation is pressing health problem. If a person is not sleeping
continuously for few days or nights, it is harmful to his health.
68

Types of sleep disorders

Primary Secondary Parasomnias Insomnia


Sleep Sleep disorder (Walking up quantitative and
Disorders during sleep) qualitative
insufficient
(only sign & (Clinical problem Sleep based
symptoms of accompanied by On the
abnormality) specific or non- individual
specific Need.
disturbance)

 Alcoholism  Sleep onset


 Cateplexy  Anorexia Bruxisam Insomnia
 Insomnia nervosa Nocturnal  Frequent
 Hypersomnia  Depression Eneuresis Nocturnal
 Narcolepsy  Hyperthyroidism Sleep talking awakening
 Nightmares  Hypothyroidism Sleep Walking  Early morning
 Night terrors  Schizophrenia awakening

Q.29 Classify the psycho sexual disorders?


Ans.:
Psychosexual Disorder

Sexual dysfunction
Not caused by organic Gender Disorder of Sexual
Disorder identify sexual orientation
disorder or preference disorder
Trans
Sexual inadequacies sexualism Homosexuality
Fetishism
Transvestism
Exhibitionism
In male In female Voyuerism
Paedophillia
Erectile Frigidity Sadism
Impotence Vaginismus :- Masochism
Premature Involuntary
Ejaculation Contraction of
vaginal introits
at penetration
Mental Health & Psychiatric Nursing 69

Unit VII
Bio Psychosocial Therapies

Q.1 What is psychotropic drugs/psychopharmacology?


Ans. Psychotropic drug/psychoactive drugs is one which has mainly effect on the
behaviour experience and other psychological functions and will be used to treat
psychiatric condition.
The psychoactive drugs will have specific purpose and action, work on client symptoms
rather than diagnosis.
Psychoactive durgs are classified into five groups :
1. Antipsychotic Drugs
2. Anti parkinsonian agents
3. Antimanic Drugs
4. Anti depressant drugs
5. Anti anxiety drugs, Sedative and Hypnotics

Q.2 What are common antipsychotic drugs used?


Ans.: It is also known as neuroleptic drugs or major tranquilizers and used in the
treatment of psychosis.
Classification of antipsychotic drugs:-
70

Antipsychotic Drugs

Conventional Atypical New generation


Antipsychotic antipsychotics Es. Antipsychotic
drugs Clozapin Drugs
Risperidone Eg. Aripiprazole

Phenothiazines Thioxanthene Butyrophenones Dibenzazepines Dihydroindolane

Chlorpromazine Thio-thexene Haloperidol Loxapine Molindone


Perphenazine Fluphenthixol (Haldol) Olanzapine (Morban)
Fluphenazine
Trifluperazine
Prochorperazine
Thioridazine
Mesoridazine

Q.3 What are the indications & contraindication's of antipsychotic drugs?


Ans: Indications of antipsychotic drugs:-
1. Schizophrenia
2. Paranoid disorder
3. Mania
4. Organic psychosis : Delirium
Dementia

Contraindication:-
1. Children under 3 Yrs. Of age
2. Comatose patient
Mental Health & Psychiatric Nursing 71

3. Drug hypersensitivity
4. Severe depression
5. Other contraindications :
 History of epilepsy
 Pregnancy
 Parkinson disease
 Peptic ulcer

Q.4 Explain extra pyramidal symptoms (EPS) ?


Ans. It is the CNS side effect of antipsychotic agents. It includes :
1. Parkinsonism:
Akinetic form
Agitating form
2. Akathisia
3. Dystonia
4. Tardive dyskinesia
5. Neuroleptic malignant syndrome (NMS)

1. Parkinsonism :
It occurs in 40 percent of patient with EPS
It occurs one week after treatment
It is of two types :
(A) Akinetic form :
a. Impairment in masticating movement
b. Weakness
c. Muscle pain
d. Fatigue
(B) Agitating form:
72

a) Muscle rigidity
b) Motor retardation
c) Mask like face
d) Shuffling gait
e) Slurred speech
f) Salivation
g) Tremors

2. Akathisia: Most common


 Most common
 Occurs in 50 % patient
 Occurs two weeks after treatment
 It includes
– Difficulty in sitting skill or rest
– Strong urge to move about (walking and talking)
– Anxious and agitated

3. Dystonia: Occurs in 6 % of patient
Occurs within few minutes of medicine
It includes-
a. respiratory difficulties
b. Rapidly developing contractions of muscle of tongue jaw, neck (producing
torticolis) and extra ocular muscles,
c. occulogyric crisis (torticolis & extra ocular muscles)
d. Opisthotonous
e. It is painful and gives a frightened experience to patient.
4. Tardive dyskinesia :
Mental Health & Psychiatric Nursing 73

It is most severe condition


Occur in 3% patient
Occurs after sudden termination or reduction of antipsychotic after long term
high dose therapy
Features :-
Involuntary rhythmic stereotype movement
Protrusion of tongue
Gritting of teeth
Lip snaking
Puffing of cheek
Note: This condition is non-treatable.
C. Neuroleptic maligment syndrome (NMS) :
– It is fatal and rare condition.
– It may develop within hour or after year of continuous drug use.
– Features -
Hyperpyrexia
Muscle rigidity
Altered consciousness
Tremors
Unstable Blood Pressure
Increases W.B.C.
74

Q.5 Classify anti parkinsonian agents ?


Ans.: These drugs are used for treatment of EPS (extra pyramidal syndrome)

Antiparkinsonian Drugs

Anti- Dopamine Antihistamine blockers Muscle relaxant Anti


Cholinergic drugs Agonists dopaminargic

Agents :- Carbidopa Diphenhydramine


Benztropine Livo dopa
Biperiden, HCL Bromocriptine
Procyclidine HCL Dantrolene Reserpine
Promethazine
Mental Health & Psychiatric Nursing 75

Q.6 Write down about indication, Contraindications and action of anti manic
drugs?
Ans. Anti manic drugs are also called mood stabilizers.

Indications :
1. Mania
2. Manic Depressive Psychosis (MDP-Bipolar disorder)
3. Hypomania
4. Recurrent depression
5. Alcoholism
6. Schizo – affective disorder
Contraindication :-
1. Side – effect of renal, CVS, liver and respiratory system
2. Thyroid disorder (Hypothyroidism)
3. Diuretic potent
4. Dehydration
5. Child below 12 yrs. Age
6. Parkinsonism
7. Obesity
8. High grade fever
Mode of action:
It reduces the level of nor-epinephrine and serotonin or catecholamine.

Q.7 Classify the anti manic drugs?


Ans.: 1. Lithium carbonate (Lithane)
2. Anti convulsant/anti epileptic drugs :-
– Carbamazapine
– Sodium Valporate
4. Gabapentine
76

Q.8 Write a short note on lithium toxicity?


Ans. Cade has describe the usage of lithium carbonate in treating mental illness. lithium
causes less drowsiness while controlling the marked psychomotor over activity because
of its toxicity.
Lithium toxicity:
1. Mild toxicity (Lithium level – 1-2.5 m Eq/l) :- Diarrhea, nausea, vomiting,
drowsiness, muscular weakness, tremors, ataxia, cardiac arrhythmias, allergic
reactions, blurred vision, glycosurea, polyurea.
2. Severe toxicity : Cerebellar ataxia, seizures, hypotension and coma.
3. Chronic administration of lithium carbonate: Goiter, leucocytosis, and embryo
toxicity.
Note: Normal lithium level: 0.5, 1.5 mg/t

Q.9 What are the indications, contraindications and mode of action of anti
depressant drugs?
Ans: It is also called mood elevators.
Indications:
1. Major depressive illness
2. MDP depressive phase of bipolor disorder
3. Anxiety
4. Psychotic depression
5. Obsessive compulsive disorder
6. Migraine headaches
7. Panic disorders
8. Eating disorder (bullemia)
9. ADHD in children
10. Sleep apnoea
11. Cataplexy
Mental Health & Psychiatric Nursing 77

Contraindications:
1. Increase manic and psychotic episode of MDP.
2. CVS problem (arrhythmias)
3. Liver problem

Mode of action:
It acts by accelerate (increase level of) receptors of nor epinephrine and serotonin in the
central nervous system and reduce anxiety.

Q.10 How will you classify the antidepressant drugs?


Ans.:
Anti depressant drugs

Tricylic Tetra cyclic MAO Sympatho


Antidepressant antidepressant Inhibitors Mimetic
Stimulant

Imipramine Mianserin Phenezine Dextroam


Tri-imipramine maprotiline Isocarbaxazid Phetamine
Clonipramine Tranylcypromine
Amitriptyline
Doxepine
Nortriptyline

Q.11 Write is detail about anxiolytic drugs (anti-anxiety drugs). ?


Ans. It is also called minor tranquillizers

Indications :
1. Anxiety disorder/Panic disorder
2. Insomnia
3. Obsessive compulsive disorder
4. Depression
5. Alcohol withdrawal symptoms.
78

6. Convulsions
7. Induce sleep pre-operatively.

Contraindications:
Patent with renal, liver, respiratory impairment and hepatic failure.
Mode of action: It acts by increasing GABA activity that can cause decrease activity of
neurotransmitter in brain results in decrease neural activity.

1. Tolerance/physical or psychological dependence


2. Inhibited behaviour
3. Memory disturbances: Anterograde & retrograde
4. CNS depression :
Drowsiness
Poor co ordination
Clouded sensorium
Confusion
Ataxia due to cerebellar action
5. Sexual dysfunction :
Erectile and ejaculatory disturbance
6. Miscellanceous :
Lethargy
Impaired psychomotor disturbance
Blurring vision
Gastric Upset
Urinary incontinence
Nightmares
Depression
Aggression
Mental Health & Psychiatric Nursing 79

Headache
Hypotension
Bodyache
Impotence

Nurses' role in providing ant anxiety drugs to the patient's


1. Assessment of patient prior to the use of anxiolytic drugs.
2. Appropriate nursing measures to induce sleep should be taken such calm & quiet
environment
3. While administrating the drug daily dose should be given at bed time to promote a
normal sleep pattern.
4. Look for side effects, record & report immediately if any occurs.
5. Give IM injection deep into muscles to prevent irritation.
6. Instruct the patient not to take any stimulants like coffee, alcohol.
7. Avoid excessive use of these drugs to prevent the onset of substance abuse.
8. Don't stop drug abruptly but it should be reduced gradually
9. For IV administration, do not mix with any other drug and give slowly.
10. Monitor vital signs during IV administration.
11. Administer with food to minimize gastric irritation.

Q.12 What are the common side effects of psychotropic drugs?


Ans.: There are following systemic side effects of psychotropic drugs :
1. CNS & ANS :
CNS :
 Drowsiness
80

 Confusion
 Tremors
 Convulsion
 Ataxia
ANS :
 Dry mouth
 Tinnitus
Note : EPS (Extra Pyramidal Syndrome) : In antipsychotic drugs

2. Cardio-vascular system (CVS)


 Tachycardia
 Orthostatic Hypotension
 Arrhythmia

Note :
Bradycardia : In Antimanic drugs
Palpitation : In anti anxiety drugs

3. Hematopoietic System :
 Agranulocytosis
 Leukopenia
 Leukocytosis
4. Endocrine System :
 Amenorrhea
 Breast enlargement
 Impotency
 Change in Libido
Mental Health & Psychiatric Nursing 81

 Galactcorrhoea
 Gynaecomostia
 Hyperglycemia
5. Gastro Intestinal tract :
 Constipation
 Diarrhea
 Anorexia
 Nausea
 Vomiting
 Weight gain
 Jaundice

Note : Weight gain : In antipsychotic and antimanic drugs


6. Hepatic side effect : Liver toxicity
7. Ocular effect :
 Blurring of Vision
 Dilated Pupils
 Retinopathy
7. Allergic effect :
 Dermatitis
 Rash
 Itching
 Alopecia
8. Urinary system:
 Urinary Retention
 Oliguria
 Polyuria
82

Q.13 Write in detail about nursing care of patient receiving psychotropic drugs?
Ans.: Psychotropic drugs are used to treat the signs and symptoms of mental illness. But
all behavioural problem are not treated by the drugs. The treatment is based on the
thorough psychiatric evaluation of the patient.
Before administering any drug, the nurse should know about the drugs that is half
life period and after dose, the side effect of drug, age of the patient, to know the liver
metabolites and kidney excretion etc
Nurse's Role:
I. General Role :
1. No drug should be administered without prescription
2. Do not leave the patient alone until the drug is swallowed
3. Do not allow patient to carry medicine to another patient.
4. Keep safety measures.
5. Give a glass of water after medicine.
6. Do not leave the drug tray within reach of patient.
7. All medicine given must be recovered on patient chart.
8. Do not force the patient orally.
9. Check drug daily for any change for colour order.
10. Drug bottle should be properly labeled .
11. Drug cupboard are always to be kept locked when not in use.
12. Nurse should know side effect indication and contraindication of drug.
13. Nurse must know the legal aspect.

II) Specific Role :


1. Close observation
2. Decrease EPS with antiparikinsonian drugs.
Mental Health & Psychiatric Nursing 83

3. While administrating drug, if any doubt arises without hesitation nurse should
consult with doctor.
4. Observe drowsiness, sore throat, fever
5. Record blood pressure.
6. Provider good oral hygiene to reduce dry month.
7. Weight recording and low salt in case of anti-psychotic/anti manic drugs.
8. Discourage the patient to take antacids as they cause decrease absorption.
9. Maintain intake/output chart
10. Advice to protect the skin.
11. Record in client's chart about which drug administered; if any side effects
observed.
12. Nurse need to have an effective drug attitude.
13. Nurse has to be familiar with regular usage of drugs, their actions, side effects and
they hold responsibility while administering to avoid errors.
14. Uses a variety of techniques with different clients in different situations.
15. While administering the drug, confirm the client by calling their name.
16. While administering lithium, complete investigation as urine analysis, BUN
creatinine electrolytes, 24 hrs creatinine clearance, thyroid test etc should be
checked.
17. Every 3 month, lithium level to be checked.
18. Blood level of lithium is tested 12 hrs after last dose. The therapeutic level should
always be maintained 0.6-1.4 m Eq/lt.
19. While administering MAOI, caution should be taken food substances, as cheese,
pickle, beer, red, wine chicken, liver, overripe fruit, banana peel, yoghurt and
some medications as cold medication, nasal and sinus decongestants, narcotics,
local anesthetics, epinephrine, cocaine, amphetamine should be avoided
84

20. While administering anxiolytic/hypnotic, care to be taken to avoid addiction and


not to disturb usual sleep pattern. For children, special care should be taken
especially while administering hypnotics and lithium.
21. In antipsychotic drugs, ask the client to take sugar free fluids and eating sugar free
hard candy to ease dry mouth.
22. Avoid calorie beverages and candy to avoid weight gain.
23. Usage of sunscreen lotion to overcome photosensitivity
24. Advice the patient not to increase/decrease stop drug without doctor permission.
25. Find out menstrual changes in female.
26. Advice not to get up quickly from lying down to sitting position.
27. Do not give medicine in empty stomach as patient complain nausea and vomiting.

Q.14 Define psychotherapy, write down the goals, indications, contraindications,


advantages and disadvantages of psychotherapy?
Ans.: Definition of Psychotherapy:
Psychotherapy is a treatment use for patient with emotional and mental disorder in which
the basic concept of therapeutic nurse patient relationship is maintained between nurse
and patient. The purpose of this is to modified/remove and reduce the factors causing
disturb behaviour.
Certain psychological processes are used for the treatment of emotional a problem in
which professionally trained person deliberately establishes therapeutic relationship.
According to psychiatric glossary: A process in which a person who wishes to relieve
symptoms or resolve problem in living or seeking personal growth, inter act with a
psychotherapist in a explicate/implicate manner.

Goals of psychotherapy:
1. To achieve remission of symptoms
2. To modify disturbed pattern of behaviour
3. To strengthen the ego
4. To improve growth & development of the client.
5. Modify environment causing maladaptive behaviour.
6. Improve IPR skills.
Mental Health & Psychiatric Nursing 85

7. To produce deeper insight


8. To develop positive attitude
9. To modify deviated personality, thereby develops positive personality
10. To correct psychopathology
11. To helping the patient to over comes a feeling of handicap.

Indicated of Psychotherapy
1. First choice for neurotic illness
2. Very useful in psychosomatic illness.
3. Schizophrenia
4. Mania, depression
5. Alcoholism
6. Drug addiction
7. Sexual deviation
8. Personality & character disorder
9. Childhood disorder
10. Marital disharmony
Contraindications
1. Severe psychotic illness
2. Unresponsive, unmotivated and in cooperated patient.
3. Violent/ excitement
4. Unconscious patient
5. Assaultive and destructive behaviour
6. Negativism
7. Organic Psychosis
8. Psychotic Depression
9. Group psychotherapy in hysteria and hypochondriasis.
Advantages:
86

1. Reduce intensity of symptoms


2. Increase working ability
3. Increase adjustment in various condition
4. Increase understanding situation, self confidence, of request
5. Start goal directed activity
6. Bring positive mood changes
7. Reduce maladaptive behaviour
Disadvantages
1. Time consuming
2. Ineffectiveness caused waste of mental power
3. Inappropriate for who give best response to ECT and drugs
4. Patient become excessively depends on therapy and therapist
Mental Health & Psychiatric Nursing 87

Q.15 How will you classify the psychotherapy?


Ans.
Psychotherapy

According to depth of probing According to No. of patient


In the unconscious mind treated in any one
therapeutic session

Superficial or Deep or long Psycho-Educative Counseling


short term term (analytical (Group Discussion)
(supportive psychotherapy) I. Individual Psychotherapy
psychotherapy) – Psychoanalysis
– Hypnosis
– Abreaction
– Reality
– Insight
– Supportive therapy
 Mental Ventilation
 Persuasion
 Re-education
 Re-Assurance
 Suggestion
II. Group therapy
III. Behavioral psychotherapy
 Systematic desensitization
 Flooding
 Aversion therapy,
 Assertive therapy
 Modelling
 Shaping
 Cognitive behavior therapy
 Token economy
IV. Inter personal psychotherapy
 Marital therapy
 Family therapy
V. Other psychotherapy:
 Therapeutic Community/Milieu therapy
 Attitude therapy
 Activity therapy
Recreational therapy
Occupational therapy
Play therapy
Art therapy
Music therapy
Dance therapy
Education therapy
88

Q.16 What are the role of nurse in psychotherapy?


Ans: Nurses role in psychotherapy :
Nurse plays various roles during psychotherapy
1. Nurse psychotherapist
2. Nurse as a parent substitute
3. Nurse as a role model
4. Nurse as a resource person
5. Nurse as a Supporter
6. Nurse as a socializing agents
7. Nurse as a communication
8. Nurse as a counselor
9. Nurse as a catalyst
10. Nurse as a occupational therapist
11. Nurse as a administrator
12. Nurse as a interpreter
13. Nurse as a teacher
14. Nurse as a technician

Following are the responsibilities of a nurse during psychotherapy :-


– Nurse should be a good listener
– Should be have patience, sympathetic & tact full.
– Should understand the patient's family & cultural background
– Should not be upset with patient's irritational behavior
– Should not show counter transference during psychotherapy
– Nurse should have an interest in patient's problem
– Manipulate environment according to type of patient.
– Nurse should be non-judgmental
o Good listener
o Trustful
Mental Health & Psychiatric Nursing 89

o Attractive
o Patience
– Nurse should maintain T-NPR
– Accept the patient as unique individual
– Nurse should encourage the patient for involvement in psychotherapy
– Nurse must know proper knowledge of different types of psychiatric illness
– In occupational therapy, nurse help the patient to teach new skills related to as a
job.
– Demonstration to the nursing students.

Q.17 What do you know about individual psychotherapy?


Ans.: Individual Psychotherapy : It is a method of bringing about change in a person by
exploring his or her feelings attitudes, thinking and behaviour.
Therapy is conducted on a one to one basis, that is the therapist treats one patient at a
time.
This therapy helps to:
1. Understand themselves and their behaviour.
2. Make personal changes
3. Improve interpersonal relationship
4. Get relief from emotional pain or unhappiness.
Indication:
– Stress related disorder
– Alchohol and drug dependence
– Sexual disorder
– Marital disharmony
Types of individual psychotherapy:
1. Psychoanalysis
2. Hypnosis or hypnotherapy
3. Abreaction
90

4. Reality therapy
5. Uncovering or insight psychotherapy
6. Supportive psychotherapy :
o Mental ventilation
o Environmental modification
o Persuasion
o Re-education
o Re-assurance
o Suggestion

Q.18 Define group therapy. Write in detail about the objective, types of groups,
steps & merits and demerits of group therapy.
Ans.: Definition : Group therapy is a mean of psychotherapy of psychological problem
in which a group of patients is provided psychotherapy by a group of psychiatrist as well
as the patient interact with each other & help in problem solving.
Description:
1. Group therapy is less time consuming
2. Group consist of 8-10 patient.
3. Session of psychotherapy are held once in a week & generally continue for 12-18
months.
4. Duration of session longer than individual therapy. It is one or two hour.
5. It uses many type of psychotherapy technique.
6. The patient in group generally have some problem eg. alcoholic patient.
Objective:
1. The member of group gain personal insight
2. The group member Improve their IPR
Mental Health & Psychiatric Nursing 91

3. The patient can change their destructive behaviour & can modify their
behavior.
4. The patient can share their intimate feelings, ideas, experiences.
5. It provide an environment of mutual respect that further improve respect & self
understanding.
Types of Groups

1. Therapeutic groups: It is groups of patient. This group works together under


the guidance of a therapist to improve the mental health usually the patient self
help group.
2. Adjunctive group: It is not the group of patient’s it helps the other selective
group of patient by providing stimulation as music therapy, art therapy &
dance therapy.
3. Traditional group: The members of traditional group are patient from
hospital in patient department. The method of psychotherapy are lecture film
show. The therapist first says few words & then allows the patient to interact
with each other.
4. Non- traditional group: It is also called psychodrama. In this the group
member act out various drama based upon situation. This role play helps him
in expression of feeling, idea.
5. Encounter Group /"T" Group (Training Group): In this group, the focus is
on the expression & feeling of people that remain unexpressed. It is not
necessary for a group of member by ill patient. The inter action between
member of encounter groups is more intense or rapid.
6. Homogenous group: The members of homogenous are similar on basis of
sex, age, race, socio economical level in society etc.
92

7. Heterogeneous group: The group member does not have similarity on basis
of sex, age, socio-economic in society. It is just opposite to homogenous
group.
8. Open or close group: In open group member are free to join or leave the
group at any time. Closed group have certain number, certain duration. Patient
can not join or leave the group any time.
9. Group according To mental illness: The group classified according to their
nature of illness.
Psychotic group
Neurotic group
10. Psychodrama group : The group acts event from the life of one member.

Steps of group therapy:


1. Pre-interaction phase:
 Determination of physical set up
 Determination of place & time
 Determination of types of group
 Determination of session no. & no of group member.
2. Initial/orientation phase :
 Introduction of group member To each other
 Introduction of member To therapist
 Instruction of group member
 Selection of group member
 Selection of group leader
 Preparation of environment for problem solving
3. Working phase :
 Problem solving with mutual understanding & co operation
Mental Health & Psychiatric Nursing 93

 Resolving of internal conflict


 Role distribution to group member
 Development of "we feeling"
4. Termination phase :
 Evaluation of group experiences
 Evaluation of result

Merits of group therapy:


1. This method is cost effective. Many patients can be treated by this therapy at a
time.
2. Group member learn new method of problem solving through this therapy
3. It provides opportunity to know about the problem of other patients. It reduces
their feeling of hospitality loneliness.
4. Group therapy provides a safe environment for communication.
5. Group therapy provide an opportunity for patient to play a functional role.
Patient work as a co-therapist with therapist.
Demerits:
1. It is not appropriate for those patient who keep hesitation & unable to
communicate properly.
2. In group therapy patient loses his privacy because patient’s personal
emotional problem are discusses in open.
94

Q.19 Explain behaviour therapy.


Ans.
 Definition : Behaviour therapy is a type of psychotherapy that is based upon
learning theory & it focuses at changing or modifying the maladaptive behaviour.
 Behaviour therapy is a type of psychotherapy in which conversational interchange
is the primary vehicle used to treat people with problems.
 Behaviour therapy is more action – oriented, directed towards changing specific
types of maladaptive Behaviour.

Concept of behaviour therapy:


1. Most abnormal behaviour are acquired & maintain as normal behaviour.
2. Abnormal behaviour can be modified through social learning principles.
3. People are best known by their behaviour in life situations.
4. The treatment method should be precisely specified according to behaviour &
should be objectively evaluated.
Indications: It is the treatment of choice in:
 Anxiety
 Phobia
 Obsessive compulsive disorder
 Hysteria
 Nocturnal enuresis
Mental Health & Psychiatric Nursing 95

 Sexual disorder
 Thumb sucking/nail biting/tics
 Migraine
 Anorexia nervosa
 Bulimia nervosa
 Obesity
 Psycho – somatic disorder

Contra Indications:
Psychotic disorder that have acute pervasive symptoms and in which reinforcement is not
applicable
Steps: it has 3 steps
1. Training of relaxation technique before the main therapy.
2. Hierarchy formation - Patient is asked to construct a hierarchy of anxiety
causing stimulus.
3. Systemic desensitization:-
It is done in two ways:
(a) SD-1 the stimulus is confronted in imagination
(b) SD-2 The stimulus is confronted in reality
96

Q.20 Write a short note on occupational therapy.


Ans. Introduction: Occupational therapy is a rehabilitation therapy. In occupational
therapy, focus is laid upon the use of activities of as treatment medium. Its short term goal
is improvement of quality of life & long term goal is rehabilitation.

Definition:
 Any activity which engages a person's resources of time, energy & is composed of
skills and value.
–"REED & SENDER SON".
 Any goal directed activity meaningful to the individual providing feedback to him
about his worth & value as an individual & about his inter relatedness to other-
–"JOHNSON".

Objectives:
The major goals of patient in rehabilitation:
1. To assess need of patient
2. To identify the skills of the patient
3. To remove or modify mal adaptive behaviour
4. To improve mood & reduce, anxiety
5. To role performance
6. To stimulate self confidence
7. To give opportunity for self expression
8. To reverse psychopathology
9. To increase socialization & communication
10. To improve old skills & acquire new ones.
Mental Health & Psychiatric Nursing 97

Basic Requirement:
1. Knowledge levels of patient
2. Background of patient
3. Psychological problem/diagnosis.
4. Capacity or skills of patient.
5. Therapeutic nurse patient Relationship.
6. Interest of patient.
7. Continuous evaluation of progress.

Type of activity in occupation therapy :


 Craft work
 Needle and tailoring work
 Basket making
 Carpentry
 Gardening
 Painting
 Mat weaving
 Cooking

Various setting in occupation therapy :


1. Psychiatric hospital
2. Nursing home
3. Psycho-social rehabilitation centre
4. Physical rehabilitation centre
5. Sheltered workshop
6. Community group homes.
7. Community mental health centre
8. Day care centers
9. Half way homes
98

10. De-addition centers

Process of occupation therapy:

Initial evaluation of pt.

Development of short term & long term objective

Development of therapy plan

Implementation of plan

Continuous monitoring of progress

Call for reviews meeting with patient & staff

Resetting of new goals

Discharge planning of patient.


Mental Health & Psychiatric Nursing 99

Q.21 Write a short note on aversion therapy ?


Ans. Version Therapy:
Indication:

Alcohol dependence
Homosexuality
Child disorder
Principle: Principle of this therapy is the pairing of the pleasant stimulus (eg - alcohol)
with an unpleasant response. This pairing convert the pleasant into unpleasant stimulus
after the therapy is over.
 20-40 session are given.
 Duration of session is about 1 hour
 Booster sessions are given after completion of treatment.
E.g. : Pairing of alcohol [pleasant] with drug appmorphine disulfirum (unpleasant)
Thumb sucking (pleasant) with low voltage. Electric current (unpleasant)

Q.22 Discuss about the family therapy?


Ans: Family Therapy
Definition : It is a type of psychotherapy which involve both parents together with child,
Grand parents & other member of extended family.
Objective :
The main objective of family therapy is to improve – family functioning & to help the
identified patient The other goals are :
 To improve communication among family member.
 To reduce conflict between parent or member
 To reduce distress in the suffering member of the family
 To determine role of each member & establish agreement about roles.
 To provide sufficient autonomy for each member
Indication:
It is mainly used for young people in family, who have :
 Communication problem
 Substance abuse
100

 Conduct disorder
 Role identify difficulty
 Depression
 Anorexia nervosa
 Relapse in schizophrenia

Approaches in family therapy :


1. Psychodynamic
2. Structural Approach
3. Systemic approach
4. Electric approach

1. Psychodynamic: This approach is based on this concept that the entire family
problem arise from past experiences of each member & unconscious conflicts. The
therapist helps to gain insight that how their own problems, unconscious conflict
effect the inter relations.
2. Systemic Approach: It concentrates on the present problems rather than past
experiences. This therapy has 5-10 session with interval of month long. The
therapist arrange family interview to assess the family disagreement, ways of
communication.
3. Structural approach: The term family structure refers to the hierarchy in the family
& to a set of unspoken rules regarding task & responsibility.
Eg. Usually in every family both parents have more authority & responsibility. In
this therapy, the therapist identifies the rules which be family tension & try to
bring about changes.
Mental Health & Psychiatric Nursing 101

4. Elective family therapy: It is a short term method planned to bring about restricted
changes in the family. It also concentrates on the present situation of family & the
way of communication.

Q.23 Write a short note on activity therapy?


Ans. Activity therapy: Many patients in psychiatric hospital spend their energy in
destructive activities. For example: manic, violent patient: An activity therapy is an effort
to re-direct their energy into useful or meaningful activity. The example of activity
therapies are:

1. Occupational therapy
2. Recreational therapy
3. Play therapy
4. Biblio therapy
5. Dance– therapy
6. Art therapy
7. Education therapy

Aims of activity therapy:

1 to facilitate emotional expression.


2 To improve interaction & communication.
3 To provide outlet for aggressive feelings.
4 To release tension and pent up emotions.
5 To increase attention span and concentration power.
6 To improve cognitive skills. E.g. Learning, listening.
7 To increase self confidence and feeling of self worth.
102

1. Recreational Therapy: It is a type of divisional therapy that encourage social


interaction as well as it increase physical confidence & feeling of self worth. It
provide activities that are enjoyable & self satisfying.
2. Play therapy: Play therapy is emerged out of efforts to apply psycho dynamic
therapy to children because children are not able to talk about their problems.
They also lack the capabilities for insight & self scrutiny. Through play, children
often express their feeling, fear, and emotions providing a clear picture of their
problems. Thus it has diagnostic functions also.
3. Education therapy: Education therapy is helpful when the problems arise out of
inadequate knowledge & misconceptions. In this therapy provide enough
knowledge about the disease, its causes, and its prognosis and treatment
modalities. This therapy is centered upon both patient and her family. This
knowledge may help in eliminating the psychological problems
4. Bibilo Therapy: Biblio therapy means treatment through reading In this therapy
patient is encourages to use library facilities Sometimes reading about other
emotionally disturbed patients and experiment of other may have therapeutic
effect. It is also a diversion therapy as well as it promote and sustain mental
health.
5. Music/Dance/Art Therapy: Music/dance and any form of art promote emotional
expression. It also promotes physical integration. The art & like poetry, drama act
as catharsis (emotional release).

Q.24 Define ECT. What are the types of ECT techniques/methods, indication
contraindications, complications of ECT?
Ans. Electro Convulsive Therapy:
It is a painless form of electric therapy primarily used for patients with depression and
schizophrenic disorders.
Definition: ECT is a physical/somatic therapy in which with the help of two electrodes,
current is passed through the temporal region in between the two hemisphere of the
brain, to produce a grand mal type of seizures.
Mental Health & Psychiatric Nursing 103

Cerleti and bini are the first neuropsychiatric who used ECT in 1937.

Method/Techniques of ECT :
ECT can be given by direct or indirect method.
I. Direct ECT
ECT has been used directly on the patient. The patient is administered atropine
subcutaneously (SC) 0.6 mg to 1.0 mg, half an hour before the treatment or IV
immediately before the treatment minor tranquilizers like calmpose is also used.
A gland mal seizure is induced in the patient by passing an electric current through
the temporal lobe Atropine prolongs the period of disorientation after the seizures.
It also reduces vomiting. Immediately after The ECT treatment appropriate
resuscitative and other emergency management equipment and supplies are kept
ready A skilled person & nurse to resuscitate the patient should be available.
ECT given by this technique causes a lot of anxiety to the patient.
II. Indirect/Modified ECT : ECT is modified with the use of anesthesia, muscle
relaxant & oxygenation. Anesthesia is necessary to allay anxiety & achieve the
maximum effect, avoid compilation, modify the force of convulsion.

Placement of Electrode :
The location of electrode depends on the unilateral or bilateral ECT.
Bilaterally, ECT involves the placement of electrodes in the bitemporal
region.
To minimize post convulsive confusion & amnesia, unilateral ECT has
been devised in which electrodes are placed so as to avoid the dominant
temporal area.
104

Amount of current :
The nature and range of a stimulus intensity setting varies from device to device.
70 to 1.50 volts for .1 to 1 sec. will produce a convulsive effect.
The actual amount, range from 200-600 milliamphers

No. & frequency of ECT treatment:


5-10 treatment for bipolar disorders, manic type, schizoaffective disorder or
catatonic schizophrenia.
20 to 25 treatment may required for chronically ill schizophrenic patient.
ECT can be given 3 times a week.

Preparation of patient for ECT


1. Patient is called for ECT accompanied by his relatives.
2. Starvation of the patient for at least 5 hours is necessary. Longer starvation
is desirable
3. Informed consent of the patient & the relatives for the treatment is obtained.
The patient & the relatives are explained the risks & complications of
treatment before obtaining the consent.
Complete physical examination is absolutely necessary.

X-ray of the chest haemogram urine analysis and ECG should be given whenever
indicated.
4. Removal of denture if any is desirable
5. Mouth gag is put resting on the 3rd molar to prevent the tongue bite, cheek bite
and lip bite.
6. Physical restraints may be necessary to prevent powerful jerky movement of the
body.
7. The patient lies down comfortable on a bed in a supine position.

Observation following the ECT


Mental Health & Psychiatric Nursing 105

The patient must be observed for at least half an hour after the treatment is
given.
The production of gland mal seizure is necessary.
In direct ECT, the tonic phase i.e. muscle contraction last for 10 sec.
approximately. The clonic phase i.e. movement or convulsions last for 25-
30 sec. approximately. Then patent goes into relaxation phase.
Pulse & respiration recorded every 15 min.
The patient should be prevented from fall & injury.
If the patient become excited & rowdy IM inj. 8-10 ml of paraldehyde or
50-100 mg. if chlorpromazine or diazepam 5-10 ml have to be given to
control the patient.

Indication of ECT :
The indication of ECT depends upon the availability and non-availability of psychotropic
drugs. The common condition for ECT are :
1. Major depressive episode is primary indication – 80 90 patient.
2. Involutional melancholia – 80-90 %
3. Depression
Suicidal & stuporous patient
Endogenous depression of moderate to severe degree.
Delusional & psychotic depression
Unipolar - bipolor depression
Post partum depression
Depression of old age as long as there is no atherosclerosis & brain
changes.
4. Manic phase (mania)
1. Severe attack
2. Delirium Mania
106

3. Mania not responding to drug


4. Destructive & assaultive behaviour
5. Catatonia
6. Schizophrenia
Catatonic & paranoid type
Other type of schizophrenia not responding to other treatment
7. Schizophrenia form symptom in case of epilepsy, alcoholism & drug
addiction
8. For symptomatic treatment of confusion in cases of organic psychosis
like GPI, atherosclerotic psychosis, senile & pre-senile dementia.
9. Other responsive groups to ECT treatment.
Premorbid personality
Stupor (catatonic)
Previous depressive episode
Paranoid delusion
Anorexia
Early morning insomnia
Weight loss
Lack of concentration
Ideas of guilt & worthlessness
Note:
ECT in not effectives in
Reactive depression (Neurotic)
Psychoneurosis, hysteria, hypochondrias, anxiety states.
Schizophrenia only hebephrenic and simple
Drug dependence
Mental Health & Psychiatric Nursing 107

Contraindication
No absolute contraindication

1. Patient with increased ICP


2. Including tumors.
3. Hematomas
4. Subarachnoid hemorrhage
5. Presence of an acute MI, hypertension
6. Patient with cardiac disease, aneurysm , thrombophlebitis, bleeding disorders
embolism
7. First trimester of pregnancy
8. Disease of bone like osteomalacia, fracture
9. Systemic disease involving heart, kidney, lung & other wise versa

Complication or side effect :


Complication may be reduced with modified ECT.
Complications are few and rarely serious.
Immediately after ECT body ache, headache, painful masticatory movement to
drowsiness
1. Abrasions on the lip of tongue bite
2. Dislocations of joints like shoulder & temporomendibular.
3. Fracture of bones like spine of vertebra
4. Confusion & excitement
5. Dyspnea & Apnea
6. Cardiac irregularities including arrest

Delayed Compilations i.e. after the patient had a few ECT.


1. Amnesia for recent events.
2. Confusional psychosis
108

Impairment of memory may vary from mild tendency to forget name to sevre confusion.

Neurological & cardiac complications are very rare.

Q. Describe the role of nurse before, during & after ECT.


Ans. Role of nurse in ECT:
ECT can be administered in hospital/clinic/nursing Home.
It converts AC main supply into stimulus by using step down transformer.
In hospital setting, nurse sees the set up of ECT.
Waiting/ Resting room :
patient take rest before ECT
Room should be calm with dim light & light colour of wall.
Put some flower for pleasant feeling
Some magazines managing to divert mind & decrease anxiety
Preanaesthetic keep ready.
ECT Room :
(a) Article for patient comfort:
Room must be near to the waiting room
Bed side screen for privacy.
Well padded low level bed with railings.
(B) Article for patient preparation
Small pillow to put under patient waist to prevent injury.
Mouth gag [to prevent tongue bite & clear airway), curved tongue depressor,
Endotracheal tube sterile catheter
O2 cylinder & ambu bag.
(C) Article for the procedure:
Trolly with ECT machine in working condition
Jelly for putting electrode
Emergency drug
Mental Health & Psychiatric Nursing 109

Resuscitation tray
Mouth wipes.
B.P. apparatus, sterile syringe, spirit swab
3. Recovery Room
Observation of vital sign
Mouth wipe & toilet facilities
4. Role of nurse before ECT
Thorough physical examination
Informed consent
NBM (Nothing by mouth) before treatment
Remove metallic articles from body.
Remove lipstick, nail polish
Loosen the tight cloth
Empty bowel & bladder
Maintain personal hygiene
Give premedication, atropine, calmpose
Nurse should display a warm supportive attitude.
Take the patient to the waiting room
5. Role of nurse during ECT
Transfer the patient on a well padded bed placed in supine position.
Place tongue depressor in between teeth
Give short acting anesthetic to the patient
Support the shoulder or arm
Restraint the thigh with the help of sheet
Hyperextension of head with support to the chin give few breath of O2
(Oxygen)
110

Apply jelly on temporal region.


Make observation of grandmal seizures.

6. Role of nurse after ECT


Placed the patient on a side lying position on a railed cot.
Observe & record vital sign.
Transfer the patient to recovery room, only if he can answer a simple
question.
Observe patient condition in every 15 minute, once stabilized, then
after 30 min.
Allow the patient to take sleep for 30 minutes to 1 hour.
Reassurance to patient.
Reorient the patient to time, place & person.
Note any injury or complain of pain. Encourage patient for bath &
change cloth.
Allow patient to take breakfast.
Help the patient in ADL's (activity of daily livings).
Make observation on any change.
Mental Health & Psychiatric Nursing 111

Unit-VIII
Forensic psychiatry/legal aspects
Q.1 How a mentally ill patient get admitted in a mental hospital and how he get
discharged?
Ans. Admission and discharge of the clients in a psychiatric unit/mental hospital is
based on section 31,34 of Indian lunacy Act (ILA) 1912 later it was modified on
1st October, 1931.
Admission and discharge can be made in one of following:
1. Admission procedure on voluntary basis :
(a) For major client and desires to have admission into the mental
hospital based on his suffering:-
He will approach medical superintendent of hospital, along with two
visiting medical officers (who are appointed by state govt.) will observe
the case, at their own discretion, they can admit the case into the hospital,
provided the client has to submit the filled up performa stating that he is
interested to be admitted.
(b) For minor cases: the nearest guardian has to apply request for admission,
medical officer within 24 hours of receipt such application can admit the
case cast into the hospital.
Discharge Procedure :
(a) For major client: If he feels his condition is better, he can ask for discharge by
writing a written notice of 24 hours.
(b) For minor client: If minor attains "major" and "cured", he has to write an
application. The medical superintendent will observe and decide whether he
can be discharged or not, within a month.

2. Reception order on petition under special circumstances:


112

Admission is made, if the family members or the relatives of the patient have
to submit the request or petition for admission of the client into mental
hospital.
The petitioner must be a major and personally observed the client within 14
days of making the petition. Petition Has to be written on a special form,
denoting all the particulars of an individual which has to be supported by two
medical certificate (one form greeted govt. medical officer and other from
registered medical practitioner) Both medical officers have to be
independently examine the "alleged lunatic" at different times and within 7
days of applying for reception order and have to certify that the lunatic needs
admission and detained under care and treatment.
The medical practitioner has to be very careful in giving a certificate in order
to avoid legal complications for a wrong certification.

Discharge Procedure:
In this clause, the clients can be admitted for a period not exceeding 90 days.
If relative feels that medical officer is misusing the lunatic, he can obtain
permission from magistrate for discharge. The magistrate will verify the
condition of the client through personal inquiry and if he satisfies, thinks that
the client condition was improved, he recommends for discharge.
The petitioner has to apply to the superintendent of the mental hospital for
discharge. If the person is not dangerous and is fit to live safely, he can be
discharged.

3. Admission under temporary treatment order:


It was mentioned is MHA sections 20, 21 of 1981. When there is risk to their
own life or of others, magistrate will issue reception order. If medical officer
Mental Health & Psychiatric Nursing 113

in-charge feets that it is necessary to bring the legal authorities into the scene,
he can apply to the magistrate or relatives can approach magistrate to issue an
reception order for treatment. This order is valid for 6 months. In these cases
only one medical certificate is required.

Discharge: After recovery, if medical officer feels he can be fit to live safely
in the society, he will discharges.

4. Admission and discharge procedure through magistrate: On receipts of


petition by the relatives or the person who observed lunatic 14 days prior to
petition or if lunatic is causing harm either to himself or the other.
In these cases magistrate will inquiry in private and personally examines the
alleged lunatic. If he is satisfied he will issue reception order, if he is not
satisfies, he fixes a date for the consideration of the petition, in mean time he
carries out further inquires until then, he will order for the safe custody of
lunatic. If magistrate is not willing to issue an reception order and refuse the
petition, he will give the probable reasons in writing and a copy will make the
reception order often the medical in charge shows willingness to admit the
client and the petitioner would bear the maintenance cost.
Discharge procedure :
If he feels that client is having sound mind and capable of managing himself
and his affairs. The magistrate will obtain consent of medical officer in charge
regarding the soundness of the client to live safely in the society.
5. Admission in emergencies (immediate restraint of the insane) :
If insane is dangerous to himself or the other or likely to injure the property, he
can be lawfully kept, consent of low full guardian may be obtained.
114

If the mentally ill patient is very dangerous, and the medical officer in charge
think that patient needs hospitalization, he can admit the patient but within 72
hours. The patient need to be examined by the magistrate to produce a
reception order.

Discharge procedure
If the client condition improves, he can be able to take care and found to be
sound, he will be discharged.

6. Reception order other than petition/ Admission through police: Police


officer can arrest any person, whom he believes to be a wandering, or a
dangerous lunatic, the arrested person has to be produced before a magistrate.
Magistrate will do personal inquiry and he asks the medical officer to examine
a case. If he feels the necessity, he will admit the case into hospital. After the
reception order has been passed, the magistrate has to arrange for suitable
place for detaining the lunatic, till he is transferred to a mental hospital.
Discharge Procedure: For discharging the client, when family member or
relatives agree in writing that they will take proper care and the client is found
to be medically fit.
7. Reception order After Judicial inquisition: If a person is found lunatic after
judicial inquisition, the high court or the district court has the authority to issue
reception order to admit the case into the mental hospital.
Discharge procedure : If client is found to be medically fit and family
members agree that they will take care of client, he may be discharged.
8. Reception of criminal lunatic : A criminal lunatic has to be admitted into a
mental hospital on the order of the presiding officer or court. The criminal
lunatic are to 3 types :
Mental Health & Psychiatric Nursing 115

1. Those who suffering with unsound mind and incapable of making their
defense.
2. Those who committed the crime, but were acquitted on the ground of
unsound mind at time of committing suicide.
3. Those who contacted the disease after imprisonment.
Discharge procedure: The visitors of the hospital has to report every 6 month once about
the client's mental status and authority which has ordered detention. As soon as the client
is fit to lead normative life they have to inform about the same to authority concerned.
The person will be handed over to the prison officer for the further legal action.

Q.2 What is Indian lunatic Act (ILA 1912) ?


Ans.: It is derived from English lunacy Act, 1890, contain eight chapters. ILA extends
whole of India except Jammu and Kashmir in act no-4.

Chapter I – Terminologies
It contain some terms, preliminary conditions and its definition. Some of the terms used
are:
Asylum.
Cost maintenance
Lunatics
Criminal Lunatics
Reception order etc.

Chapter II Admission and transfer procedure


It describes voluntary admission, reception, order, through petition, admission of
dangerous lunatic or criminal lunatics, transfer of lunatics from one state to other state
with permission.
Chapter III-Board of visitors
116

State govt. will appoint board of visitors (at least 3 member’s one medical officer not
necessary to have psychiatrist. Other two may by PSW or politicians)

It also deals about the treatment of client and his discharge.

Chapter IV – The care of lunatic by family members or relatives


Court appeal by the lunatic or relatives for properties disbursement for a term not
exceeding 5 yrs.

Chapter V
Lunatic properties, court amendments for assessing, disbursement of properties
Fine of Rs.500/- will be collected by manager of lunatic appointed by court, if he
is not maintaining properly.

Chapter VI
Establishment of Asylums
Board of visitors has to conduct monthly visits and periodically they have to observe
standard diet, medical checkup, parameters etc. and report it to govt.

Chapter VII Expenses of lunatics


Asylums and state government will bear the expanses of lunatics.

Chapter VIII Rules


State govt. will formulate rules related to :
Prescribed forms for proceedings, place of detention and regulate the care and treatment
of a person detained.
Mental Health & Psychiatric Nursing 117

Q.3 Write a short on Indian mental Health Act, 1987 (IMHA, 1987) ?
Ans.: IMHA, 1987 is an amendment of Indian lunatic Act, 1912
Mental Health Act was introduced in Rajya Sabha in 1981, mental health bill no. XLI act
14 came into practice as a MHA from 22nd may 1987. Later government of India issued
order that came in force with effect from April, 1 1993 in all state and union territories of
India. It includes ten chapters. This act is applicable throughout India.

Objectives:
1. To formulate rules and regulation for the procedure related to admission and
discharge of the client in psychiatric hospital units
2. To regulate establishment & maintenance charges of psychiatric hospitals
3. To provide facilities for establishing the guardianship of mentally ill, who are
incapable of managing their own affairs.
4. Discarding custodial care, safeguarding mental patient from community and
incorporating better provision relating to treatment & care.
5. Judicial safeguard for patient right to prevent any dignity or cruelty to mentally ill.
6. Introduces humanitarian consideration
7. To establish and coordinate the central and state authorities for mental health
services.
8. To regulate the power of government for establishing, licensing and controlling
psychiatric hospitals.
Mental health act is divided in the ten chapters consisting 98 sections.

Chapter-I Terminologies (preliminary)

It deals with definitions related to mental health practice.

Mentally ill person :


A person who is in need of treatment of reasons of any mental disorder other than mental
retardation. The lunatic changed into mentally ill person.
118

Mentally ill prisoner:


Criminal lunatics changed into mentally ill prisoner.

Cost of maintenance:
A mentally ill person admitted in psychiatric hospital shall mean the cost of such items as
per state government by general and special order specify in this behalf.

Licensing authority: State govt. will appoint and authorized an inspective officers, who
will have an authority to inspect any psychiatric hospital within the state and gives license
under section 8.

Licensee: The holder of a license:

Licensed psychiatric hospital:


Psychiatric hospital will be inspected and if it is appropriate to have the psychiatric unit
facilities will be given permission to admit and treat the psychiatric cases.

Minor and major:


Minor : client below age of 18 yrs.
Major : Client above 18 yrs. Age.

Reception order: Order made provision for the admission and detention of mentally ill
persons in a psychiatric unit.

Chapter II: Mental health authority


It deals with establishment of central and state authorities for development regulation,
direction and co – ordination of mental health services.

Chapter III
It provides guidelines for establishment and maintenance of psychiatric hospital.
There is a provision of licensing authority who will process application for licenses.
Valid license has to be reviewed every 5 yrs.
Chapter IV
It describes the procedures for admission and detention of the clients in psychiatric units
Chapter V
It deals with inspection, discharge, leave of absence and removal of mentally ill person.
Chapter VI
Mental Health & Psychiatric Nursing 119

Judicial inquisition regarding alleged mentally ill persons possessing property, custody of
his persons and management of his property court may appoint guardian to look after self
and property.
Chapter VII
It deals with liability to meet the cost of maintenance of mentally ill person detained in
psychiatric hospital or nursing homes.
Chapter VIII
It aimed at protection of human right of mentally ill person. No, mentally ill
person during treatment will be subject during treatment to any indignity.
Mentally ill persons under treatment cannot be used for research purpose, Unless it
benefit him.
Consent has to be obtained either from client or from relatives for discharge.
No communication or no letter has to be sent to mentally ill cannot be read or
interpreted or detained or destroyed.
Chapter IX
It deals with penalties and procedures for establishment of maintenance of psychiatric
hospital or psychiatric nursing home.

Chapter X
It deals with provision for miscellaneous action.
It deals with clarification pertaining to certain procedure to be followed by the medical
officer incharge of the psychiatric hospital.
The Medical Officer prepares the report of hospital operations every 6 months once and
will send it to the authorities.
Incharge Medical Officer is responsible for the supply of requisites (like food, sanitation
etc) in the psychiatric hospitals,

Q.4 what are the legel responsibilities of a nurse in care of mentally sick patient?
Ans.: Legals responsibilities/legal aspect :
A psychiatric nurse have many responsibilities while caring a psychiatric patient.
She is responsible for providing quality nursing care to reduce malpractice
litigation. Quality nursing care can only be legally proved by its accurate,
complete documentation. So a psychiatric nurse has some legal responsibilities are
as following :
120

1. Collection of informed consent/substituted/consent: mentally ill patient also


have right to informed consent before any nursing intervention for e.g.: before
ECT. Concept can defense a nurse against litigation.
Informed consent means the patients should:
Have a clear and full understanding of the nature of illness to be treated.
Should agree freely to receive the treatment
Should know about the procedure available and their probable side effect.
The competent to take decisions.
When consent is refused: The consent may be refused by both competent and
incompetent patient.
Consent is refused by competent patient due to misunderstanding or fear about the
illness and treatment. For this nurse should explain once made some patient
continue to refuse the treatment.

When consent is refused by incomplete patient there is provision for a form of


proxy consent such as the application of a guardian.

Situation when consent is not required:


When death is likely to occur without intervention and there is doubt the
competency of patient
Substituted consent: In minor cases and involuntary admission and when patient is
unable to understand their surroundings, the consent is obtained from another
person or from court appointed guardian on behalf of patient.

2. To maintain confidentiality : confidentiality is particularly important in


psychiatric field become information in psychiatry is often collected about private
matters.
Confidentiality in an issue that establish trust in nurse patient relationship.
The principles related to confidentiality are :
1. The personal information must be safeguarded, records must to kept securely and
unintentional disclosure should be avoided
2. When there is need of disclosure, an informed consent should be taken for
disclosure.
Mental Health & Psychiatric Nursing 121

3. The information can be shared with the parents who have a legal duty to act in
their children's best interest
4. Patient's permission should be obtained before information in sought from
other persons.
5. Patient should know from the start that information can be shared among the
members of health care team.
6. Rules of confidentiality can be breached in following condition:
In patient's interest
In the public interest
For legal representatives
7. The patient should be told in advance about the special condition in which all
the information may be revealed such as group therapy and family therapy.
Census report
Inter department report
Special report on unusual condition of patient.
Reports on mistakes.
Reports on complaints
Evaluation on report etc.

3. Protection of patient's right :


It is the responsibility of nurse of protects the right of patients because the psychiatric
patient are unable to protect their rights by themselves. The advocacy role of nurse is
more important here than providing nursing care.
Nurse have following responsibilities regarding protection of pt's right:
1. Nurse should discuss about right of patient within treatment team
2. Nurse should ensure that ward procedure and policy does not violet patient's right.
122

3. Nurse should review periodically the mechanism that provides right


accountability.
4. Nurse should review periodically the rights & issues of violation
5. Nurse should know the right of psychiatric patient in specific condition for eg.
Involuntary patient have limited right to refuse medication:

5. To keep knowledge about right of patient :


A psychiatric nurse should have complete knowledge about the right of psychiatric
patient.
Right of psychiatric patients are :
1. The right to wear their own cloths
2. The right to see visitors everyday
3. Right to refuse ECT
4. Right to manage and dispose of property
5. Right to keep and use their own personal possessions, including toilet articles
6. Right to keep money for canteen expenses
7. Right to have ready access to letter writing material
8. Right to mail & receive unopened envelope.
9. Right to hold civil service status
10. Right to treatment in least restrictive setting.

6. Maintain standard of nursing care :


American nurses association has formulated many standards to follow and to
update her knowledge. This helps her to keep pace with the growing scientific
world.
Standard I – Theory (Appropriate & scientifically sound)
Standard II : - Data collection
Mental Health & Psychiatric Nursing 123

Standard III : - Diagnosis


Standard IV : Planning
Standard V : Intervention

a. Psychotherapeutic Intervention
b. Health Education
c. Self care activities
d. Somatic therapies
e. Therapeutic environment
f. Psychotherapy
Standard VI : Evaluation of her nursing action.
Standard VII: Peer Review
Standard VIII: Continuing Education/Action
Standard IX : Interdisciplinary collaboration
Standard X : Utilization of community health system
Standard XI : Research
124

Unit IX
Psychiatric emergencies and crises
intervention
Q.1 Define psychiatric emergencies, write the classification of psychiatric
emergencies.
Ans: Emergency: It is situation in which immediate action is essential for the survival
of system.
Psychiatric Emergency : It is explained as a disturbance is behaviour, affect and
thought (BAT) to that extent, that it needs immediate therapeutic intervention.
It is defined as a sudden onset of an unusual disorder and socially inappropriate
behaviour caused by an emotional situation.
-"Bimla Kaooor, 2002"

Classification of Psychiatric Emergency

Psychiatric Emergency

Over activity/ Underactive Suicide Others


Over excitement Patient

1. Violent 1. Depression 1. AIDS associated


2. Anxious 2. Catatonic stupor 2. Adolescent crisis
3. Drunkenness 3. Post partum psychosis
4. Drug withdrawal

Note : AIDS : Acquired immune deficiency syndrome

Q.2 How will you manage the psychiatric emergency?


Mental Health & Psychiatric Nursing 125

Ans. Nurse have to assume overall in-charge for interventions and seeks guidance from
the psychiatrist whenever necessary.
Handle the case tactfully
Provide calm & watchful environment
Emergency cases has to be shifted as early as possible where he will be
safeguarded against injury either to himself or to the others.
Protect other patient.
Encourage verbal expression of feeling.
Provision of care in meeting the client's need accordingly.
Use communication techniques
Always remain with patient.
Build trusting relationship with patient.
Talk in simple language and slow volume.
Do not threaten theater the patient but set limit on his behaviour
Remain aware of pt's right, feeling & dignity
Constant observation on patient activity
Crises intervention
Education to family and friends of patient.

Q.3 Define suicide, what are the risk factors of suicide? Classify the suicide and
how the patient with suicidal ideation be managed?
Ans. Suicide:
It is commonest psychiatric emergency
It is act of killing on self.
Patient's threats, gestures are always taken seriously.
Definition of suicide:
"Aggression towards the self following the internalization of frustration or disappointment
related to loved one".
According to Clayton
"Ultimate act of self destruction"
126

Myths about suicide:-


Suicidal threat is just a bid for attention and should not taken seriously
It is not harmful for a person to talk about suicide.
Only psychotic person commit suicide.
Nice home, good job, intact family prevent suicide.
Risk factors of suicide:
1. Psychotic disorder :
Schizophrenia
Depression
Alcoholism
2. Social Causes :
Failure in exam
Love failure
Marital disput
Social isolation
Parental separation
Family problem with substance abuse
Lack of parental & maternal care
More scholastic difficulty
Unemployment of parents
3. Medical disorder :
AIDS (Acquired Immune deficiency Syndrome)
Cancer
Estimation of lethality & degree of suicide
Mental Health & Psychiatric Nursing 127

High lethality Low lethality

Use of gun Wrist cutting

Hanging burning Hypochondriasis

Jumping from a high building, Train Inhaling domestic gas

Mild depression

Classification of suicide :
In 1951 E-mail Durkheim classified social categories of suicide:
1. Egoistic suicide: one who may lose social integration with their social group.
2. Altruistic suicide: Results from a response to a cultural expectation e.g. sathee
sahagamanam which has followed in ancient India.
3. Anomic suicide: Occurs in response to the changes occurs in individual life. For
e.g.: divorce, loss of job.
4. Sam sonic suicide of revenge:
Experiencing as being unfriendly for e.g.: if the husbands is unfaithful to his wife.
She may attempt to commit suicide to take revenge from him.

Management of suicidal patient:


"When the firstly patient come in emergency main attention to stabilize physical
conditions" then:
1. Inform psychiatrist
2. A taking psychiatric history
3. MSE
4. Past medical history of patient
128

5. Continuous survey
6. Provide calm & safe environment to the patient.
7. ECT for major depression
8. Antidepressant for OPD patient.
9. Keep strict observation to prevent repeat attempt.
Nursing management :
1. Make a treatment plan
2. Conduct suicide assessment, lethality plan
3. Engage the client in purposeful activities by diverting the mind.
4. Careful observation of client is needed in vulnerable time.
5. Provide symptomatic psychotherapeutic treatment.
6. Administer the drug, if any prescribed.
7. Report to the team members if any clues related to suicide are identified.
8. Encourage the client to develop optimistic ideas or sense of hope and self
control.
9. Motivate the client to express his repressed feelings
10. Involve the family members in provisions of care and guide them to provide
situational support.
11. All psychiatric drugs should be kept under lock
12. Patient should not left alone.
13. Constant observation on patient activity.
14. Give the patient opportunities to express feeling.
15. Remove object which might be used as a means of suicide.
16. Teach better problem solving techniques, alternative expression, sense of
achievement in personal life, decision making ability and importance of
positive self esteem.
Mental Health & Psychiatric Nursing 129

17. Encourage the client to explore his hobbies one by one, restart it
constructively.
18. Staff has to be aware of problems raised by the client.
19. If client leave ward without intimation take immediate action.
20. Discharge plan has to be made in advance, inform follow up visits.

Q.4 Define crisis, what are the types of crisis situation? Which types of techniques
used in crisis intervention and describe nurses role in crisis intervention?

Ans. Crisis: In Chinese language crises word has two meaning:


1. Danger
2. Opportunity
When people face problems which they are unable to solve by well tried defense
mechanism, a brief psychotherapeutic intervention focus on the immediate crisis can be
great assistance.
Definition:
1. According to oxford English dictionary: crisis is " A time when a problem, great
danger difficulty or uncertainty is at its worst points and needs immediate
attention.
2. Crisis in an initial disturbance that results from a stressful event or perceived
threat
3. "A sudden event that occurs in one's life, which disturbs the individual
homeostasis and usual copying mechanism, will not resolve the problem.
Classification/types of crises situation:
Crises are classified in various types:
1. Development crisis/maturational crisis/Internal crisis: Erik H Erikson divided
the whole life into eight development stages. When a person enters into next phase from
one phase he goes through many emotional and psychological changes. This transition
phase make work as a crisis for that person. For e.g.: Puberty, adolescence, adult, old,
age menopause, pregnancy, retirement etc. Maturational, crisis involves how an
individual will perceive themselves, their role and their status.
130

2. Situation crisis/External crisis/Accidental crisis: If biopsychosocial equilibrium


upsets because of external event or due to environment influence. It is sudden,
unexpected onset for example :
Death loved one
Loss of employment
An accident
Marital disput
Sexual assault
Change in living place
Severe suicidal ideation
Loss of status an acute illness
Loss of valued object
Technological changes

3. Accidental crisis adventitious/community crisis: It is most common type, also


called unexpected crisis, results in multiple loses may be because of environment changes.
For Ex.
Any Accident
Severe illness
Loss of both parents
Natural disasters
Tidal waves
Nuclear war etc.

4. Crisis resulting from traumatic stress: It results when unexpected stress


over which individual has little or no control.
For e.g.:
Rape
Robbery
Terrorism
5. Socio cultural crisis : For e.g. Discrimination between race & robbery
6. Psychiatric emergencies :
Mental Health & Psychiatric Nursing 131

For e.g.:
 Suicide
 Addicts

Techniques used in crises intervention:


Aguilera modal of crises intervention:

Human being

Stressor –––Balanced condition––– stresses

Imbalance state
Felt need was not fulfilled
To restore equilibrium

Presence of Balancing Absence of one of more balancing


Factors factor

Right perception of event Wrong perception of event

Adequate situational Inadequate situational


Support Support

Resolution of problem No resolution

Normal condition Crisis


132

Crisis Intervention: Crisis intervention is form of psychotherapy which includes


ventilation, abreaction,. Resolving the conflict. It starts with identifying the problem &
ends with helping the patient to understand the methods to solve them.

Crisis intervention is type of brief psychological method of treatment in emotional crisis.


Techniques:
1. Reassurance
2. Sedative/Hypnotics
3. Suggestion
4. Mental ventilation
5. Environmental modification
6. Behaviour modification
7. Abreaction
8. Providing support
9. Clarification
10. Manipulation
11. Raising self-esteem
12. Exploration of situation
13. Support of defenses

Role of nurse in crisis intervention: Nurse has the following role in the crisis
intervention: -
 Establish trusting relationship with patient.
 Actively listen the problem of patient and his family it is challenging but very
important skill.
 Encourage an honest disclosure, ensure confidentiality.
 Do not attempt to avoid emotional reaction such as anger or crying.
 A change in environment may serve to alleviate stress and may produce a sense of
comfort.
Mental Health & Psychiatric Nursing 133

 Support the patient in use of defense mechanism that supports an adaptive


adjustment.
 Never criticize the patient's method of coping at a time of crises.
 Be aware of crisis groups or support group in their local communities for reference
purpose.
 Use warmth, acceptance, empathy, reassurance to provide general support of
patient.
 Use various techniques of crisis intervention.
 Identify feeling of anger, guilt, and hopelessness and not to reinforce these
feelings
 Guide the patient through complete problem solving process. It may bring positive
life changes.