Psych notes : review mental status exam notes before next week.
8/28/09
Class Notes
Theoretical Bases and Approaches to Care
Patricia H. Foster, Ed.D., R.N.
Associate Professor
Pre-enlightment Era
Ship of fools (sent people out in boats & drowned)

ABCs of what used to happen to psych patients…

Assistance:
Banishment: more common, drove people away, led to “bans of lunatics”, stole or

begged for survival.

Confinement: most calculated approach, but in those days mentally ill were
often chained to each other.. sometimes living to dead.
People thought mentally ill didn’t have feelings… ultimately led to reaction by Tunnell,
Dirks & Dorothy ? who began trying to treat the mentally ill…
Benchmarks in Psychiatric Care




I Period of enlightenment: near end of 18th century this began… not going to
treat people like animals. We will give them shelter & food. Punnell (France)
clothed them & fed them. Turk took care of English Quakers. Dorothea Dicks
visited the Quakers & began to change the care of mentally ill of people here in
USA. Opened a number of places. 1873 Linda Richards developed better care
for psych… First Psych nurse!
II Period of scientific study: period of time when clinicians of krephlin (biological
perspective), freud… laid framework… Bueler? Sig of this period: causes & cure of
psych illness. Led to individual & group therapies. Drug & electric therapies as well as
others.
III Period of psychotropic drugs 1950s: started 1949 John Kaden, Australian,
discovered lithium for bi polar. Thorazine to treat schizophrenia. 1958 anti-depressent
therapies…In one decade 3 types of meds were discovered. 1955, state hospitals reached
560,000 (peak). In 2004 only 50,000.
IV Period of Community Mental Health Care: Demand for reforms. Outpatient
care now possible. Problems w/ homeless populations. 1999 dept of justice 288,000
mentally ill patients in hospital.
Community Mental Health Centers Act 1963










1. Community Mental Health Centers
diagnosis
treatment
rehabilitation
2. Crisis Intervention: when a person is in crisis they need action right now…
need help w/ anxiety & coping & look for situational support. Need access.
o easy access
3. Coordination with Networks:
4. Special Populations
elderly
children
Financing: will the funds continue w/ bad economic time.
Federal Action Steps to Promote Systems Integration





1. Access Initiative
2. Improve Outreach & Access to Existing Programs
3. Expand Housing Options & Alternative Services
4. Generate & Disseminate Knowledge and Information
5. Research and evaluation
Psychiatric Nursing







1873 Linda Richards graduated from New England Hospital for Women &
Children: first psych nurse, need to deal w/ emotional needs of patients
First American psychiatric nurse
emphasis on physical & emotional needs
Somatic therapies
insulin shock 1935: not used any more
psychotherapy 1936
electroconvulsive therapy 1937: can be done inpatient and/or outpatient now.
Sometimes pts complain about short term memory loss.
John Hopkins was first school that had psych nursing.
Developments in Psychiatry

Dr. Hildegard Peplau (1952) Interpersonal Relations in Nursing : talked about the
power of interactions of nurses w/ their patients.

Maxwell Jones (1953) The Therapeutic Community: A New Treatment Method
in Psychiatry : he thought that when a person was in the hospital that setting should be
like out in the world. Patients had to vote on things w/in the hospital.
Criteria for Abnormal Behavior



Subjective Distress:
Social Deviance: alcoholism, hearing & responding to voices
Psychological Handicap: can’t function & take care of responsibilities, someone w/
OCD that has so many rituals that they can’t function (bathing over & over & over).
Psychoanalytical Model Sigmund Freud



Id (basic instincts), Ego, Superego (conscience)
Anxiety = motivator according to Freud.
All behavior is meaningful
o Conscious
o Unconscious
o Preconscious
Psychoanalytic Process (maybe chapter 3)





Free association : Freud did this…
Resistance
Dream analysis
Interpretation
Transference
Interpersonal (relationships) Model

Harry Stack Sullivan, Hildegard E. Peplau : felt that empathic comm. Is VERY
important.




Empathic communication (empathy… feels w/ the person)
Develop self esteem
Basic drives for security
Develop satisfactory relationships :
Social Model

Thomas Szaz (people are to blame for mental illness) & Gerlad Caplan
o Primary (things we do to help people such as teaching people how to be
parents by doing parenting classes… classes to take in terms of
o
preparation), secondary (acute care, often seen today in hospitals)
tertiary prevention (rehabilitation)
crisis intervention (sometimes called primary, sometimes secondary
intervention)


Patient = consumer
Therapist= active community member
Existential Model


Ellis, Frankl, Glaser, Perls, Rogers,
Frankl wrote book called “will to meaning” was in nazi concentration camp ,
delt w/ the power a person has to deal w/ what comes their way & help them to survive.



Authentic self awareness
free choice
Existential encounter
Behavior Therapy : Wolpe, Skinner

Behavior model seen a lot w/ discipline & kids,

Behavior = conditioned response
Without behavioral change = failure
Reciprocal inhibition
Assertiveness
Aversion therapy
Token economy : rewards for certain behaviors





Operant Conditioning





Positive reinforcement
Negative reinforcement
Combination of + and Extinction
Punishment
Deconditioning Methods


Assertive behavior
Desensitization (can be used for someone that has a phobia of something… crossing a
bridge, getting on an elevator)


Evoke strong anxiety
Operant conditioning
Medical Model
See a lot of this now
Treat the ill :
Avoids the blame (stigma) :
Psychiatric Nurse ANA








1. Therapeutic milieu (environment); 2. Here and now
3. Surrogate parent
4. Care for somatic problems (also do physical assessment, not just psych issues)
5. Teach (about psychotropic meds).
6. Act as a social agent
7. Leadership
8. Psychotherapy
9. Social and community action
Goals of the Nursing Interview




Establish a trusting relationship
Elicit pertinent information
Assess verbal & non-verbal behavior
Facilitate education of the client
Causes of Distorted Messages








Personal Factors:
Emotional
Physical
Intellectual
Social
Environmental Factors
physical
social
Skills to Facilitate Communication



Self-disclosure : can give info about being nursing student… not much more.
Silence : can be very therapeutic… allows pt to collect thoughts.
Touch
Mental Status Examination













General Description
Appearance
Speech
Motor Activity
Interaction during interview
Emotional State
Mood (self reporting… “what kind of mood are you in?”
Affect (emotional tone that we perceive)
Experiences
Perceptions (any hallucinations or illusions)
Thinking
Thought content (delusions)
Thought process (flight of ideas, never answers question)
o
We will be charting about these things
Sensorium and Cognition



Level of consciousness
Memory
Level of concentration & calculation
Information and intelligence


Judgment
Insight
Criteria of Mental Health






Positive attitude toward self
Growth, development & self actualization
Integration
Autonomy
Reality perception
Environmental mastery
Diagnostic & Statistical Manual of Mental Disorders DSM IV




Axis I: Clinical syndromes
Axis II: Personality disorders (antisocial, passive aggressive, borderline)
Axis III: General medical conditions (hypertension, cardio issues, pain, etc)
Axis IV: Psychosocial & environmental problems (stress, lost job)

Axis V: Global assessment of functioning (score on scale from 0 to 100), usually in
40s to 30s. They are in appendix of small Townsend book.
Discussion




Dress
Confidentiality
Concerns or fears
Splitting
Class Notes
Mental Status Examination
General Description




Appearance
Speech
Motor Activity
Interaction during interview
Emotional State


Mood
Affect
Experiences

Perceptions
Thinking


Thought content
Thought process
Sensorium and Cognition






Level of consciousness
Memory
Level of concentration & calculation
Information and intelligence
Judgment
Insight
JOIMAT : way to remember this…






J = Judgment
O = Orientation
I = Intellectual function
M = Memory
A = Appearance
T = Thought
Observations

apparent age : often will look must older than stated age, often have been through so
much stress

manner of dress : up, showered, dressed, (someone has to watch them shave, can’t
have razor w/out supervision)







cleanliness
posture :
unusual gait :
facial expressions
eye contact : is he making eye contact or not?
pupil dilation or constriction
general state of health and nutrition
Speech




rate :
volume-loud or soft
amount-minimal (paucity [no conversation, just yes or no response]), mute,
pressured (pushing, fast, rapid & pressured)
characteristics-stuttering, slurring of words or unusual accents
Motor Activity



level= lethargic, tense, restless or agitated
type= tics, grimaces, or tremors
unusual gestures or mannerisms-compulsions
Interaction during the interview




hostile, uncooperative, irritable ?
guarded, apathetic, defensive, suspicious?
seductive?
Important to document from the interview.
Mood



Self report of the emotional state and reflects the patient’s life situation
How are you feeling today?
Rate mood on a scale of 0-10
Affect





The patient’s emotional tone observed by the nurse during the interview
range
duration
intensity
appropriateness
Terms to describe affect





flat (not show much emotion)
restricted (not as flat, judgment)
blunted (
labile (changes rapidly)
incongruent with speech content (laughing while talking about the death of a
loved one)
Perceptions: Hallucinations or Illusions




Auditory
Visual
Tactile
Gustatory (taste)


Olfactory
Hallucination (seeing something not there at all) Illusion (seeing
something different than what is really there… a shape in the clouds)
Thought content

Delusions
o religious (think they are Jesus)
o somatic (has distorted body issues or think they have an illness)
o grandiose (I’m a CEO at the hospital)
o paranoid
o thought broadcasting (my thoughts are being broadcast)
o thought insertion (others are putting thoughts in my head)
Thought content descriptors





Depersonalization (feeling of unreality… not here… distance from body)
Hypochondriasis (all kinds of complaints)
Ideas of reference (that Hollywood star is singing to me)
Magical thinking
Nihilistic ideas-thoughts of nonexistence (I have no heart, it is gone or this world
no longer exits)


Obsession
Phobia
Thought process descriptors







Circumstantial (person will FINALLY get to the point)
Flight of ideas (jumps quickly from one thought to another)
Loose associations (very little connection between thoughts)
Perseveration (stay on same topic over & over… can’t change subject)
Tangential (person goes off on a tangent & never gets to the point)
Thought blocking (talking & then just stop & may or may not pick back up)
Word salad (doesn’t make any sense at all… just words)
Level of consciousness



Confused, sedated or stuporous
Orientation (oriented X 4 means situation as well as person, place & time)
Person


Place
Time
Memory




Remote-distant past
Recent-past week; past 24 hours
3 words--ask to repeat in 15 minutes
Immediate recall-repeat numbers forward or backward within 10
seconds
Concentration & calculation




Count from 1-20
2x3 or 21+7
serially subtract 7 from 100
"How many nickels are there in $1.35?"
Ability to conceptualize & abstract
(typically people w/ schizophrenia often are so concrete that they can’t understand abstract
concepts)





When it rains, it pours.
A stitch in time saves nine.
A rolling stone gathers no moss.
The proof of the pudding is in the eating.
People who live in glass houses shouldn’t throw stones.
Ability to abstract -- list similarities between objects



Bicycle and bus
Apple and pear
Television and newspaper
General knowledge



Last five presidents
Who is the Mayor?
Give the occupation of a well-known person
Judgment




What would you do if you found a stamped, self addressed envelope on
the ground?
How would you find your way out of a forest in the daytime?
What would you do if you entered your house and smelled gas?
If you won $10,000 what would you do with it?
Insight




Does person accept or deny illness?
Does the patient blame the problem on someone else or external
factors?
What does the patient think the nurse has been told?
What does the patient want the staff to do?