Psychiatric Nursing
Nurse-Client Relationship - (2way)
 Series of interactions between the nurse and the client.
GOAL: Positive Behavioral Change
Questions:
When does Therapeutic Relationship meet - TRUST
Tool of the Nurse : SELF - Self Awareness
Transference : Patient relates to the Nurse (NORMAL)
Counter Transference : Nurse relate to the Patient (ABNORMAL)
Elements of Therapeutic Relationship
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Trust
Rapport
Unconditional Positive Regard
Set Limit
Therapeutic Use of Self
When is Trust establish? - When patient start sharing
Therapeutic Behaviors:
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Genuineness – sincerity and honesty
Concreteness – ability to identify the clients feeling
Respect – Consideration that a patient is a unique being
Phases of Therapeutic Relationship (4 phases)
1. Pre-interaction/ Pre-orientation
 no contact with the client, data are form secondary source ( Chart, journals,
books, internet)
2. Interaction / Orientation
 establish trust, assess the client mutual agreement (Contract) - informing
about TERMINATION
3. Working – Longest phase (achieving goals and sharing facts
 resolve the problems (PREPARATION FOR TERMINATION)
4. Termination – (Last Phase) moving towards independence
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observe for regressive behaviors - (s/s coming back)
Therapeutic Communication (dynamic process of Exchanging Information)
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Compose of Verbal and Non-verbal
Elements of Therapeutic Communication:
1. Sender – encoder or source of the message
2. Message – actual information
3. Receiver – decoder or recipient of the message
4. Feedback – receiver’s response
***BARRIERS- Inhibits the communication process; ex. Noise, age, slow net
Verbal and Non-verbal Communication
(Non-verbal)
1. Proxemics – physical space or distance between nurse (s) and client (r)
- (3-6 ft or 1 arm and half)
2. Kinetics – body movements such as gesture, facial expression, mannerism
- enhance credibility of the message
3. Touch – an intimate physical contact – invasive (need CONSENT)
4. Silence – encourages the patient to talk
5. Paralanguage – Voice quality (tone, inflection) how the message delivers.
(Verbal Communication)- Use TheraComm Techniques
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(Therapeutic, appropriate, concise, simple, adaptive, credible)
1. Offering self – Let me sit here with you for 5 minutes
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Specific
Measurable
Attainable
Realistic
Time bounded
2. Active Listening - ―ah huh‖, yes, no
3. Exploring – ex. You said Hannah was the best, Can you describe her?
4. Broad Opening – where would you like to begin?
5. Making Observations – ―I noticed you have combed your hair today‖
6. Summarizing – In the past 15 minutes, we have talked about…
7. Encouraging description of perception – ―What are the voices telling you‖
8. Presenting Reality – common in patient with illusion or hallucination
9. Reflecting – ibalik ang tanung sa patient
10. Restating – ex. Patient : I am down
Nurse : Are you depressed?
11. General Leads – Go on…
12. Focusing – Let us look at it more closely
Non-Therapeutic Communication : Common pitfalls
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Giving advise
Talking about self
Telling the client is wrong
False reassurance
Asking why; (demanding) -- except suicidal threatening
Spheres
1. ID – pleasure principle, irrational, pleasure seeking
2. EGO – reality base, balance
3. SUPEREGO – conscience, ego ideal, guilt feeling
Defense Mechanism
1. Repression – Unconsciously forgetting (di sadya)
2. Suppression – Consciously forgetting (sadya)
3. Reaction Formation – Acting opposite how you truly feel (plastic)
4. Rationalization – reasoning out
5. Introjection – blaming self / getting others personality
6. Projection – blaming others (verbal)
7. Displacement – Blaming of others w/ actions (object, person, animal)
8. Compensation – small goals to big goals (going up) - achieve in other area
(ex. Weak in nursing but good in engineering)
9. Denial – Unacceptance of the truth
10. Regression – going back to early stage of development
11. Undoing – Doing something to relieve one’s guilt.
12. Conversion – Anxiety becomes physical symptoms. (stomach ache during exam)
13. Intellectualization – making excuses with detailed explanation to subject matter
14. Substitution – (High to low) replace unattained goal to smaller goal.
15. Sublimation – Unacceptable to acceptable behavior
16. Identification – idolization ( certain character)
Crisis -- 3 Classes
1. Maturation / Developmental
2. Situational
3. Adventitious / Social
Maturational – Expected, Normal part of life
Situational – Unexpected, Sudden
Adventitious / Social – Calamities, Social involvement, disaster
Stages of Death
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2.
3.
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Denial – Unacceptance, Shock / Disbelief
Anger – Projection / Introjection
Bargaining – Bargain
Depression – Suicidal tendencies
Acceptance – Final stage
Disturbances in Appearance
1. Automatism – Repeated purposeless behavior ( neuro transmitter)
2. Psychomotor – Retardation - slowed movement (depressed person)
3. Waxy flexibility (moldable) / Catatonia (back to previous position)–
 Maintenance of an awkward posture
4. Echopraxia – Purposeless imitation (mirror like imitation)
Disturbances in Communication
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Mutism – mute
Negativism – ―no‖
Circumstantiality – beating around the bush (Segway- with answer but pa
ikot2)
Tangentiality – beating around the bush (paikot2- di sinasagot ang tanung)
Stilted language – flowery messages / words
Flight of ideas – slightly related
Loose association – no meaning at all, not related
Perseveration – persevere (one topic only) ex. Nurse already moved to
another topic but the patient go back to the previous topic.
Echolalia – Parrot like imitation of words (words repeated)
Palilalia – repetition of stereotyped words/ last syllable
Verbigeration – the same word speak repeatedly
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Coprolalia – Copro: feces, lalia: words--- trash talking
Neologism – creation of new words
Blocking – sudden cessation of thoughts
Word Salad – mixture of unrelated words
Clang Association – Rhyming
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Jargons – gay lingo (new words but nagkakaintindihan)
Disturbance in Perception (how they perceive ideas)
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Delusions – fixed false ―belief‖
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Magical thinking – belief in myth/ magic
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Paranoia – extreme suspiciousness
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Religiosity – obsession of religious ideas
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Phobia – irrational fear
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Obsession – persistent thoughts
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Compulsion – persistent acts
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Preoccupation – idea with intense desire
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Thought broadcasting – others know what I am thinking (advance thinker)
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Delusion of reference – feeling of he’s the talk of the town, tv’s, radio
Affect
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Inappropriate – incongruent affect (inappropriate reactions)
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Blunted – little response
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Restricted affect – display one type of expression
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Labile mood – unpredictable mood
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Apathy – Flat affect (no reaction)
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Ambivalence – two opposing feelings ( happy and the same time afraid)
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Anhedonia – absence of pleasure (with emotion but not satisfied)
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Euphoria – extreme pleasure (happiness)
Stress
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Stage one – Alarm Reaction
 You have determined that there is stress
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Stage 2 – Stage of Resistance
 You will utilize all of your resources to solve the problem
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Stage 3 – Stage of Exhaustion
 You have utilized all of your resources but the problem is not solved
Anxiety (unspecific) vs Fear (specific)
 Identify anxiety causing events
Mild - (good anxiety) increase concentration, logical thinking, increase alertness
 Problem solving approach
Moderate - selective in inattentiveness, decrease attention span
 Relaxation technique, encourage verbalization of feeling  Medications
Severe – do not know what to do/say, difficult of focusing even w/ assistance,
distorted perception: REMAIN W/ CLIENT
Panic – suicidal attempts, fixed eyes, hysterical, mute: Decrease stimuli
 Stay with the client, PAPER BAG prevent (hyperventilate)
Neurotransmitters
Dopamine / Epi / Norepi- Excitatory
Serotonin – Inhibitory --- excitatory (synapse)
GABA (balancer) – Gamma aminobutyric acid
Anxiety Disorders
Generalized Anxiety Disorder (GAD)
- worry a lot
--> No apparent reason
- 6 months anxiety
- no phobias, no panic attack, no OC manifestation
S/sx:
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Palpitations
Headache
Insomnia
Chest pain
Management:
- Assist w/ problem solving
- Teach coping behaviors
- DOC: Benzodiazepines/ Anxiolytics – “pam/lam”
Panic Disorder
- Recurrent
- Unpredictable
- Panic attacks
 (trembling, racing heart/tachycardia, chest pain, DOB, choking sensation,
numbness)
Management:
- assist in problem solving
- teach coping behavior
- DOC: Benzodiazepines/ Anxiolytics
Other meds:
- Betablockers- beta adrenergic blocking agents (heart, decrease anxiety)—―olol‖
- MAOI’s (Monoamine oxidase inhibitors), SSRI’s (Selective Serotonin Reuptake
Inhibitors)
Antihistamines – if with addiction to benzodiazepines
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Primary – anti allergic reaction
Secondary – depressant
Acute Stress Disorder
- after 2 days to one month (4 weeks)
Management: Progressive review of the trauma
DOC: Benzodiazepines
PTSD (Post Traumatic Stress Disorder)
- more than 4 weeks
- Recurrent flashbacks (intrusive thoughts)
- Re Experiencing the TRAUMA
- Defense mechanism: Displacement
S/sx:
- General Numbing - Somatic Symptoms
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Irritability
Aggressiveness
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Depression
Anger
Social withdrawal
Management:
- assist in gaining control over angry impulses - ACCEPTANCE
DOC: Benzodiazepines
Other meds: Beta Blockers, Anti histamines
Phobic Disorder
- Persistent irrational fear
- Fear is unreasonable proportion to the actual danger
Types of Phobia
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Agoraphobia – fear of open public places (always stay at home or stay next
the exit)
Social Phobia – fear of socializing
Simple Phobia – specific phobias
Management:
- Systemic desensitization (gradual exposure to the feared object or stimulus)
- Flooding – sudden exposure
- Breathing exercises
- Thoughts stopping (form of Diversion) ex. Rubber band (make star)
- Guided Imagery – conditioning
OCD (Obsessive Compulsive Disorder)
- they are aware of the disorder
- real obsession and compulsion
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Obsession - repetitive thoughts
Compulsive - repetitive actions
Management:
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Aversion Therapy – PAIN
DOC: SSRI
- give time for ritualistic behavior unless dangerous
- establish limits
- Diversional activities
- Set limits
- Reality
- Consistency
Somatoform Disorders (psychological problem)
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Doctor shopping / hopping
No identifiable physical origin
Precipitated by stress
Over the counter meds
GAIN:
Primary – alleviates anxiety personally
Secondary – getting emotional support/ benefits gained from having the symptom.
Conversion disorder – Involuntary alteration of physical function
 Affects motor (ataxia)(paralysis), neuro (pseudoseizures), sensory
(blindness, deafness)
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Hypochondriasis - feeling of having serious disease even though none
exist (GI and Cardio)
Labelle indifference – (+) med diagnosis, (-) s/sx (manhid)
Body Dysmorphic Disorder – feeling of having defect in physical
appearance /physical anomaly (loss of hair, nose not aligned, small penis) -
plastic surgeries (one part only)
Factitious Disorder - You produce or exaggerate the symptoms
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Munchausen – gain attention to self (nagkunyari my sakit)
Munchausen by proxy – use others -- HERO (uses by mothers)
(mother made sickness to daughter to become hero)
Nursing Diagnosis
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Chronic low self esteem
Impaired judgment
Ineffective coping
Disturbed body image
Social isolation
Management
- Decrease secondary gain by giving attention with or without symptoms
- Assess new physical complains for they may have organic origin
- Encourage independence
- Set limits on manipulative behaviors in a matter of fact (reality)
Mood Disorders
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Bipolar 1
Bipolar 11
Manic Disorder
Major Depressive Disorder
Cyclothymia
Dysthymia
Positive – Sobra sobra
Negative – Kulang kulang
Mood Disorder
BP1
BP2
Manic
Mania
Hypomania
Normal
Hypo depress
Major Depress
Major Depression
Problem: over dependent and loss
Def. mech : Introjection
S/sx: Anhedonia
Psychomotor retardation
Negative S/sx
Attitude therapy: kind firmness
Activity: Counting object or anything, writing
Therapy: group therapy
Non-competitive activity
WOF: Suicide
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put near Nurse Station
Open door
Irregular visit
Bipolar Disorder (Mask of Depression)
Def. Mech: Reaction Formation
S/sx: Hyperactivity
Manipulative
Major Dep
Cyclothymia
Dysthymia
Inattentive
Attitude therapy: Matter of fact (reality)
Activity: Breaking leaves, Modeling clay
Walking (pagurin ang pt)
Therapy: Solitary therapy (Non-Competitive)
*Finger foods
Schizophrenia (Excessive Dopamine ) more than 6months
caused: Genetic
3 Main Types
1. Catatonic
2. Disorganize
3. Paranoid
Catatonic: Abnormal motor behavior
S/sx:
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Catatonia
Waxy flexibility
Mutism
Negativism
Defense Mech: Repression
Nursing Diagnosis: Impaired motor activity
Management: Circulation (passive range of motion), nutrition
Disorganized: Bizarre behavior
S/sx:
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Thoughts
Movements
Speech (neologism)
Def. Mech. : Regression
Nursing Diagnosis: Impaired social functioning
Management: ADL Assistance
Paranoid : Suspiciousness / ideas of reference
- extremely suspicious
S/sx:
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Delusion
Hallucinations
Flight of ideas
Def. Mech: Projection
Nursing Diagnosis: Potential for injury directed to others
Management: Nutrition, safety
Personality Disorders
Cluster A: Eccentric
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Paranoid: Extreme suspiciousness and distrust
Schizoid: Social withdrawal, problems in maintaining relationships, aloof
Schizotypal: Bizarre behaviors, ―silly laughing‖, magical thinking
Management:
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Antidepressant
Low dose antipsychotic
Cluster B: Dramatic / Erratic
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Antisocial: No guilt, no remorse, disregard laws, rules, no conscience
(<18 y/o: conduct disorder)
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Borderline: suicidal tendencies, fear of being alone, manipulative, body
mutilation.
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Histrionic: ―I love the attention‖, attention seeker, seductive, dramatic,
excessively emotional.
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Narcissistic: ―I love my self‖, Grandiosity, Need constant admiration from
others, exaggerated sense of being important.
Management: Anticonvulsants, lithium, MAOI’s
Cluster C: Anxious / fear
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Avoidant: ―I avoid coz I hate criticism‖ (Low self-esteem),
Dependent: ―I cant live without you‖, over reliance, submissive
OCPD (Obsessive Compulsive Personality Disorder): Unaware of condition, no
real obsessions and compulsive, perfectionist, rigid, inflexible
Management:
DOC: Benzodiazepines