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Concerned with the promotion of mental health, prevention of mental disorders, and the nursing care of patients during

mental illness and rehabilitation.

Core of Psychiatric Nursing Interpersonal Process human to human relationship (NPI) where by the professional nurse practitioner uses of therapeutic Self Psychiatric Nursing as Science & Art Knowledge, Skills & Attitude (KSA) Science use of different theories in the practice of nursing Arts Therapeutic use of self Clientele in Psychiatric Nursing Individual, Family and the Community Mentally ill and Mentally Healthy Person

WHO definition: state of complete physical, mental, and social wellness, not merely absence of disease or infirmity State of emotional, psychological, and social wellness evidenced by:
Satisfying interpersonal relationships

Effective behavior and coping

A positive self-concept Emotional stability

Individual factors: Biologic make-up, autonomy, independence, self-esteem, capacity for growth, vitality, ability to find meaning in life, emotional resilience or hardiness, a sense of belonging, reality orientation, and coping or stress management abilities Interpersonal factors: Effective communication, ability to help others, intimacy, and a balance of separateness and connectedness Social/cultural factors: A sense of community, access to adequate resources, intolerance of violence, support of diversity among people, mastery of the environment, and a positive, yet realistic, view of ones world

Historically viewed as possession by demons, punishment for religious or social transgressions, weakness of will or spirit, violation of social norms Today seen as a medical problem, although some stigma from previous beliefs remains

Mental disorder is a clinically significant

behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom (APA)

Individual factors include biologic makeup, anxiety, worries and fears, a sense of disharmony in life, and a loss of meaning in ones life (Seaward, 1997) Interpersonal factors include ineffective communication, excessive dependency or withdrawal from relationships, and loss of emotional control. Social and cultural factors include lack of resources, violence, homelessness, poverty, and discrimination such as racism, classism, ageism, and sexism.

The DSM-IV-TR is a taxonomy published by APA

and used by all mental health professionals that describes all mental disorders according to specific diagnostic criteria The DSM-IV-TR is based on multiaxial classification system:
A multi-axial classification system that involves

assessment on several axes, or domains of information, allows the practitioner to identify all the factors that relate to a persons condition:

DSM-IV-TR (contd)
Axis I: Major psychiatric disorders except mental retardation and personality disorders Axis II: Mental retardation, personality disorders, maladaptive personality features, and defense mechanisms

Axis III: Current medical conditions

Axis IV: Psychosocial and environmental problems

Axis V: Global Assessment of Functioning (GAF) score

The ability to establish therapeutic relationships with clients is one of the most important skills a nurse can develop

Components include: Trust Genuine interest Empathy (not sympathy) Acceptance of person, not necessarily his or her behavior Unconditional positive regard Self-awareness and therapeutic use of self

Nurse Client Interaction Direct interaction Establishing Rapport to patient Working & Communicating to patient Nurse Patient Relationship Therapeutic nursepatient relationship, which includes four phases: orientation, identification, exploitation, and resolution

Self-awareness: process of understanding ones own values, beliefs, thoughts, feelings, attitudes, motivations, strengths, and limitations and how ones thoughts and behaviors affect others Therapeutic use of self: the nurse uses aspects of his or her personality, experience, values, feelings, intelligence, needs, coping skills, and perceptions to establish relationships with clients that are beneficial to clients

Tool that is useful in learning more about oneself is the Johari window (Luft, 1970), which creates a word portrait of a person in four areas and indicates how well that person knows himself or herself and communicates with others.

The Johari window is a self-awareness tool that categorizes qualities of self as: Open/public Blind/unaware Hidden/private Unknown

The four areas evaluated are as follows:

Quadrant 1: Open/public self: qualities one knows about oneself and others also know Quadrant 2: Blind/unaware self: qualities known only to others Quadrant 3: Hidden/private self: qualities known only to oneself Quadrant 4: Unknown: an empty quadrant to symbolize qualities as yet undiscovered by oneself or others

Social Relationship

A social relationship is primarily initiated for the purpose of friendship, socialization, companionship, or accomplishment of a task. Communication, which may be superficial, usually focuses on sharing ideas, feelings, and experiences and meets the basic need for people to interact.

Intimate Relationship

A healthy intimate relationship involves two people who are emotionally committed to each other. Both parties are concerned about having their individual needs met and helping each other to meet needs as well. The relationship may include sexual or emotional intimacy as well as sharing of mutual goals.

Therapeutic Relationship The therapeutic relationship focuses on the needs, experiences, feelings, and ideas of the client only. The nurse and client agree about the areas to work on and evaluate the outcomes. The nurse uses communication skills, personal strengths, and understanding of human behavior to interact with the client.

Therapeutic relationships are focused on the needs, experiences, feelings, and ideas of the client, not the nurse The therapeutic relationship consists of three phases:
Orientation Working Termination

ORIENTATION The orientation phase begins when the nurse and client meet and ends when the client begins to identify problems to examine. During the orientation phase, the nurse establishes roles, the purpose of meeting, and the parameters of subsequent meetings; identifies the clients problems; and clarifies expectations.

Nurse task is to:

Build trust Reads background materials available on the client Becomes familiar with any medications the client is

taking Gathers necessary paperwork Arranges for a quiet, private, comfortable setting

Outline the responsibilities of the nurse and client. both nurse and client should agree on these responsibilities in an informal or verbal contract. formal or written contract may be appropriate if a written contract has been necessary in the past with the client or if the client forgets the agreedon verbal contract.

The contract should state: Time, place, and length of sessions When sessions will terminate Who will be involved in the treatment plan (family members, health team members) Client responsibilities (arrive on time, end on time) Nurses responsibilities (arrive on time, end on time, maintain confidentiality at all times, evaluate progress with client, document sessions

Respecting the clients right to keep private any information about his or her mental and physical health and related care. The nurse must clearly state information about who will have access to client assessment data and progress evaluations. He or she should tell the client that members of the mental health team share appropriate information among themselves to provide consistent care and that only with the clients permission will they include a family member

Revealing personal information such as biographical information and personal ideas, thoughts, and feelings about oneself to clients (Deering, 1999). The nurse can use self-disclosure to convey support, educate clients, demonstrate that a clients anxiety is normal, and even facilitate emotional healing (Deering, 1999).

Divided into two sub phases

Problem identification the client identifies the issues or concerns causing problems Examination of the clients feelings and responses Exploitation (exploration) the nurse guides the client to examine feelings and responses and to develop better coping skills and a more positive self-image; this encourages behavior change and develops independence.

The specific tasks of the working phase include the following:

Maintaining the relationship Gathering more data Exploring perceptions of reality Developing positive coping mechanisms Promoting a positive self-concept Encouraging verbalization of feelings Facilitating behavior change Working through resistance Evaluating progress and redefining goals as appropriate Providing opportunities for the client to practice new behaviors Promoting independence

In the working phase, the nurse must be acutely aware of 2 common elements can arise:
Transference: when clients unconsciously transfer

feelings they have for significant persons in their life onto the nurse
Patient to nurse

Countertransference: when the nurse responds to

the client based on his or her own unconscious needs and conflicts
Nurse to patient

Begins when the clients problems are

Ends when the relationship is ended
Deals with feelings of anger or

abandonment that may occur

Inappropriate boundaries (relationship becomes social or intimate)

Feelings of sympathy and encouraging

Nonacceptance of the client as a person

because of his or her behaviors, leading to avoidance of the client Nurse self-awareness is the way to avoid such problems

the nurse may teach the client new methods of coping and


solving problems.

role in mental health settings is the implementation of the


therapeutic relationship to build trust, explore feelings, assist the client in problem solving, and help the client meet psychosocial needs.

In the advocate role, the nurse informs the client and then

Parent surrogate

supports him or her in whatever decision he or she makes (Kohnke, 1982).

nonverbal communication.

Assume the parental role as evidenced in choice of words and