The Biopsychosocial Context 0f

Psychiatric Nursing Care

Ns. Heni Dwi Windarwati, M.Kep.Sp.Kep.J
Biological context of
psychiatric nursing care
 Bio context-the brain

The Cerebrum- conscious

perception, abstract
reasoning, and thinking

4 lobes:
Frontal-speech & motor
function
Temporal-auditory
processing & language
Parietal-sensory function
Occipital-visual function
 The brain cont.

The cerebellum-
equilibrium, muscle
tone, balance,
posture.
 Limbic system

Forms the border of

temporal lobes

Associated with
emotional subjective
states, fight or flight
reactions, and
memory.
 Brain cont.

Thalamus
influences mood and
affect

Hypothalamus-
temperature
regulation, endocrine
function, feeding &
drinking behavior
Brain cont.

Brainstem
Pons-reflex center
Medulla-breathing,
HR, swallowing,
Reticular formation-
core of brainstem-
involved with
consciousness & the
sleep-wake cycle.
 Neurotransmission

Process by which
neurons communicate
with each other
through electrical
impulses and
chemical
messengers.

We all have about

100 billion brain cells.
Neurotransmitters

Are released from the

axon into the
synapse, then
received by the
dendrite of the next
neuron.
Neurotransmitters cont.

Serotonin-5HT ( 5
hydroxytryptophan)
derived from a dietary
amino acid. Located
only in the brainstem.
Plays a role in mood
and activities of the
CNS. Plays a role in
anxiety disorders.
Antidepressants block
its uptake.
Neuroimaging techniques

Measure activity, function,

and blood flow & allow for
visualization of the brain
CT- computed tomography
MRI- magnetic resonance
imaging
PET-positron emission
tomography
SPECT-single photon
emission computed
tomography
Biological rhythm

Circadian rhythm- is a
network of internal clocks
in the body that work
according to a 24-hour
cycle.
Sunlight is the time cue
from the external
environment that resets
our clock.
The hypothalamus is the
internal timekeeper.
Sleep

5 stages:
Stage 1-falling
asleep
Stage 2- sleep itself
Stages 3 & 4- delta
sleep or deep sleep
Stage 5- REM sleep
occupies 25% of sleep
time
Psychoneuroimmunology

Explores the interactions

between the CNS & the
endocrine, and immune
system.

Research indicates
increased susceptibility to
illness following sleep
deprivation, depression,
and death of a spouse.

Also NK (natural killer) cells

decrease in # with
increased levels of stress.
Genetics

The search for genes that

cause mental illness has
been inconclusive but
has stimulated scientific,
political, and clinical
debate.

Currently based on
studies based on
inheritance such as
family, twin, & adoption
studies.
Proposed uses of genetics in psychiatry

Developing new drugs that will target

molecular regulators of gene expressions in
brain regions shown to be abnormal in a
psychiatric illness.

Conducting gene therapy to treat psychiatric

illness.

Implementing studies that use cloned genes

in research procedures in psychiatry.
 Biological assessment of the patient
Includes:
Screening patients for
the major signs of
physical or organic
disorders that may
complicate a patients
psychiatric status.
A complete health care
history and lifestyle
review
Physical exam & labs
Psychological context of
psychiatric nursing care
Psychological context of psychiatric nursing
care

The Mental Status

Exam-nurses
observation of the
patients current state;
not past or present
state.
 What it is it?
The Mental Status Exam (MSE) is the
psychological equivalent of a physical exam
that describes the mental state and
behaviors of the person being seen. It
includes both objective observations of the
clinician and subjective descriptions given
by the patient.
 Why do we do them?
The MSE provides information for diagnosis and
assessment of disorder and response to treatment.
A Mental Status Exam provides a snap shot at a
point in time
If another provider sees your patient it allows them
to determine if the patients status has changed
without previously seeing the patient
 To properly assess the MSE information about
the patients history is needed including
education, cultural and social factors

It is important to ascertain what is normal for

the patient. For example some people always
speak fast!
 Components of the Mental Status Exam

Appearance
Behavior
Speech
Mood
Affect
Thought process
Thought content
Cognition
Insight/Judgment
Appearance: What do you see?
Build, posture, dress, grooming,
prominent physical abnormalities
Level of alertness: Somnolent, alert
Emotional facial expression
Attitude toward the examiner:
Cooperative, uncooperative
 Behavior
Eye contact: ex. poor, good, piercing
Psychomotor activity: ex. retardation or
agitation i.e.. hand wringing
Movements: tremor, abnormal movements
i.e.. sterotypies, gait
 Speech
Rate: increased/pressured,
decreased/monosyllabic, latency
Rhythm: articulation, prosody, dysarthria,
monotone, slurred
Volume: loud, soft, mute
Content: fluent, loquacious, paucity,
impoverished
 Mood
The prevalent emotional state the
patient tells you they feel
Often placed in quotes since it is
what the patient tells you
Examples Fantastic, elated,
depressed, anxious, sad, angry,
irritable, good
 Affect
The emotional state we observe
Type: euthymic (normal mood), dysphoric
(depressed, irritable, angry), euphoric (elevated,
elated) anxious
Range: full (normal) vs. restricted, blunted or flat,
labile
Congruency: does it match the mood-(mood
congruent vs. mood incongruent)
Stability: stable vs. labile
 Thought Process
Describes the rate of thoughts, how they flow
and are connected.
Normal: tight, logical and linear, coherent and
goal directed
Abnormal: associations are not clear,
organized, coherent. Examples include
circumstantial, tangential, loose, flight of ideas,
word salad, clanging, thought blocking.
Thought Process: examples
Circumstantial: provide unnecessary detail
but eventually get to the point
Tangential: Move from thought to thought
that relate in some way but never get to the
point
Loose: Illogical shifting between unrelated
topics
 Flight of ideas: Quickly moving from one idea to
another- see with mania
Thought blocking: thoughts are interrupted
Perseveration: Repetition of words, phrases or
ideas
Word Salad: Randomly spoken words
 Thought Content
Refers to the themes that occupy the patients
thoughts and perceptual disturbances

Examples include preoccupations, illusions,

ideas of reference, hallucinations,
derealization, depersonalization, delusions
 Thought Content: examples
Preoccupations: Suicidal or homicidal
ideation (SI or HI), perseverations,
obsessions or compulsions
Illusions: Misinterpretations of environment
Ideas of Reference (IOR): Misinterpretation
of incidents and events in the outside world
having direct personal reference to the
patient
 Hallucinations: False sensory perceptions.
Can be auditory (AH), visual (VH), tactile or
olfactory

Derealization: Feelings the outer

environment feels unreal

Depersonalization: Sensation of unreality

concerning oneself or parts of oneself
 Delusions: Fixed, false beliefs firmly held in spite of
contradictory evidence
Control: outside forces are controlling actions
Erotomanic: a person, usually of higher status, is in love with the
patient
Grandiose: inflated sense of self-worth, power or wealth
Somatic: patient has a physical defect
Reference: unrelated events apply to them
Persecutory: others are trying to cause harm
 Cognition
Level of consciousness
Attention and concentration: the ability to focus,
sustain and appropriately shift mental attention
Memory: immediate, short and long term
Abstraction: proverb interpretation
Mini-Mental State Exam
Folstein Mini-Mental State Exam
30 item screening tool
Useful for documenting serial cognitive
changes an cognitive impairment
Document not only the total score but
what items were missed on the MMSE
 Insighdt/Jugment
Insight: awareness of ones own illness
and/or situation
Judgment: the ability to anticipate the
consequences of ones behavior and make
decisions to safeguard your well being and
that of others
 SP
Psychological tests

2 types;
Evaluation of
intellectual &
cognitive ability

Evaluation of
personality
functioning
(projective tests)
 Personality tests

Rorschach test
Thematic
Apperception Test
(TAT)
Minnesota
Multiphasic
Personality Inventory
(MMPI)
 Thematic Apperception Test

Person tells a story

about a series of
pictures.
What has led up to
the event.
Whats happening at
the moment.
What the characters
are feeling.
What the outcome is.
 Behavioral rating scales

Standardized scale
Gather a number of
measurable
behavioral indicators
of the patients
adaptive and
maladaptive
responses.
Social, cultural and spiritual
context of psychiatric nursing
care
 Cultural competence

Implies cultural
awareness.

The ability to view

each patient as a
unique individual.
Functions of culture

Creates a perception
of reality
Motives for behavior
Identity
Values
Communication
Emotions
Sociocultural risk factors &
protective factors
Age
Ethnicity
Gender
Education
Income
Beliefs
 Gender

Being female can

increase the risk of
depression in women.

Being male is
associated with
increased risk of
suicide.
 Age

Depressed elderly
patients tend to
recover more quickly
than younger age
groups.
 Ethnicity
Includes a persons racial, tribal,
linguistic, and cultural origin or
background.
Each cultural group has its own
custom, beliefs, and traditions.
Influences the development and
recovery from psychiatric disorders.
 Research on ethnicity

Members of ethnic
groups are admitted
to psychiatric
institutions 3 times
more than the general
population (Shin
2002)
Asians have low
admission to rates to
state hospitals.
Research cont.

Members of minorities
have difficulty gaining
access to mental
health services.
(Hough et al.,2002,)
Latino youths are less
likely than white
youths to use
specialty mental
health services.
 Education

Education is more important than

income in determining the use of
mental health services. Patients with
less education are less likely to seek
psychiatric care and are more at risk
for dropping out of treatment.
Income

The impact of all

other risk factors are
multiplied by poverty.
Higher prevalence of
poverty rates are
consistently found
among women, the
elderly, and ethnic
and racial minorities.
(Alegria, 2002)
 Questions to facilitate cultural
competency

What labels am I subconsciously applying to this

patient and how did I learn them?
What socioeconomic status am I assuming for the
patient, and what are my assumptions about that
socioeconomic level?
What other explanations might account for the
patients behavior.
 Sociocultural Stressors
Disadvantagement: the lack of socioeconomic
resources that are basic to biopsychosocial
adaptation.
Stereotype: a depersonalized conception of
individuals within in group.
Discrimination: differential treatment of individuals
not based on actual merit.
Racism: the belief that inherent differences among
races determine individual achievement and than
one race is superior.
 Therapeutic nurse-patient
interactions
Sociocultural differences
can be a source of
misunderstanding by the
nurse and resistance by
the patient.

Healthy recognition of
nurse-patient
sociocultural differences
can enrich the health care
experience for both the
nurse and the patient.
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