Review notes some of the information is not in your
psychiatric text book.
Read chapter 2 and 3 (will have question on quiz)
 Personality is defined by the DSM-IV-TR as “enduring
patterns of perceiving, relating to, and thinking about
the environment and oneself that are exhibited in a
wide range of social and personal contexts.”
 Life-cycle developmentalists believe that people
continue to develop and change throughout life,
thereby suggesting the possibility for renewal
and growth in adults.
Theories
 Freud’s theory of psychosexual development
 Erikson’s eight development stages
 Harry Stack Sullivan’s interpersonal theory
 Mahler’s theory of object relations development
 Piaget’s cognitive development
 Kohlberg’s theory of moral development
 Nursing Peplau’s stages
Youtube site
 Mental Health Video
 http://www.youtube.com/watch?v=7H-joP-QXXo
Mental Health
 Defined as “The successful adaptation to stressors
from the internal or external environment, evidenced
by thoughts, feelings, and behaviors that are ageappropriate and congruent with local and cultural
norms.”
 Stages are identified by age. However, personality is
influenced by temperament (inborn personality
characteristics) and the environment.
 It is possible for behaviors from an unsuccessfully
completed stage to be modified and corrected in a
later stage.
Mental Illness
 Defined as “Maladaptive responses to stressors from the
internal or external environment, evidenced by thoughts,
feelings, and behaviors that are incongruent with the local
and cultural norms and interfere with the individual’s social,
occupational, or physical functioning.”
 Horwitz describes cultural influences that affect how individuals
view mental illness. These include
 Incomprehensibility – the inability of the general
population to understand the motivation behind the
behavior.
 Cultural relativity – the “normality” of behavior is determined
by the culture.
Psychological Adaptation to
Stress
 Anxiety and grief have been described as two
major, primary psychological response patterns to
stress.
 A variety of thoughts, feelings, and behaviors are
associated with each of these response patterns.
 Adaptation is determined by the extent to which
the thoughts, feelings, and behaviors interfere
with an individual’s functioning.
Anxiety
 A diffuse apprehension that is vague in nature and is
associated with feelings of uncertainty and
helplessness.
 Extremely common in our society.
 Mild anxiety is adaptive and can provide motivation
for survival.
Peplau’s four levels of anxiety
 Mild Moderate –
 Severe –
 Panic –
Behavioral Adaptation
Responses to Anxiety
 At the mild level, individuals employ various coping
mechanisms to deal with stress.
A few of these include eating, drinking, sleeping, physical
exercise, smoking, crying, laughing, and talking to persons
with whom they feel comfortable.
 Anxiety at the moderate to severe level that remains
unresolved over an extended period of time can contribute
to a number of physiological disorders – for example,
migraine headaches, IBS, and cardiac arrhythmias.
Extended periods of repressed severe anxiety can result in
psychoneurotic patterns of behaving – for example, anxiety
disorders and somatoform disorders.
Small Group Discussion
 Discuss experiences you have had in clinical were a
patient was very anxious and how this effected you in
providing care or educating the patient.
 How did you deal with the patient.
Grief
 The subjective state of emotional, physical, and social
responses to the loss of a valued entity; the loss may be
real or perceived.
 Elisabeth Kübler-Ross
(5 Stages of Grief)
Defense Mechanisms
 Compensation
 Denial
 Displacement
 Identification
 Intellectualization
 Introjection
 Isolation
 Projection
 Rationalization
 Reaction formation
 Regression
 Repression
 Sublimation
 Suppression
 Undoing
DSM-IV-TR Multiaxial Evaluation
System
 Axis I
 Axis II –
 Axis III –
 Axis IV –
 Axis V –
Psychobiology
 The 101st Congress of the U.S. designated the 1990s
as the “Decade of the Brain,” with the challenge
for studying the biological basis of behavior.
 In keeping with the neuroscientific
revolution, greater emphasis is
placed on the study of the
organic basis for psychiatric
illness.
Youtube site to review
 The Brain--Emotions, Neurons, Neurotransmitters
 http://www.youtube.com/watch?v=r71RoIkftd4
 NEURONS AND NEURO-TRANSMITTERS
 http://www.youtube.com/watch?v=DF04XPBj5uc
 Neurotransmitter Synapse 3D Animation
 http://www.youtube.com/watch?v=90cj4NX87Yk
 Synapse animation
 http://www.youtube.com/watch?v=CiZLnbKVIhM
Implications for Nursing
 Emphasis in psychiatric nursing is on a smooth
transition from a psychosocial approach to a
biopsychosocial focus
 Psychiatric nurses must have a specialized knowledge
about
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Neuroanatomy and neurophysiology
Neuronal processes
Neuroendocrinology
Circadian rhythms
Genetic influences
Psychoimmunology
Psychopharmacology
Diagnostic technology
Neurotransmitters
play an important role in human emotions and
behavior and are the target for the mechanism of
action in many psychotropic medications.
Major categories of neurotransmitters
Circadian rhythms
Follow a near-24-hour cycle in humans and may influence
a variety of regulatory functions, including the
sleep-wake cycle, body temperature regulation,
patterns of activity such as eating and drinking, and
hormone secretion.
 Some mood disorders have been linked to increased
secretion of melatonin during darkness hours.
 Symptoms that occur in the premenstrual cycle have
been linked to disruptions in biological rhythms.
Sleep-wake cycle is one of the most common biological
rhythms that demonstrates circadian influence.
Sleep stages
0 – Alpha
1 – Beta
2 – Theta
3 – Delta
4 – Delta
REM - Beta
Neurochemical influences on sleep-wake cycle
Serotonin and L-tryptophan
Norepinephrine and dopamine
GABA
Acetylcholine
Ethical and Legal Issues in
Psychiatric/Mental Health
Nursing
Definitions
 Ethics  Bioethics  Values –
 Moral behavior –
 Values clarification –
Ethical Considerations
Theoretical Perspectives
 Utilitarianism – an ethical theory that promotes actions based
on the end results that produce the most good (happiness) for
the most people
 Kantianism – suggests that decisions and actions are bound by
a sense of duty
 Christian ethics - do unto others as you would have them do
unto
you; alternatively, do not do unto others what you would not
have them do unto you.
 Natural law theories – do good and avoid evil. Evil acts are
never condoned, even if they are intended to advance the noblest
of ends.
 Ethical egoism – decisions are based on what is best for the
individual making the decision.
Ethical Dilemmas
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Ethical dilemmas occur when moral appeals can be
made for taking either of two opposing courses of
action.
Taking no action is considered an action taken.
Group Discussion
 Have you had any ethical dilemmas?
 How did you deal with them?
Avoiding Liability
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Respond to the client
Educate the client
Comply with the standard of care
Supervise care
Adhere to the nursing process
Document carefully
Follow up and evaluate
Maintain a good interpersonal
relationship with client and family
Ethical Principles
 Autonomy – This principle emphasizes the status of
persons as autonomous moral agents whose rights to
determine their destinies should always be respected.
 Beneficence – This refers to one’s duty to benefit or
promote the good of others.
Nonmaleficence – abstaining from negative acts toward another;
includes acting carefully to avoid harm
Justice – principle based on the notion of a hypothetical social
contract between free, equal, and rational persons. The concept
of justice reflects a duty to treat all individuals
equally and fairly.
Veracity – principle that refers to one’s duty to be truthful always.
A Model for Making Ethical
Decisions
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Assessment
Problem identification
Plan
Implementation
Evaluation
Ethical Issues in Psychiatric/Mental
Health Nursing
 The right to refuse medication
The right to the least restrictive treatment alternative
How do you feel about this related to Psy. patient?
Legal Considerations
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Nurse Practice Act defines the legal parameters of professional
and practical nursing.
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Types of Laws
 Statutory law
 Common law
 Civil Law – protects the private and property rights of individuals
and businesses
Tort
 Contracts
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 Criminal law – provides
protection from conduct
deemed injurious to the
public welfare
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Confidentiality and right to privacy
 Doctrine of privileged communication
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Informed consent
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Restraints and seclusion
 False imprisonment
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Commitment issues
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Voluntary admissions
Involuntary commitment
Emergency commitment
The mentally ill person in need of treatment
Involuntary outpatient commitment
The gravely disabled client
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Malpractice and negligence
Types of lawsuits that occur in psychiatric nursing
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Breach of confidentiality
Defamation of character
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Libel
Slander
Assault and battery
False imprisonment
Invasion of privacy
Questions
 True or False- A client who is admitted involuntarily
to an acute care mental health facility automatically
loses his right to informed consent for medical
procedures or treatments.
 True or False- An example of the principle of justice is
allowing a hospitalized patient to refuse to attend a
scheduled counseling session with her clear
understanding that she must accept the consequences
for not attending.
 True or False- A nurse is committing battery against a
patient by forcefully holding the patient and insisting
that he swallow a pill. The nurse tells the patient that
he will be punished if he does not do it.
 Which of the following is an example of a patient who
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requires emergency admission to a mental health
facility?
A. A patient with schizophrenia who has frequent
hallucinations
B. A patient with symptom of depression who
attempted suicide a year ago
C. A patient with psychosis who assaulted a home less
man with a metal rod
D. A patient with bipolar disease who paces quicklyl
down the sidewalk talking to himself
 A patient tells a student nurse. “Don’t tell anyone. But I
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hid a sharp knife under my mattress in order to protect
myself form my roommate, who is always yelling at me and
threatening me.” Thinking about the principles of patient
confidentiality and veracity, the student makes a correct
decision to
A. Keep the patient’s communication confidential but talk
to the patient daily, using therapeutic communication to
convince him to admit to hiding the knife
B. Keep the patient’s communication confidential, but
watch the patient and his roommate closely.
C. Tell the patient that this must be reported to health care
staff because it concerns health and safety.
D. Report the incident but do to inform the patient of
having the intention to do so
 A nurse decides to put a patient with psychosis in
scelusion overnight because the nit is very short-staff
and the patient fequejntly fights with the other
patients. This is an example
 A. Beneficence
 B. a tort
 C. A facility
 D. justice