BASIC CONCEPTS IN PSYCHIATRIC NURSING

MENTAL HEALTH

 Balance in a persons' internal life and adaptation to reality

 A state of well being in which a person is able to realize his potentials

Characteristics:

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

MENTAL ILLNESS

 A state of imbalance characterized by a disturbance in a persons' thoughts, feelings and

behavior
 Poverty and abuses are major factors which increases the risk of mental illness in the home

PSYCHIATRIC NURSING

Interpersonal process whereby the professional nurse practitioner through the use of self, assist an
individual family, group or community to promote mental health, to prevent mental illness and
suffering, to participate in the treatment and rehabilitation of the mentally ill and if necessary to find
meaning in these experiences

It is both Science and an Art.

Science in Psychiatric Nursing.

the use of different theories in the practice of nursing

serves as the science of psychiatric nursing

Art in Psychiatric Nursing.

The therapeutic use of self is considered as the art of

psychiatric nursing

Core of Psychiatric Nursing.

The interpersonal process, that is, the human to human

relationship, is the core of psychiatric nursing.

Clientele in Psychiatric Nursing.

The individual, family, and the community, both mentally

healthy and mentally ill

Mental Hygiene.

It is the science that deals with measures to promote

mental health, prevent mental illness and suffering and

facilitate rehabilitation.

THERAPEUTIC USE OF SELF

-THERAPEUTIC USE OF SELF SERVES AS THE NURSES' MAIN

TOOL

CORE CONCEPT

-It is the positive use of one's self in the process of therapy

- It requires self-awareness.

BASIS OF THERAPEUTIC USE OF SELF

JOHARI WINDOW

METHODS USE TO INCREASE SELF AWARENESS

INTROSPECTION

DISCUSSION

ENLARGING ONE'S EXPERIENCE

ROLE PLAY

CORE CONCEPTS IN THE CARE OF PSYCHOTIC

PATIENT.

COMMON BEHAVIORAL SIGNS AND SYMPTOMS

1 Disturbances in perception:

lusion-misperception of an actual extemal stimuli

Hallucination-false sensory perception in the absence of extemal

stimuli

2 Disturbances in thinking

Neologism - pathological coining of new words

Circumstantiality-over inclusion of details.

Word salad-incoherent mixture of words and phrases.

Verbigeration-meaning less repetition of words or phrases

Perseveration-persistence of a response despite absence of

stimulus/ inability to shift actions despite new settings

Echolalia -pathological repetition of words of others

Flight of ideas-shifting of one topic form one subject to another in a

somewhat related way

Looseness of association-shifting of a topic from one subject to

another in a completely unrelated way

Clang association-the sound of the words gives direction to the flow

of thought

Delusion-false belief which is inconsistent with one's knowledge and

culture and cannot be corrected by reasons

3. Disturbances of affect

Inappropriate affect-disharmony between the stimuli and the

emotional reaction

Flat affect-absence or near absence of emotional reaction

Apathy-dulled emotional tone

Blunted affect-severe reduction in emotional reaction

Ambivalence- presence of two opposing feelings

Depersonalization-feeling of strangeness towards one's self

Derealization- feeling of strangeness towards the environment

4. Disturbances in motor activity

Echopraxia-the pathological imitation of posture/action of others

Waxy flexibility-maintaining the desired position for long periods of

time without discomfort

5. Disturbances in memory

Confabulation-filling in memory gap

Amnesia -inability to recall past events

Anterograde amnesia- loss memory of the immediate past

Retrograde am nesia -loss of memory of the distant past

Déjà vu- feeling of having been to place which one has not yet

visited.

Jamais vu-feeling of not having been to a place which one has

visited.

CORE CONCEPTS ON THERAPEUTIC

COMMUNICATION

Communication -refers to the reciprocal exchange of ideas between

or among persons

Elements of Communication:

Sender-originator of information.

Message-information being transmitted

Receiver -recipient of information

Channel-mode of communication

Feedback- return response

Context-the setting of communication.

Criterla of successful communication:

Feedback

Appropriateness

Flexibility

Efficiency

Common problems in communication

Dysfunctional communication (perception, interpretation,social

isolation)

Double blind communication (conflicting messages)

Differences between the denotative and connotative meaning

Incongruent communication (conflict bet. Verbal&non-verbal)

Common techniques in communication

To initiate conversation
-Giving broad opening: giving the patient an opportunity to set the

direction of the conversation

Example "Is there anything that you want to talk about?"

-Giving recognition: focusing on the positive aspects of the patients

personality

Example: "I noticed that you combed your hair today."

To establish rapport and build trust

-Giving information: responding with the needed facts

Use of silence: refraining from speech to give the patient a time to

sort out thoughts and feelings

To gather information

-Focusing: assisting a patient to explore a specific topic.

Example: Patient 1 can't decide about.

Nurse: Let's tak about that Perhaps d we ta

about t,

will help you to decide.

Validating confirming one's observation.

Example: "Are you saying that...

- Reflecting: directing back ideas, feelings and content

Example: You feel tense when you fight

- Restating: repeating what the patent had said.

-Summarizing: developing a concise resume of what has transpired

NURSE PATIENT RELATIONSHIP

-Series of interaction between the nurse and patient in which the

nurse assist the patient to attain positive behavioral change

CHARACTERISTICS

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

time limited and professional

BASIC ELEMENTS
Trust

Rapport

Unconditional positive regard

Setting limits

Therapeutic communication

PHASES

A.PRE-INTERACTION PHASE

Begins when the nurse is assigned to a patient.

Phase of NPR in which the patient is excluded as an active

participant

Nurse feels certain degree of anxiety

Includes all of what the nurse thinks and does before interacting with

the patient

Major task of the nurse: develop self awareness

Dala gathering. planning for first interaction

B.ORIENTATION PHASE

Begins when the nurse and the patients interacts for the first time

Parameters of the relationship are laid

Nurse begins to know about the patient

Major task of the nurse: develop a mutually acceptable contract

Determine why the patient sought help

Establish rapport, develop trust, assessment

C.WORKING PHASE

It is highly individualized

More structured than the orientation phase

The longest and most productive phase of the NPR

Limit setting is employed

Major task: Identification and resolution of the patient's problems

Planning and implementation

D.TERMINATION PHASE

It is a gradual weaning process

It is a mutual agreement

It involves feelings of anxiety

It should be recognized in the orientation phase

Major task: to assist the patient to review what he has learned and

transfer his learning to his relationship with others

Evaluation

When to Terminate?

When goals have been accomplished

When the patient is emotionally stable

When the patient exhibits greater independence

When the patient able to cope with anxiety separation, fear and loss

How to Terminate?

Gradually decreased interaction time

Focus on future oriented topics

Encourage expression of feelings

Make the necessary.referral

COMMON PROBLEMS AFFECTING COMMUNICATION

Transference -the development of an emotional attitude of the

patient either positive or negative towards the nurse

Resistance -development of ambivalent feeling towards self-

exploration

Counter transference-transference as experienced by the nurse

PRINCIPLES OF CARE IN PSYCHIATRIC SETTINGS

The nurse views the patient as a Holistic human being with

interdependent and interrelated needs

The nurse accepts the patient as a unique human being with inherent

value and worth exactly as he is

The nurse should focus on the patient's behavior non-judgmentally

while assisting the patient to learn more adaptive ways of coping

The nurse should explore the patient's behavior for the need it is

designed to meet and the message it is communicating

The nurse has the potential for establishing a nurse-patient

relationship with most if not all patients

The quality of the nurse-patient relationship deternmines the degree of

change that can occur in the patient's behavior

LEVELS OF INTERVENTIONS IN PSYCHIATRIC NURSING

Primary-interventions aimed at the promotion of mental health and

lowering the rate of cases by altering the stressors

Examples: Health education

Information dissemination

Counseling

Secondary-Intervention that limit the severity of a disorder

Two components

1. Case finding

2. Prompt treatment

Examples: Crisis intervention

Administration of medications

Tertiary-interventions aimed at reducing the disability after a disorder

Two components

1. Prevention of complication

2.Active program of rehabilitation

Examples: Alcoholic anonymous

Occupational therapy

CHARACTERISTICS OF A PSYCHIATRIC NURSE

Empathy-the ability to see beyond outward behavior and sense

accurately another persons' inner experiencing

Genuineness/Congruence-ability to use therapeutic tools

appropriately

Unconditional positive regard-RESPECT

ROLES OF THE NURSE IN PSYCHIATRIC SETTINGS

Ward manager-creates a therapeutic environment

Socializing agent- assists the patient to feel comfortable with others

Counselor-listens to the patient's verbalizations

Parent surrogate- assists the patient in the performance of activities

of daily lining

Patient advocate-enables the patient and his relatives to know their

rights and responsibilities

Teacher- assists the patient to learn more adaptive ways of coping

Technician- facilitates the performance of nursing procedures

Therapist-explores the patient's needs, problems and concerns

through varied therapeutic means

Reality base-enables the patient to distinguish objective reality and

subjective reality

Healthy role model-acts as a symbol of health by serving as an

example of healthful livings

BASIC CONCEPTS ON PSYCHOPHARMACOLOGY

C-heck why the medication is given and know the classification of the

drug. In other words you should know the purpose why the medication is

given.

H-ow will you know if the medication is effective. What is your

assessment parameters in monitoring the effects of the drug

E-xactly what time should the medication be given. Some drugs are

best taken with meals, some after meals, and some on an empty

stomach Other drugs may also be taken without regard to meals.

You should know all of these

C-lient teaching tips. What would you tell your patient to expect You

should be able to give instructions related to the therapeutic and

side effects of the drug

K-eys to giving it safely. You should be able to identify interventions to

counteract the adverse/side effects of the drug

Psychopharmacolgic agents

A.Major tranquilizers/antipsychotic/neuroleptics

Common indication : Schizophrenia

Examples:

Haloperidol (Haldol)

Prochlorperazine (Compazine)

Fluphenazine (Prolixin)

Chlorpromazine (Thorazine)

Clozapine (Clozaril)

Olanzapine (Zyprexa)

C-Antipsychotic

H-Decreased delusions, hallucinations, and looseness of association

E-Best taken after meals

C-Report sorethroat and avoid exposure to sunlight. Report elevated

temp and muscle rigidity it indicate Neurologic Malignant Syndrame

K-check the BP, the drug causes hypotension. Observe for EPS,

check the CBC, drygs cause leukopenia

B.Anti-parkinsonian drugs

Indication: EPS (Extrapyramidal Syndrome)

Two Types:

1. DOPAMINERGIC DRUGS

Examples: Amantadine (Symmetrel)

Levodopa

Levodopa-Carbidopa (Sinemet)
2 ANTICHOLINERGIC DRUGS

Examples: Trihexylphenidyl (Artane)

Biperiden Hydrochloride (Akineton)

Benztropine Mesylate (Cogentin)

Diphenhydramine Hydrochloride (Benadryl)

C-Antiparkinsonian drug

H-Muscles become less stiff, decreased pill-rolling tremors

E-Best taken after meals

C-Avoid driving, the drug causes blurred vision

K-Check the BP the drug may .cause hypotension

C.Minor Tranquilizers/Anxiolytics

Common indication: Anxiety disorders

Examples: Diazepam (Valium)

Oxazepam (Serax)

Chlodiazepoxide (Librium)

Chlorazepate Dipotassium (Tranxene)

Alprazolam (Xanax)

C-Antianxiety, given as muscle relaxant to patient's in traction

H-Decreased anxiety, adequate sleep

E-Best taken before meals, food in the stomach delays absorption

C-Avoid driving, intake of alcohol and caffeine containing foods,

since it alters the effect of drug

K-Administer it separately, it is incompatible with any drug

D.Tricyclic Antidepressants

Examples: Imipramine Hydrochloride (Tofranil)

Amitriptyline (Elavil)

C Tocyclic anti-depressant prevents the reuptake of norepinephone

H-Increased appetite, adequate sleep

E-Best given after meals

C-Therapeutic effects may become evident only after 2-3 weeks of

intake

K-Check BP, it causes hypotension,Check the heart rate, it causes

cardiac arrythmias

E. Antidepressant MAO inhibitors

Examples: Tranylcypromine (Pamate)

Phenelzine (Nadril)

Isocarboxazid (Marplan)

C-Antidepressant MAO inhibitors

H-Increased appetite; adequate sleep

E-Best taken after meals

C-Report headache, it indicates hypertensive crisis, avoid tyramine

containing foods like:

Avocado

Banana

Cheddarand aged.cheese

Soy sauce and preserved foods

It takes 2-3 weeks before initial therapeutic effects become

noticeable

K-Monitor BP, There shoulb be at least a two week interval when

shifting from one antidepressant to another

F.Anti-Manic agent

Lithium Carbonate

C-Anti- Manic

H-Decreased hyperactivity

E-Best taken after meals

C-Increase fluid intake (3L/ day) and sodium intake (3 gm/ day)

Avoid activities that increase perspiration

K-It takes 10-14 days before therapeutic effect becomes evident

Antipsychotic is administered during the first two weeks to

manage the acute symptoms of mania until lithium takes effect

Monitor serum level, normal is 0.5-1.2meq/L, NAUSEA, ANOREXIA

VOMITING, DIARRHEA, AND ABDOMINAL CRAMPS Indicates

Lithium Toxicity

ELECTRO-CONVULSIVE THERAPY

Mechanism of action: Unclear at present.

Voltage applied to the patient: 70-150 volts

Duration of application: 05-2 seconds

Usual number of treatments to produce

therapeutic effect: 6-12 treatments

Frequency of treatments: An interval of 48 hours for each treatment

Indications of effectiveness: Generalized tonic-clonic seizure

Indication for ECT: Depression, Mania, Catatonic Schizophrenia

Contraindication to ECT: Fever, Increased ICP, Cardiac problems

TB with history of hemorrhage, Recent fracture, Retinal detachment,

Pregnancy

Consent needed prior to ECT: YES

Medication prior to ECT

Atropine Sulfate-to decrease secretions

Anectine (Succinylcholine)-to promote muscle relaxation

Methohexital Sodium (Brevital)-serve as an anesthetic agent

COMMON COMPLICATION LOss off memory, Headache, Apnea,

Fracture, Respiratory depression.

COMMON PSYCHOTHERAPEUTIC INTERVENTIONS

REMOTIVATION THERAPY-treatment modalitythat promotes

Expression of feeling through interaction facilitated by discussion of

neutral topics

5 Different Steps
1. Climate of acceptance

2. Creating of bridge of reality

3.Sharing the world we live in

4. Appreciation of the works of the world

5 Climate of appreciation

MUSIC THERAPY-involves the use of music to facilitate relaxation,

expression of feelings and outlet of tension

PLAY THERAPY-treatment modality which enables the patient to

experience intense emotion in a safe environment with the use of play

GROUP THERAPY-treatment modality involving therapeutic

interactions of three or more patients with a therapist to relieve

emotional difficulties increase self-esteem develop insight and

improve behavior in relation with others. The minimum number of

members in a group therapy is 3, while the ideal number is 8-10

MILIEU THERAPY-Consists of treatment by means of controlled

modification of the patients environment to facilitate positive behavioral

change

FAMILY THERAPY-a method of psychotherapy which focuses on

the total family as an interactional system.

PSYCHOANALYSIS

the exploration of the unconscious, to facilitate identification of the

patient's defenses

HYPNOTHERAPY- a therapeutic modality which involves various

methods and techniques to includes a trance state where the patient

becomes submissive to instructions

- a method of psychotherapy which focuses on

HUMOR THERAPY -involves the use of humor to facilitate

expression of feelings and to enhance interaction.

BEHAVIOR MODIFICATION-a therapeutic intervention involving the

application of learning principles in order to change maladaptive

behavior

AVERSION THERAPY-an example of behavior modification in which

a painful stimulus is introduced to bring about an avoidance of another

stimulus with the end view of facilitating change in behavior

TOKEN-ECONOMY

which utilizes the principle of rewarding desired behavior to facilitate

change

DESENSITIZATION-periodic exposure of the individual to a feared

object, until the undesirable behavior disappears or is lessened.

COGNITIVE THERAPY-short term structured therapy between the

patient and the therapist oriented towards present problems and

solutions. The main focus of cognitive therapy is depressive disorders