MENTAL HEALTH
ƒ "A state of well-being where a person can realize his or her own abilities to
cope with the normal stresses of life and work productively." (WHO)
ƒ Balance in person’s internal life and adaptation to reality.
ƒ State of well-being in which a person is able to realize his potentials.
Criteria for Mental Health:
ƒ Self-awareness
® Ability to:
 recognize one’s thoughts feelings, asset potentials and weakness.
 experience genuine feelings as anger, happiness, resentment
 leads to self-acceptance, self-understanding in order to understand
others
ƒ Autonomy: ability to function independently and function with others
ƒ Perceptive ability
 Awareness of stimuli, reality orientation.
 Orientation to: Time, Place, Person
ƒ Integral capacity: Ability to harmonize psychic forces (id, ego, super ego).
ƒ Self-actuation
 Ability to adopt to life changes, happy to work with others
 Satisfaction in every endeavor
 Genuine cooperation
ƒ Mastery of one’s environment: Awareness of the changes around him
MENTAL HYGIENE
ƒ a science that deals with: Promotive, Preventive, Curative, Rehabilitative
aspects of care.
MENTAL DISORDER
ƒ A medically diagnosable illness which results in significant impairment of
one's cognitive, affective or relational abilities and is equivalent to mental
illness.
Criteria for Mental Disorder:
a.n.g./n.a.l.
PSYCHIATRIC NURSING
ƒ Dissatisfaction with:
 one’s characteristics, abilities and accomplishments
 one’s place in the world
ƒ Ineffective:
 interpersonal relationship
 coping or adaptation to the events in one’s life
MENTAL ILLNESS
ƒ A state in which an individual shows deficit in functioning and is unable to
maintain personal relationship.
ƒ State of imbalance characterized by a disturbance in a person’s thoughts,
feelings and behavior
ƒ Factors that increase the risk are: Crises, Abuses, Poverty
Historical View of Mental Illness
ƒ In the past, mental illness has been viewed as:
 Demonic possession
 Influence of ancestral spirits
 Result of violating taboo or neglecting cultural, ritual, and spiritual
condemnation
ƒ Period of Enlightenment (1745-1886)
 Lunatics were restrained in iron menacles
 Mentally ill were exhibited as diversion and entertainment for the
public
 Establishment of asylums
 Opening of state hospitals for mentally ill.
ƒ Period of Scientific Study
 Psychoanalysis by Sigmund Freud
ƒ Psychotropic Drugs (1950)
 Use of chlorpromazine and imipramine
 Mental illness is caused by chemical imbalance in the brain.
ƒ The Decade of the Brain (1990)
 Focused on the connections between mental illness and biological
malfunction in the brain and the neuroendocrine-immune system.
Page 1 of 32

Biological views holds that biological defects are responsible for
certain serious mental illness.
Diagnosis of Mental Illness
ƒ Use of the Diagnostic and Statistical Manual of Mental Illness (DSM-IV)
ƒ Provides diagnostic criteria for each mental disorder and a system of 5
axes to give a comprehensive view of the client’s mental illness.
 Axis I: The clinical disorder that is the focus of treatment
 Axis II: Personality disorders and mental retardation
 Axis III: Medical conditions
 Axis IV: Psychosocial and environmental problems
 Axis V: Global assessment of functioning (GAF)
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Counselor
Healthy role model
Parent surrogate
Patient advocate
Reality based
Researcher
Socializing agent
Teacher
Technician
Therapist
Ward manager
Levels of Interventions in Psychiatric Nursing
PSYCHIATRIC NURSING
Level
Primary
ƒ An interpersonal process
ƒ Concerned with all the aspects of care
ƒ Both a Science and an Art
 Science – uses different theories
 Art - therapeutic use of self
ƒ Clientele:
 Individual, family and the community
 Both mentally healthy and mentally ill
Secondary
Tertiary
Main tool of the nurse: Therapeutic use of Self
Characteristics of a Good Psychiatric Nurse:
ƒ Empathy
ƒ Genuineness
ƒ Congruence
ƒ Unconditional positive regard
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Examples
Health education
Information
dissemination
Counseling
Crisis intervention
Drug administration
Alcoholics
anonymous
Occupational therapy
THE PSYCHIATRIC SETTING
Admitting a Client in the Psychiatric Setting
Areas to be assessed:
ƒ Health perception
ƒ Orientation
ƒ Metabolic pattern
Roles of the Nurse in Psychiatric Setting:
 Clinician
 Collaborator
a.n.g./n.a.l.
Description
Aimed at altering the stressors
through:
 promotion of mental health
 lowering the rate of cases
Interventions that limits the severity of
a disorder thorugh:
 Case finding
 Prompt treatment
Aimed at reducing the disability after
a disorder through:
 Prevention of complication
 Active program of rehabilitation
PSYCHIATRIC NURSING
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ƒ Elimination pattern
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COMMON BEHAVIORAL SIGNS AND SYMPTOMS
Cognitive pattern: Judgment, Insight, Memory
Activity and exercise pattern
Thought process
Sleep-rest pattern
LEGAL ASPECTS OF PSYCHIATRIC NURSING
Types of Admissions:
ƒ Voluntary
 Persons admit themselves
 Client consents to all treatment
 Client can refuse treatment, including drugs, unless danger to self or
others
ƒ Involuntary
 Judicial process
 Initiated when someone files a petition
 Certification of the likelihood of serious harm to self or others, or
unable to care for self
 Under 18, parents can confine with confirmation by a neutral fact
finder
 Must be released at end of statutory time or put on voluntary
status or have a hearing
‘
Judicial Precedents
Unless incompetent, client maintains all previous rights
Management:
ƒ Acknowledge the feelings
ƒ Reorient to reality
ƒ Provide distractions
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Insanity as a Defense
ƒ Insanity : determined in court; legal terminology
McNaughten Rule
“At the time of the crime, the individual didn’t know the nature and quality of the
act or didn’t know right from wrong.”
a.n.g./n.a.l.
Disturbance in Perception
ƒ Illusion - misperception of an actual external stimuli
ƒ Hallucination - false sensory perception in the absence of external
stimuli
PSYCHIATRIC NURSING
Neologism - pathological coining of new words
Circumstantiality - over inclusion of details
Word salad - incoherent mixture of words and phrases
Flight of ideas - shifting of one topic from one subject to another in a
somewhat related way
Looseness of Association - shifting of a topic from one subject to another
in a completely unrelated way
Verbigeration - meaningless repetition of word or phrases
Perseveration - persistence of a response to a previous question
Echolalia - pathological repetition of words of others
Clang association - the sound of the word gives direction to the flow of
thought
Delusion - false belief which is inconsistent with one's knowledge and
culture
 Grandeur - is an exaggerated belief of identity
 Nihilistic - the client denies the existence of self or part of self
 Persecution - belief that he or she is the object of environmental
attention and being singled out for harassment
 Self-depreciation - worthlessness or hopelessness
 Somatic - false belief to body function.
Page 3 of 32
Disturbances of Affect
ƒ Inappropriate affect - disharmony between the stimuli and the emotional
reaction
ƒ Blunted affect - severe reduction in emotional reaction
ƒ Flat affect - absence or near absence of emotional reaction
ƒ Apathy - dulled emotional tone
Disturbances in Motor Activity
ƒ Echopraxia - the pathological imitation of posture/action of others
ƒ Waxy flexibility - maintaining the desired position for long periods of time
without discomfort
ƒ Akinesia - loss of movement
ƒ Bradykinesia - slowness of all voluntary movement including speech.
ƒ Ataxia - loss of coordinated movement
Disturbances in Memory
ƒ Confabulation - filling in of memory gaps
ƒ Amnesia - inability to recall past events
• Anterograde - immediate past
• Retrograde - distant past
ƒ Deja vu - feeling of having been to place which one has not yet visited
ƒ Jamais vu - feeling of not having been to a place which one has visited
ƒ Dementia
• gradual deterioration of intellectual functioning
• results in the decreased of capacity to perform ADL
Other behavioral signs & symptoms
ƒ Agitation - severe anxiety associated with motor restlessness.
ƒ Agnosia - inability to recognize and interpret sensory stimuli.
ƒ Akathisia - subjective feeling of muscular tension, restlessness and pacing
repeated sitting and standing.
ƒ Ambivalence - presence of two opposing feelings at the same time.
ƒ Aphasia - inability or difficulty to speak or recall words
ƒ Apraxia - inability to carry out specific task or activity.
ƒ Delirium
a.n.g./n.a.l.
PSYCHIATRIC NURSING
•
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refers to acute change or disturbance in a person's: LOC, cognition,
emotion , perception
Depression - feeling of sadness
Derealization - feeling of strangeness towards the environment.
Dysthymia - persistent state of sadness
Elation (euphoria)- a feeling of high degree of confidence, boastfulness
and joy with increase motor activity.
Narcolepsy - sleep disorder characterized by frequent irresistible urge to
sleep with episodes of cataplexy (sudden loss of muscle power)
USE OF APPROPRIATE COMMUNICATION TECHNIQUES
Communication: reciprocal exchange of ideas between or among persons
Modes:
ƒ Verbal - written/spoken
ƒ Non-verbal - posture, tone of voice, facial expression
Types of Non-verbal communication:
ƒ Kinesis
• body movement
• eye contact
• gestures
ƒ Paralanguage
• voice quality
• non-language vocalization (crying, sobbing, moaning)
ƒ Proxemics – law of space relationship
ƒ Touch – physical act
ƒ Cultural artifacts
ƒ Meta communication
• based on role expectations
• hidden meaning of words
Elements:
Page 4 of 32
FEEDBACK
Examples: Therapeutic Technique
Technique
Example
Accepting
Yes, that must have been difficult for you.
Acknowledging or giving
I noticed that you've fixed your bed.
recognition
Asking direct questions
How does your wife feel about
hospitalization?
Message
(Channel)
(Context)
Therapeutic Communication: a way of interacting in a purposeful manner to
promote the client’s ability to express his thoughts and feelings openly.
Essentials for a Therapeutic Communication:
ƒ Genuineness
E
G R A T
ƒ Respect
ƒ Empathy
ƒ Attentive listening
ƒ Trust (rapport)
Confronting or presenting
reality
Encouraging comparison
Encouraging description
Encouraging evaluation
Exploring
Focusing
Giving broad openings or
asking open-ended
questions
Informing
Barriers to a Therapeutic Communication
ƒ Belittling
ƒ Interrupting / ignoring
ƒ Giving advice
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Clarifying
Making observations
Social response
Changing the subject
Approving / disapproving
Moralizing
Offering general leads
Restating
Summarizing
Using silence
a.n.g./n.a.l.
PSYCHIATRIC NURSING
your
I'm not sure that I understand what you are
trying to say.
I see no bats flying in this room.
Has this ever happened before?
How do you feel when you
medication?
take
your
Does participating in group therapy enable you
to discuss your feelings?
Tell me more about your job. Would you
describe your responsibilities?
(assisting a patient to explore specific topic)
Is there something you'd like to do?
(giving needed facts)
I'll be your nurse for today, from 7:00 until 3:00
this afternoon.
You appear to be angry. / I noticed that you're
trembling.
Go on. / You were saying…
Client: I can't sleep, I stay awake all night.
Nurse: You can't sleep at night, (restating)
During the past hour, we talked about your plans
for the future, they include...
(to induce thought, pacing, acceptance)
Page 5 of 32
Validating
Voicing doubt
ƒ data gathering, planning for first interaction
(confirming one's observation)
“So you mean . . .”
I find that hard to believe.
Examples: Non-therapeutic Technique and Ineffective Communication
Agreeing and disagreeing
“I think you did the right thing.”
Advice
“You should.….”
Belittling
"Don't be concerned, evervone feels like that".
Defending
"All doctors here are simply great".
False reassurance
"Don't worry, everything will be all right".
Focus
on
caregiver’s “I feel that way too.”
feeling
Judging
"It's your own mistake".
Orientation phase
ƒ when the nurse-patient interacts for the first time
ƒ establish of contract with the patient
ƒ establish of trust and rapport
ƒ learn about the patient and his initial concerns and needs
ƒ encourage the patient to feel comfortable with the meeting
ƒ conduct initial interview
ƒ manage present emotion of the patient
ƒ provide support and empathy of the patient’s feelings
ƒ assure of confidentiality
NURSE – PATIENT RELATIONSHIP
Working / Therapeutic Phase:
ƒ it is highly individualized
ƒ identification and resolution of the patient's problems
ƒ more structured than the orientation phase
ƒ the longest and most productive phase
ƒ limit setting must be employed
ƒ planning and implementation
Hildegard Peplau
Phases:
Pre-Interaction Phase
ƒ begins when the nurse is assigned/chooses a patient
ƒ patient is excluded as an active participant
ƒ nurse feels certain degree of anxiety
ƒ includes all of what the nurse thinks and does before interacting with the
patient
ƒ develop self-awareness
a.n.g./n.a.l.
PSYCHIATRIC NURSING
Problems:
ƒ Transference
 the development of an emotional attitude towards the nurse
 positive or negative
ƒ Counter transference – experienced by the nurse / therapist
Termination Phase
ƒ Evaluate the summary of progress
ƒ Reinforce change and strength of patient
ƒ Give rewards for the cooperation during interaction
ƒ Encourage expression of feelings about termination of the relationship
Page 6 of 32
ƒ Terminate the relationship without giving promises
Superego
ƒ Libido - are the instinctual drives
ƒ Regression and fixation are common terms in this theory.
ƒ Gave prominence to sexual feelings: defined "sex" as anything that gives
gratification
Stages:
Oral Stage (0-2 years)
ƒ The area of gratification is the mouth
ƒ Pleasures: sucking activities like fingers, toes or nipples
ƒ Dissatisfaction: resurface at a later
 overeating, smoking, nail-biting
THEORIES OF HUMAN DYNAMICS
Psychosexual Development : Sigmund Freud
Levels of Consciousness
Nursing Implication:
ƒ Provide oral stimulation by giving pacifiers
 Breastfeeding may provide more stimulation.
ƒ Do not discourage thumb sucking
Anal Stage (2-4 years)
ƒ Children's attention is focused on the anal region.
ƒ Pleasure: elimination.
ƒ Covers the ideal age for "toilet training" (2 1/2 years)
ƒ 2 concepts:
 Holding on
 Letting go
Possible problems:
ƒ Compulsive need to be clean and orderly.
ƒ Frugality and stinginess
ƒ Greed
ƒ Insistence on doing things at one's own rate at the expense of others
ƒ Rigid training
3 Psychic Energies
Id
Ego
a.n.g./n.a.l.
PSYCHIATRIC NURSING
Page 7 of 32
ƒ Excessive messiness and disorderly habits.
Psychosocial Development Theory: Erik Erikson
Nursing Implication: Help children achieve bowel and bladder control without
undue emphasis on its importance.
Phallic Stage (4-6 years)
ƒ Pleasure: genital region.
 activities associated with stroking and manipulating their sex organs.
ƒ Oedipus complex
ƒ Electra complex
ƒ Concepts
 Onset of “normal homosexuality”
Nursing implications:
ƒ Accept child's sexual interest
ƒ Help the parents answer child's questions about birth or sexual differences.
Latency Stage (6 to 12 years)
ƒ Period of calmness / stable period.
ƒ Many of the disturbing behaviors are buried in the subconscious mind.
ƒ Their energies are absorbed by the concerns in school, peers, sports and
other recreational activities
Nursing Implication: Help the child have positive experiences.
Genital Stage (12 years & up)
ƒ Oedipal feelings are reactivated toward opposite sex
ƒ The person is on his way in establishing a satisfying life of his own
Nursing Implication:
ƒ Provide appropriate opportunities for the child to relate with opposite sex.
ƒ Allow child to verbalize feelings about new relationships.
a.n.g./n.a.l.
PSYCHIATRIC NURSING
ƒ Childhood is very important in personality development.
ƒ Rejected Freud's attempt to describe personality solely on the basis of
sexuality,
 believed that social factors greatly affect
 felt that personality continued to develop beyond five years of age.
Identified 8 developmental stages throughout the whole life cycle.
ƒ Stages 1-5 - childhood and adolescent
ƒ Stages 6-8 - Adulthood
Stages:
Stage 1:
Period of Life
Infant, 0-18 months, (Hope)
Psychosocial Crisis
Trust vs. Mistrust
Relationship with
Maternal person
Positive Resolution
o Reliance on the caregiver
o Development of trust in the environment
Negative Resolution o Fear, anxiety and suspicion
o Lack of care, both physical & psychological by
caretaker leads to mistrust of environment
Stage 2:
Period of Life
Psychosocial Crisis
Relationship with
Toddler, 18 mos. to 3 years
(Willpower)
Autonomy vs. Shame/doubt
Paternal person
Page 8 of 32
Positive Resolution
o Sense of self-worth
o Assertion of choice and will
o Environment encourages independence, leading to
sense of pride
Negative Resolution o Loss of self-esteem
o Sense of external control may produce self-doubt in
others
Stage 3:
Period of Life
Psychosocial Crisis
Relationship with
Positive Resolution
Preschool, 3 to 6 years (Purpose)
Initiative vs. Guilt
Family
The ability to learn to initiate activities, to enjoy
achievement and competence
Negative Resolution
o
The inability to control newly developed power
o
Realization of potential failure leads to fear of
punishment and guilt
Stage 4
Period of Life
Psychosocial Crisis
Relationship with
Positive Resolution
Schooler, 6 to 12 yrs. (Competence)
Industry vs. Inferiority
Neighbors/School
o Learning the value of work
o Acquiring skills and tools of technology
o Competence helps to order life and make things
work
Negative Resolution Repeated frustrations and failures lead to feelings of
inadequacy and inferiority that may affect their view of
life
Stage 5:
Period of Life
Adolescent, 12 to 18 yrs, (Fidelity)
Psychosocial Crisis Identity vs. Role confusion
Relationship with
Peer group
Positive Resolution Experiments with various roles in developing mature
individuality
a.n.g./n.a.l.
PSYCHIATRIC NURSING
Negative Resolution Pressures and demands may lead to confusion about
self
Stage 6:
Period of Life
Psychosocial Crisis
Relationship with
Positive Resolution
Young Adult, 18 to 54 yrs., (Love)
Intimacy vs. Isolation
Partners in friendship
o A commitment to others
o Close heterosexual relationship and procreation
Negative Resolution Withdrawal from such intimacy, isolation, selfabsorption and alienation from others
Stage 7:
Period of Life
Middle Adult, 24 to 54 yrs., (Care)
Psychosocial Crisis
Generativity vs. Self-absorption
Relationship with
Partner
Positive Resolution
o The care and concern for the next generation
o Widening interest in work and ideas
Negative Resolution Self-indulgence and resulting psychological
impoverishment
Stage 8:
Period of Life
Late Adult, 54 yrs. to death, (Wisdom)
Psychosocial Crisis Integrity vs. Despair
Relationship with
Mankind
Positive Resolutiono
Acceptance of one’s life
o
Realization of the inevitability of death
o
Feeling of dignity and meaning of existence
Negative Resolution Disappointment of one’s life and desperate fear of
death
Cognitive Development Theory: Jean Piaget
Stages:
Sensorimotor (0-2 years)
ƒ Reflex to complex
ƒ Begins to organize visual images and control motor responses.
Page 9 of 32
ƒ Coordinates sensory impressions.
ƒ Pre-verbal stage
Preoperational Stage (2-7 years)
ƒ Transitional period
ƒ Egocentric and irreversible thinking
ƒ Words become symbols for objects – symbolic thinking
ƒ Formation of ideas of categorization.
ƒ Lack of ability to go back and rethink a process or concept.
ƒ Mental image – the symbolic process which are evident in plays
ƒ Construction of verbal schemas – preconcepts
Concrete Operations (7 – 11 years)
ƒ Thinking appears to be stabilized
o ability to think of the possible consequences of actions
ƒ Logical implications
Formal Operations
(11 years to adulthood)
ƒ Full patterns of thinking
ƒ Ability to use logic and symbolic processes
o mathematical and scientific reasoning
ƒ Combinatorial thinking - multidimensional approach
o hypothetic or hypothetico-deductive reasoning
Level Two (Conventional
Morality)
• Children’s judgments
are based on the norms
and expectations of the
group.
•
•
Level Three
(Post Conventional
Morality)
The individual
recognizes the
arbitrariness of social
and legal conventions.
The individual attempts
to define moral values
that are separate from
group norms.
Stage 2
• Actions are based largely on satisfying one’s
own personal needs.
Stage 3
• Good behavior is that which pleases others
and judgments are based on intentions.
• Children conform to rules to win the approval
of others and to maintain good relationships.
Stage 4
•
What is right is what is accepted.
If the social accepts rules as appropriate for all
group members, children will conform to them to
avoid social disapproval and censure
Stage 5
• Behavior recognizes the laws as arbitrary
and changeable.
• For aspects of life not governed by laws,
right and wrong are personal decisions
based on agreement and contracts.
Stage 6
• Morality is based on respect for others
rather than on personal desires.
• The individual conforms to both social
standards and to internalized ideals to
avoid self-condemnation rather than to
avoid social censure.
Moral Development Theory: Laurence Kohlberg
Level One
(Preconventional Morality)
• Children’s judgments
are based on external
criteria.
• Standards of right and
wrong are absolute and
laid down by authority.
a.n.g./n.a.l.
Stage 1
• Behavior is based on the desire to avoid
severe physical punishment by a superior
power.
• Right or wrong is based on consequences to
him.
• Punishment = wrong act
PSYCHIATRIC NURSING
Other Theories
Behavioral Model (Ivan Pavlov, John Watson, B. F. Skinner)
ƒ Behavior is:
• a response to a stimulus from the environment
• learned and retained by positive reinforcement
Interpersonal Model (Harry Stack Sullivan)
Page 10 of 32
ƒ Focused on the role of the environment and interpersonal relations as
the most significant influences on a individual’s development.
ƒ Anxiety is communicated interpersonally.
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Human Motivational Need Model. (Abraham Maslow)
ƒ Hierarchy of needs in order of importance
ƒ Primary needs (physiologic) need to be met prior to dealing with higher
level needs.
Psychobiologic Model
ƒ Focus is in mental illness as a biophysical impairment.
ƒ Human behavior is influenced by genetics, biochemical alterations and
function of brain and CNS.
ƒ The stress response is a neuroendoctine response.
Important structure (limbic system):
ƒ Thalamus – regulates activity, sensation, emotion
ƒ Hypothalamus – themoregulation, appetite control, endocrine function,
appetite control, impulsive behavior associated with feelings of anger, rage
or excitement.
ƒ Hippocampus and amygdale – emotional arousal and memory
ƒ Neurons – basic functioning unit of the CNS
ƒ Neurotransmitters
 Chemical substances manufactured in the neuron
 Aid transmission of information throughout the body
ƒ Dopamine
 An excitatory neurotransmitter
 Located primarily at the brain stem
 Involved in control of complex movements, motivation, cognition and
regulation of emotional responses
 Associated with pyschosis and Parkinson’s disease
ƒ Catecholamines (norepinephrine and epinephrine)
ƒ Norepinephrine
 Attention, learning and memory, sleep and wakefulness
a.n.g./n.a.l.
PSYCHIATRIC NURSING
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ƒ
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Excess of this is associated with anxiety, memory loss, social
withdrawal and depression.
Epinephrine – responsible in the fight or flight mechanism
Serotonin
 An inhibitory neurotransmitter
 Derived from tryptophan
 Involved in control of food intake, sleep and wakefulness, pain
control, sexual behavior and emotions
 Involved in anxiety and mood disorders, schizophrenia and its
symptoms
Histamine
 Primarily involved in immunity and allergic reactions
 Some psychotropic drugs are block by histamine
Acetylcholine
 Affects sleep-wake cycle
 Associated with Alzheimer’s disease
Glutamate
 An excitatory neurotransmitter
 At high levels, it can cause neurotoxicity.
 Associated with Alzheimer’s and Huntington’s disease
Gama-Aminobutyric Acid
 An inhibitory neurotransmitter
 Associated to treat anxiety and induce sleep.
PSYCHOTHERAPY
ƒ Is a process in which a person enters into a contract to interact with a
therapist to relieve symptoms, resolve problems in living, seek personal
growth
INDIVIDUAL THERAPY: Is a confidential relationship between client and
therapist.
ƒ Hypnotherapy: Involves various methods and techniques to induce a
trance state where the patient becomes submissive to instructions
Page 11 of 32
ƒ Humor therapy: Use of humor to facilitate expression of feelings and to
enhance interaction
ƒ Psychoanalysis: Focuses on the exploration of the unconscious, to
facilitate identification of the patient's defenses
GROUP THERAPY
• minimum number : 3
• Ideal number :8-10
•
Advantages:
o decreases isolation
o decreases dependence
o develops coping skills
o develops interpersonal learning
o develops opportunities for helping others
o develops ability to listen to other members
ƒ Remotivation Therapy: Promotes expression of feeling through interaction
facilitated by discussion of neutral topics
ƒ Family therapy: A method in which family members gain:
o insight into the problems
o improve communication
o improve functioning of individual members as well as the family as a
whole.
o It focuses on the total family as an interactional system
ƒ Milieu Therapy
• A therapeutic environment is organized to:
o encourage and assist the client to control problematic behavior
o function within the range of social norms
ƒ Play therapy
• Effective for children suffering from maladjustment or behavior disorder.
• The child is usually placed in a play room
• Purpose - to discover the causes of the child's conflict through
observation of his play and to interpret it to the child.
a.n.g./n.a.l.
PSYCHIATRIC NURSING
ƒ Recreational therapy
• Uses activities which vitalize the patient's interest and help him or her to
relax and feel refreshed.
• Example: Playing baseball may be prescribed for as a means of
expressing hostility in a group.
ƒ Occupational therapy: Uses any mental or physical activity prescribed or
guided to aid an individual's recovery from a disease or injury.
ƒ Musical therapy
• Involving the music which allows the child or adolescent to express
herself or himself.
• Also effective with those who have difficulty communicating.
ƒ Art therapy: Clients are encouraged to express their feelings or emotions
by painting, drawing or sculpture.
ƒ Psychodrama therapy: Patients dramatizes their emotional problems in a
group setting.
ƒ Behavior Therapy
• Is a mode of treatment that focuses on modifying observable (overt) and
quantifiable behavior
• Systematic manipulation of the environment and variables thought to be
functionally related to the behaviors.
•
•
•
Limit Setting
o Therapist gives an advanced warning of the limit and the
consequences will follow if the client does not adhere to the limit.
o The consequences should occur immediately after the client has
exceeded the limit
o Consistency must occur with all personnel.
o Purposes:
o Minimizes manipulation and splitting of the staff.
o Provide a framework for the client to function in and enable a
client to learn to make requests.
Systematic Desensitization
o Clients are exposed slowly to a feared object or a thing that inhibits
anxious responses and taught ways to relax.
o Effective in treating phobias.
Implosive therapy
Page 12 of 32
o The clients are exposed abruptly to intense forms of anxiety
•
•
•
•
•
producers, either in imagination or in real life
Cognitive Behavior therapy
o Uses confrontation as a means of helping the clients restructure or
rearrange irrational beliefs, maladaptive thinking, perception-, and
behaviors.
o Used for depression and adjustment difficulties.
Biofeedback
o Teaches the client to control or change aspects of their internal
environment.
Aversion therapy
o Uses unpleasant or noxious stimuli to change inappropriate
behavior.
o Examples
o Antabuse to treat alcoholics
o Showing films to drivers who are arrested for speeding or driving
while under the influence of alcohol or drugs.
Assertiveness Training
o Clients are encouraged and taught how to appropriately relate to
others
o Teaches the individual to ask for what is beneficial to both mentally
ill and mentally healthy persons.
Token-economy: Utilizes the principle of rewarding desired behavior to
facilitate change.
ELECTROCONVULSIVE THERAPY (ECT)
• Exact mechanism is unknown
• Requires a consent
• Usually given at 70-150 volts for about .5-2 seconds
• Effectivity: 6-12 treatments with at least 48 hour interval
• Indicator of effectiveness: tonic-clonic seizure
Indications of use:
• Depression
• Mania
a.n.g./n.a.l.
PSYCHIATRIC NURSING
• Catatonic schizophrenia
Contraindications (not absolute)
• Fever
• Increased ICP
• Cardiac conditions
• TB with history of hemorrhage
•
•
•
Unhealed fracture
Retinal detachment
Pregnancy
Before the procedure:
• Diagnostic procedures
o X-ray
o ECG
o EEG
• Drugs given
o Atrophine sulfate (decrease secretions)
o Anectine (Succinylcholine) – relax muscles
o Methohexital Na (Brevital) - anesthetic
During the procedure:
•
Observe for tonic-clonic seizure
After the procedure:
•
Position
•
Check vital signs
•
Reorient the client
•
Watch out for complications:
o
Memory loss
o
Headache
o
Apnea
o
Respiratory depression
o
Fracture
BASIC CONCEPTS ON PSYCHOPHARMACOLOGY
MAJOR TRANQUILIZERS/ ANTIPSYCHOTICS
ƒ Indication: Schizophrenia and Other Psychosis
ƒ Desired effect: control of symptoms
ƒ Best taken after meals
Page 13 of 32
Examples:
• Haloperidol (Haldol)
• Prochlorperazine (Compazine)
Side effects:
Blurred vision
Dry mouth
Tachycardia, palpitation, constipation,
urinary retention
Photosensitivity
Orthostatic hypotension
Extra Pyramidal Symptoms
o Pseudoparkinsonism
o pill-rolling tremors
mask-like face
o cog-wheel rigidity
o propulsive gait
o Akathisia - restless leg syndrome
o Dystonia - defect in muscle tone
•
•
Fluphenazine (Prolixin)
Chlorpromazine (Thorazine)
Diazepam (Valium)
Oxazepam (Serax)
Chlordiazepoxide (Librium)
•
•
Chlorazepate Dipotassium
(Tranxene)
Alprazolam (Xanax)
Nursing Action
Avoid driving
Give sugarless gum
Monitor & report
Nursing Implications:
• Best taken before meals
• Advise to avoid driving
• Avoid alcohol and caffeine-containing foods
• Administer it separately with any drug
Don’t expose skin to sunlight
Monitor BP
Advise gradual change in position
Report at once
ANTIDEPRESSANTS
Desired effects: increased appetite, adequate sleep
Tricyclic Antidepressants
Examples:
• Imipramine (Tofranil)
•
Amitriptyline (Elavil)
Nursing Implications:
ƒ Best given after meals
ƒ Effectivity: after 2-3 weeks
ƒ Check the BP, it causes hypotension
ƒ Check the heart rate, it causes cardiac arrythmias
ƒ Monitor I & O
ƒ Monitor for signs of increased IOP
Adverse effect: report promptly
• Tardive dyskinesia - lip smacking
• Agranulocytosis
o Assess for:
 Fever
 Sore throat
 Lab data: WBC count
• Hepatotoxicity
o Assess for ALT & AST
MAO INHIBITORS
Indication: refractory depression
MINOR TRANQUILIZERS/ ANXIOLYTICS
ƒ Common indication: Anxiety disorders
ƒ Desired Effect: Decreased anxiety, adequate sleep
Examples:
a.n.g./n.a.l.
•
•
•
Examples:
• Tranylcypromine (Parnate)
• Phenelzine (Nardil)
PSYCHIATRIC NURSING
PaN aM a
Page 14 of 32
•
Lithane, Lithobid)
Isocarboxazid (Marplan)
Nursing Implications:
ƒ Best taken after meals
ƒ Report headache; it indicates hypertensive crisis
ƒ Avoid tyramine containing foods like:
• Avocado
• Banana
• Cheddar and aged cheese
• Soysauce
• Preserved foods
ƒ Effectivity: 2-3 weeks
ƒ Monitor the BP
ƒ There should be at least a two-week interval when shifting from one antidepressant to another
Selective Serotonin Reuptake Inhibitors
Examples:
• Fluoxetine (Prozac)
• Celatopram (Celexa)
• Sertraline (Zoloft)
•
•
Paroxetine (Paxil)
Fluvoxamine (Luvox)
STRESS
Nursing Implications:
ƒ Avoid the use of:
• diazepam
• Alcohol
• Tryptophan
• Monitor PTT, PT
ƒ Never give to pregnant / lactating mothers.
•
•
ANTI-MANIC AGENT
Examples:
• Lithium Citrate (Cibalith – S)
a.n.g./n.a.l.
•
Nursing implications:
ƒ Best taken after meals
ƒ Increase intake of:
• fluids (3 L /day)
• sodium (3 gm/day)
ƒ Avoid activities that increase perspiration
ƒ Never give to pregnant mothers
ƒ Effectivity: 10-14 days
ƒ Antipsychotic is administered during the first 2 weeks
ƒ Therapeutic level:.5-1.5 meq/L
ƒ If ineffective: Tegretol
ƒ Signs of toxicity:
o Vomiting
o Anorexia
o Nausea
o Diarrhea
o Abdominal cramps
o Lightheadedness (late)
ƒ Antidote: Mannitol
Lithium Carbonate (Eskalith,
PSYCHIATRIC NURSING
A nonspecific response of the body to any demand made upon it. (Hans
Selye, 1936)
A state produced by a change in the environment that is perceived as
challenging, threatening or damaging to the person’s dynamic equilibrium.
(Smeltzer, 1992)
Adaptation
• A constant ongoing process that occurs along time continuum, beginning
with birth and ending with death. (Smeltzer, 1992)
• A continuous process of seeking harmony in an environment.
Page 15 of 32
•
Types of Adaptation:
General Adaptation Syndrome (GAS)
• Involves the whole body in response to stress.
• Compared to life process as it focuses on the “wear and tear of the body
tissues.
Phases:
• Alarm
o Acute phase of the syndrome
o Characterized as the “flight and fight” reaction
o Defensive by nature but self-limiting
o If stress is intense, it may lead to death.
• Resistance
o Characterized as the state of adaptation
o Person moves back to homeostasis
• Exhaustion
o Result of a prolonged exposure to stress and adaptive mechanisms can
no longer persist.
Local Adaptation Syndrome
• Refers to inflammatory response and repair processes that occur at the
local site of tissue injury.
Eustress - positive stress
Distress
• Negative stress
• Damaging stressors which may result in various physical and emotional
disorders such as: anxiety, frustration, insecurity, aimlessness
CRISIS AND CRISIS INTERVENTION
• A situation that occurs when an individual's habitual coping ability becomes
ineffective to meet the demands of a situation.
• As a serious interruption and disturbance of one's equilibrium or
homeostasis
a.n.g./n.a.l.
PSYCHIATRIC NURSING
Leads to potentially dangerous, self-destructive or socially unacceptable
behavior.
Characteristics
• Highly individualized
• Self-limiting: 4-6 weeks
• Person affected becomes passive and submissive
• Affects a person’s support system
Type
Description
Maturational/developmental expected, predictable
crisis
and internally
motivated
Situational/accidental
Unexpected,
unpredictable and
externally motivated
Example
Puberty, adolescence,
young adulthood,
marriage, or the aging
process.
Economic difficulty,
illness, accident, rape,
divorce or death
Social crisis
Due to acts of nature
Natural calamities
Phases
• Denial
• Increased Tension
• Disorganization
• Attempts to reorganize
• Stage for full reorganization
CRISIS INTERVENTION
• Major Goal:
o Restore the maximum level of functioning (pre-crisis state)
o It is an active but temporary entry into the life situation of an individual
or a family during a period of stress.
Page 16 of 32
o
A way of entering into the situation to help them mobilize their resources
and to decrease the effect of stress.
Domestic Violence Requiring Crisis Intervention:
RAPE
• Nonconsensual sexual penetration of an individual, obtained by force or
threat, or in cases in which the victim is not capable of consent.
Kinds of Rape
• Power – to prove masculinity
• Anger – means of retaliation
• Sadistic – to express erotic feelings
Silent Rape Syndrome
• Is a maladaptive reaction to rape
• The victim:
• fails to disclose information about the rape
• is unable to resolve feelings about the sexual assault
• Results to increase anxiety and may develop a sudden phobic reaction.
Rape Trauma Syndrome (RTS)
• Refers to a group of signs and symptoms experienced by a victim in
reaction to rape
Phases:
• Acute Phase – shock, numbness, disbelief
• Denial – refusal to discuss the event
• Heightened Anxiety – fear, tension, nightmares
• Stage of Reorganization
Components of Omission:
• Child abandonment – leaving the child physically
• Child neglect - lack of provision of those things which are necessary for the
child's growth and development
Types of Commission:
Physical Abuse
• Is an intentional physical harm inflicted on a child by a parent or other
person.
Emotional abuse - insult and undermining one's confidence
Sexual abuse - abuse in the form of sexual contact
Characteristics of Abusive Parents:
• They come from violent families
• They were also abused by their parents
• They have inadequate parenting skills
• They are socially isolated because they don't trust anyone
Battered Wife Syndrome (BWS)
• A form of cyclic domestic violence
• Men: low self-esteem
• Women: Dependent personality disorder
a.n.g./n.a.l.
Child Abuse
• Is an act of omission of responsibility or commission in which intentional
harm is inflicted on a child.
PSYCHIATRIC NURSING
Page 17 of 32
•
•
They are emotionally immature
They have negative attitude towards the management of the abused
Warning signs of Child Abuse / Neglect:
• Child’s excessive knowledge on sex and abusive words
• Hair growth in various lengths
• Inconsistent stories from the child and parent/s
• Low self-esteem
• Depression
•
•
•
•
•
•
Apathy
Bruised or swollen genitalia; tears or bruising of rectum or vagina
Unusual injuries for the child’s age and development
Serious injuries (fractures, burns, lacerations)
Evidence of old injuries not reported
Republic Act 7610
(Anti Child Abuse Law)
• Required reporting of suspected cases
• Report cases to the nearest authorities within 48 hours
Assessment, Planning and Nursing Actions for Crisis
• Primary concerns:
o Physical injuries
o Alleviation of psychological trauma
• Nurse should display:
o Sensitivity
o Attitude (Nonjudgmental)
o Confidentiality
o Respect
o Empathy
o Dignity
• Evidences are important:
o stained clothing
o fingernail scrapings
a.n.g./n.a.l.
•
•
PSYCHIATRIC NURSING
•
•
o mouth or anal smears containing semen
Intervention focuses family as a unit.
If the victim is a child: Play and art therapy
DEFENSE MECHANISM
These are automatic and usually unconscious processes or act by the
individuals to:
o reduce or cope anxiety or fear
o resolve emotional or mental conflict
o protect one's self-esteem
o protect one's sense of security
Becomes pathologic when overused.
Used by both mentally healthy and mentally ill individuals
Common Defense Mechanisms Used:
• Compensation
o An attempt to overcome a real or imagined short coming, inferiority,
inabilities and weaknesses.
o A blind woman becomes proficient in playing piano.
•
Conversion
o Emotional problems are converted to physical symptoms
o A student unprepared for a report suffered headache the day she is
supposed to deliver her report.
•
Denial
o Failure to acknowledge an intolerable thought, feeling, experience or
reality
o A middle-aged man after being admitted to the CCU because of an AMI,
insists that he is in the hospital for just a diagnostic work-up.
•
Displacement
o the redirection of feelings to a less threatening object
o An adolescent boy, after an argument with his father, goes to the room
and kicked his room’s door.
Page 18 of 32
•
Fantasy
o Conscious distortion of unconscious feelings or wishes
o A boy who is being bullied by his friends wished he had the power of
Wolverine.
•
Fixation
o An unhealthy mechanism which is an arrest of maturation at certain
stages of development.
o A boy never overcame being fully reliant from his mother.
•
Introjection
o Symbolic assimilation or taking into oneself a love/hatred object.
Derived from the word "introject" which literally means to take into or
ingest.
o Common to depressed clients.
•
•
•
Identification
o An individual integrates certain aspects of someone else's personality
into one's own.
o A young school teacher adopts his former mentor's teaching style when
conducting class sessions.
Intellectualization
o An overuse of intellectual concepts by an individual to avoid expression
of feelings
o A man who was asked to share a memorable experience about his
grandmother who died discussed the stages of death and dying by
Elizabeth Kubler Ross.
Projection
o Attributing to others one's unconscious wishes/fear.
o Literally, this means to "throw off.
o A student who failed a subject blames his failure on poor teaching.
a.n.g./n.a.l.
PSYCHIATRIC NURSING
•
Reaction – Formation
o Expression of feeling that is the direct opposite of one's real feeling.
o Also referred to as overcompensation.
o A student who dislikes one of her classmates may act or show concern
toward her.
•
Rationalization
o An individual finds a justifiable cause and acceptable reasons just to be
saved from an embarrassing and anxiety producing thoughts or
situations.
o A basketball player claims that he missed the shot and lost the game
because of the distractions made by the audience.
•
Regression
o Is the turning back to earlier patterns of behavior in solving personal
conflicts.
o Commonly seen to schizophrenic patients
o A person who becomes ill in the face of disappointment has regressed
to a form of childish behavior.
•
Repression
o It is the involuntary or unconscious forgetting of an unpleasant ideas or
impulses.
o During the nurse-patient relationships, patients often unconsciously
avoid discussing those experiences producing anxiety which are
emotionally difficult to verbalize.
•
Suppression
o Permits the individual to store away or consciously forget the
unpleasant, painful and unacceptable thoughts, desires, experiences
and impulses.
o "I'll think it about tomorrow", "I'd rather go now", "Can we change the
topic?"
o A boy walked out from the group and said "I have to go now", when he
was asked what was happened to their relationship with his girlfriend.
Page 19 of 32
•
Substitution
o Replacing the desired unattainable goal with one that is attainable
o A woman who failed the nursing board exam 3 times, worked as a
nursing aide just to be in the hospital.
ƒ Physical - Nausea, Anorexia, Vomiting, Diarrhea, Constipation,
Restlessness
ƒ Cognitive - narrowed perceptual field & selective inattention
ƒ Emotional - use of any defense mechanism available
•
Sublimation
o The redirection of unacceptable instinctual drive with one that is socially
acceptable
o Instead of harming his mother, a man expressed his anger by
composing a song.
SEVERE
ƒ Physical - s/sx becomes the flow of attention
ƒ Cognitive – perceptual field is greatly narrowed, focus of attention is trivial
events
ƒ Emotional – defense mechanism operate
•
Symbolization
o Less threatening object is used to represent another
o A woman, missing her husband finds comfort in hugging her son who
looks like his father.
PANIC
ƒ Physical – s/sx of exhaustion ignored
ƒ Cognitive – personality disorganized
ƒ Emotional – defense mechanism fail
•
Undoing
o An attempt to erase an act, thought, feeling, guilt or desire
o A man gives her wife a bunch of roses after their argument last night.
Nursing Diagnoses:
ƒ Ineffective individual coping
ƒ Anxiety
Nursing Management:
ƒ Calm
ƒ Administer medications
ƒ Listen
ƒ Minimize environmental stimuli
ANXIETY DISORDERS
ANXIETY
ƒ Vague sense of impending doom
ƒ Subjective response to stress
ƒ Is a state of apprehension, uneasiness, uncertainty or tension experienced
by an individual in response to an unknown object or situation.
Panic Disorder
ƒ An individual may suddenly experience frightening and uncomfortable
symptoms
ƒ May include terror, sense of unreality or fear of loosing control
ƒ Attack: 1 minute and 1 hour
Signs and symptoms:
Mild
ƒ Physical - ↑PR, RR, BP, pupillary dilatation, sweating
ƒ Cognitive - Attentive and alert
ƒ Emotional - Minimal use of defenses
Phobic Disorder
ƒ Phobia is an irrational fear of an object, place, activity or situation.
ƒ Avoidance will allow the individual to be free from anxiety.
Moderate
a.n.g./n.a.l.
PSYCHIATRIC NURSING
Page 20 of 32
Examples:
 Agoraphobia - fear of open places and of being alone in public places.
 Social phobia - irrational fear of criticism, humiliation or embarrassment.
 Acrophobia - fear of heights
 Algophobia - fear of pain
 Claustrophobia - fear of enclosed place
 Thanatophobia - fear of crowds
 Pathophobia - fear of disease
 Monophobia - fear of being alone
Generalized Anxiety Disorder
(GAD)
ƒ Unrealistic, excessive anxiety and is unable to control worry.
ƒ Clients may experience: fatigue, irritability, restlessness, muscle tension,
sleep disturbance
Obsessive Compulsive Disorder
ƒ Is characterized by recurrent obsessions and compulsions that interfere
with normal life.
Obsession
ƒ Refers to persistent, painful intrusive thought, emotion or urge that one is
unable to suppress or ignore.
Compulsion
ƒ Refers to repetitious uncontrollable act and sometimes a purposeful act to
prevent a certain mistake in an event or situation.
Post-Traumatic Stress Disorder (PTSD)
ƒ Is the delayed reaction of the person who has been involved or exposed to
a traumatic events.
ƒ Symptoms of this disorder are:
 intense psychological distress
 feeling of detachment or estrangement from others
 insomnia
 decreased concentration
a.n.g./n.a.l.
PSYCHIATRIC NURSING



avoidance of thoughts and feelings
recurrent distressing dreams
inability to recall an important aspect of the trauma
Nursing Interventions
ƒ Calm and nonjudgmental approach to convey acceptance.
ƒ Use short and simple sentences or words.
ƒ Help the client develop an increase tolerance to anxiety.
ƒ Help the client to:
 develop a problem-solving and coping skills of the client.
 develop the ability to remain calm in anxiety-producing situations.
ƒ Approach: kind-firmness
ƒ Systematic desensitization (phobic disorders)
ƒ Clients with ritualistic behavior (obsessive-compulsive disorder) should not
be prohibited or reprimanded.
ƒ Biofeedback, change of the scenery, therapeutic touch, hypnosis, massage
or relaxation exercises.
ƒ Administer medications, as ordered.
ANXIETY RELATED DISORDERS
Somatization Disorder
ƒ Free floating anxiety disorder
ƒ Clients:
 express emotional turmoil or conflict through physical symptoms.
 usually seek for repeated medical attention.
 may exhibit antisocial behavior and may attempt suicide.
ƒ Associated with anxiety and depression
Conversion Disorder
ƒ A condition in which an anxiety-provoking impulse is converted
unconsciously into functional symptoms.
ƒ Conscious counterpart of malingering
ƒ Examples: Paralysis, blindness, loss of touch or pain sensation, dyspnea,
seizures or convulsions
Page 21 of 32
Hypochondriasis
ƒ An individual presents an unrealistic or exaggerated physical complaints.
ƒ The person becomes, preoccupied with the fear of developing or having
already a disease or illness in spite of medical reassurance.
Body Dysmorphic Disorder
ƒ Preoccupation with an imagined defect in his or her appearance.
ƒ Slight physical abnormality = excessive concern / anxiety
Dissociative Amnesia
ƒ Inability to recall extensive amount of important information
ƒ Caused by trauma
ƒ Characterized by:
 Disorientation
 Purposeless wandering
 Impairment in ability to perform ADL
ƒ Rapid recovery generally occur
PERSONALITY DISORDERS
ƒ Are pervasive and inflexible patterns of functioning that is stable overtime,
and leads to distress or impairment.
Types of Personality Disorders:
Eccentric Personality Disorder (Type A)
ƒ Paranoid (Suspicious and distrustful)
 Persons who display pervasive and long stand suspiciousness
 More common in men
ƒ Schizoid (Socially distant and detached)
 Pattern of detachment from social relationship
 Chooses solitary activities
 Topics are inanimate objects and ideas
ƒ Schizotypal (Odd and eccentric)
 “mild schizophrenia”
a.n.g./n.a.l.
PSYCHIATRIC NURSING


Acute discomfort in close relationships
Cognitive or perceptual distortion
Dramatic-Erratic Personality Disorder (Type B)
ƒ Antisocial (aggressive and manipulative)
 Pattern of disregard for the violation of the rights of others
 Low self-esteem
ƒ Borderline (destructive and unstable)
 Characterized by patterns of instability in relationships, self image and
mood
 Self-mutilating behavior
 Affective instability
 More common in women
ƒ Narcissistic (boastful / superiority complex)
 Grandiosity and need for constant admiration
 Exploitation of others for fulfillment of own desire
Anxious or Fearful Personality Disorder (Type C)
ƒ Avoidant (inferiority complex)
 Social inhibition
 Feelings of inadequacy and sensitivity
 Low self-esteem
 Social withdrawal in spite of a desire for affection and acceptance
ƒ Dependent (submissive)
 Submissive clinging behavior related to excessive need to be cared for
by others
 Lack of self-confidence
 Perceive self as helpless and stupid
ƒ Obsessive-Compulsive (perfectionist)
 Preoccupied with orderliness, perfectionism, inflexibility, need to be in
control
 Formal and serious interpersonal relationship
 Judgmental of self and others
ƒ Passive-Aggressive
Page 22 of 32


Intentional inefficiency
Passive resistance to demands for adequate performance in both
occupational and social functioning
Nursing Diagnosis:
• Ineffective individual coping
• Self-esteem disturbance
DISORDERS COMMONLY DIAGNOSED TO CHILDREN
AUTISM
ƒ Characterized by:
 impairment in communication skills
 presence of stereotyped behavior, interests and activities.
 associated with impairment on social interactions
ƒ treatable but not curable
ƒ more common among boys
ƒ usually diagnosed at age 2
ƒ Main problem: Interpersonal functioning
ƒ Most acceptable cause: Biological factors - brain anoxia, intake of drugs
Signs and Symptoms
ƒ Odd play
ƒ Not cuddly
ƒ Echolalia
ƒ Crying tantrums
ƒ Head towards anything
ƒ Inanimate object attachment
ƒ Loves to spin objects / self
ƒ Difficulty interacting with others
ƒ Wants blocks
ƒ Acts as deaf
ƒ Resists normal teaching method / routine changes
ƒ No fear of danger
a.n.g./n.a.l.
ƒ Insensitive to pain
ƒ No eye contact
ƒ Giggling or silly laughing
Nursing Interventions
ƒ Environment: safe & consistent
ƒ Encourage the client to participate for self-care
ƒ Speak calmly when giving instructions
ƒ Use simple words or phrases
ƒ Repeat instructions as necessary.
ƒ Haloperidol - symptomatic relief for hyperactivity, stereotypical and selfdestructive behavior
MENTAL RETARDATION
ƒ Not a mental illness.
ƒ Problem of inadequate mental functioning.
ƒ Onset: 18
ƒ IQ below 70
ƒ Manifested by sub-average intellectual functioning in:
ƒ Communication
Self-care
Home living
Social skills
Health and safety
Causes
ƒ HIV/ AIDS / rubella infection
ƒ Alcoholic mother
ƒ Thyroid deficiency
ƒ Excessive lead poisoning
ƒ Damage to the brain
ƒ Neurological / neurodevelopmental impairment
ƒ Exact gestational age is not reached (premature)
PSYCHIATRIC NURSING
Page 23 of 32
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
Opiate intoxication
Nutritional deficiency (lack in Folic Acid)
Anoxia
Toxemia (pregnancy-induced hypertension)
Environmental factors
Severe RH incompatibility
Levels:
Level
Mild/moron
IQ
51-70
Moderate/Imbecile
36-50
Severe/Idiot
20-35
Below
20
Implication
o Difficulty adapting to school
o Educable – needs assistance
Poor awareness of needs of others
Trainable – needs moderate supervision
o Unable to learn academic skills
o Poor motor development and minimal
speech
o Needs complete and close supervision
o Has minimal capacity for sensorimotor
function
o Needs custodial care with a totally
structured environment
Principles of Nursing Care
ƒ Protective care
Education of the family
 Their involvement is an important factor in the plan of care to promote
progress and to minimize the stress.
ƒ Repetition
ƒ Role modeling
ƒ Restructuring
ƒ Focus of Education
 Reading
 Arithmetic
 Writing
a.n.g./n.a.l.
PSYCHIATRIC NURSING
ATTENTION DEFICIT HYPERACTIVITY DISORDER
ƒ Common in boys
ƒ Usually diagnosed before age 7
ƒ Problems:
ƒ Inattention
ƒ Hyperactivity
ƒ Impulsivity
Causes: Intranatal factors
Signs and Symptoms
ƒ Obstinacy
ƒ Negativism
ƒ Egocentrism
ƒ Fighting syndrome
ƒ Aggressiveness
ƒ Tolerance is low
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
Difficulty concentrating
Excessive talking
Fidgeting
Interrupt/intrudes on others
Child exhibits hyperactivity
Indulges in destructive behavior
Temper tantrums
Nursing Diagnosis
• Potential for injury
Principles of Nursing Care:
ƒ Provide nutrition and safety
Page 24 of 32
ƒ Environment:
structured
enable appropriate reaction to the environmental stimuli
ƒ Plan a firm and consistent environment in which limits and standards are
set.
Drug of choice : Methylphenidate (Ritalin)
DISORDERS COMMONLY DIAGNOSED TO ADULTS
 purges after eating
 extreme exercise
ƒ Signs of purging
 swelling of the cheeks or jaw area
 cuts and calluses on the back of the hands and knuckles
 teeth that look clear
ƒ Peculiar signs
 depression
 loss of interests in activities
EATING DISORDERS
ƒ More common among females.
Causes:
ƒ Psychological factors
 Parental factors (domineering parents)
 Individual factors (conflict about growing up)
 Sociocultural factors
Anorexia Nervosa
ƒ Main sign: Morbid fear of gaining weight
ƒ Other signs:
 Sensitivity to cold temperatures
 Amenorrhea
 Deliberate self-starvation with weight loss




Findings: (for both)
ƒ Weight loss of 15% or more of original body weight
ƒ Amenorrhea
ƒ Social withdrawal and poor family and individual coping
ƒ History of high activity and achievement in academics, athletics
ƒ Electrolyte imbalance
ƒ Depression / distorted body image
Denial of hunger
Obvious thinness but feels fat
Lanugo all over the body
Loss of scalp hair
Bulimia Nervosa
ƒ Extreme measures to lose weight
 uses diet pills, diuretics or laxatives
a.n.g./n.a.l.
Nursing Diagnosis:
PSYCHIATRIC NURSING
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ƒ Body image disturbance
ƒ Ineffective individual coping
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
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Nursing Interventions:
ƒ Establish a trusting relationship
ƒ Monitor vital signs
ƒ Reinforce:
 dietician’s prescription to accomplish realistic weight gain
 treatment plan that establishes privileges and restrictions based on
compliance
ƒ Decrease emphasis on foods, eating, weight loss or gain
ƒ Weigh client daily at the same time
ƒ Remain with the client after meal and for 1st four hours
ƒ Set limit on time allotted for eating
ƒ Encourage client to express feelings
ƒ Promote feeling of control by
 participation in treatment
 independent decision making
SEXUAL DISORDERS
ƒ Sexuality - is the result of biologic, psychological, social and experimental
factors that mold an individual's sexual development, self-concept, body
image and behavior.
Phases of the Sexual Response Cycle
ƒ Desire
 the ability, interest and willingness to receive sexual stimulation
ƒ Excitement / Arousal
 Result of psychological stimulation
 Example is fantasizing during the desire phase and foreplay which
involves petting and fondling of erogenous zones or areas of the body
that are particularly sensitive to erotic stimulation.
ƒ Plateau
ƒ Orgasm
a.n.g./n.a.l.
PSYCHIATRIC NURSING
formerly termed as climax
the shortest stage in the sexual response cycle
occurs when stimulation proceeds through the plateau stage to a point
where the body suddenly discharges accumulated sexual tension
ƒ Resolution phase
 the final phase of sexual response
 organs and body systems gradually return to the unaroused state
Sexual Dysfunction Disorders
ƒ Sexual Desire Disorders: have little or no sexual desire or have an
aversion to sexual contact.
ƒ Sexual Arousal Disorder: Individuals cannot complete the physiologic
requirements for sexual intercourse
Examples
 Women cannot maintain lubrication
 Men cannot maintain an erection
ƒ Orgasm Disorders: Inability to achieve orgasm phase
Example: Premature ejaculation
ƒ Sexual Pain Disorders: Individuals suffer genital pain (dyspareunias)
Example: Vaginismius
Paraphilia (Sexual Deviation)
ƒ A term which generally refers to abnormal sexual behavior
ƒ Lasts for 6 months leading to distress or impairment to functioning.
Examples
Anilingus
Bestiality or Zoophilia
Coprophilia
Cunnillingus
Exhibitionism
tongue brushing the anus
contact with the animals
smearing feces on the partner
tongue brushing the vulva
 Involves exposing one’s genitals to unsuspecting
strangers.
Victims are usually women or children.
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
Fellatio
Fetishism
Frotteurism
Masochism
Necrophilia
Partialism
Pedophilia
Sadism
Telephone Scatalogia
Transvestism
Urophilia
Voyeurism
They are stimulated by the effect of shocking the
victim.
inserting the penis into the mouth
inanimate / non-living objects or articles
 Touching or rubbing against the unsuspecting
people.
 Usually occurs in crowded places where escape is
into the crowd is possible.
 Sexual gratification from experiencing pain
 Involves the acts of being humiliated beaten,
restrained, or otherwise made to suffer
 involves the use of corpses
 inserting the penis into the other parts of the body
 use of prepubertal children
 could be an actual sexual act or a fantasy
 child is generally 13 years of age or younger
inflicting pain
 Involves telephoning someone and making lewd,
obscene remarks or conversation.
 AKA sex on phone
sexual excitement through wearing the clothing of a
woman
urinating on the partner
Act of observing unsuspecting person who is naked, in
the process of disrobing, or engaging in sexual activity
Includes cyber-voyeurism
Gender Identity Disorder
ƒ AKA Transexualism
ƒ Believe that they were born as the wrong sex
ƒ Leads to persistent discomfort and feels inappropriate in the role of the
assigned sex.
ƒ Attitude:
 Accepting
 Empathic
 Non-judgmental
ƒ Accept his feelings related to sexuality
ƒ Have a private area to discuss fears or concerns about sexuality
ƒ Intervene to discuss self-esteem issues, anxiety, guilt, and empathy for
victims.
ƒ Employ limit setting.
ƒ Referral to the correct clinic.
SUBSTANCE-RELATED DISORDERS
Alcoholism
ƒ Is a chronic disease or a disorder characterized by excessive alcohol intake
and interference in the individual’s health, interpersonal relationship and
economic functioning. (WHO)
ƒ Considered to be present when there is .1% or 10 ml for every 1000 ml of
blood
Signs of use:
ƒ .1-.2% - low coordination
ƒ .2-.3% - presence of ataxia, tremors, irritability, stupor
ƒ .3 and above - unconsciousness
Progression:
ƒ Pre-alcoholic Phase - starts with social drinking; tolerance begins to
develop
ƒ Prodromal Stage - alcohol becomes a need; blockout's occur; denial
begins to develop
ƒ Crucial - cardinal symptoms of alcoholism develops (loss of control over
drinking)
ƒ Chronic Phase - the person becomes intoxicated all day
Nursing Interventions:
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PSYCHIATRIC NURSING
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ƒ serious medical complications may occur if the client is left untreated
Outcome:
ƒ Brain damage
ƒ Alcoholic hallucinosis
ƒ Death
Korsakoff's Psychosis
ƒ Is a form of amnesia
ƒ characterized
 short-term memory loss
 Disorientation
 inability to learn new skills
 confabulation
ƒ Deficiency in vitamin B complex, especially B1 and B12.
Behavioral problems:
ƒ Denial
ƒ Dependency
ƒ Demanding
ƒ Destructive
ƒ Domineering
Alcohol Withdrawal
ƒ Occurs when an individual abruptly stops drinking after alcohol has become
a necessity of life to maintain functioning.
ƒ Symptoms include:
 autonomic hyperactivity
 grand mal seizures
 psychomotor agitation and anxiety
 increased hand tremors
 sleep disturbances (insomnia and nightmares)
 illusions hallucinations
 hyperthermia
 tachycardia (impending delirium tremens)
Alcohol Withdrawal Delirium
ƒ AKA delirium tremens
 experienced within 24 to 72 hours after the last intake:
o agitation
o elevated vital signs
o illusions and hallucinations
o restlessness
o hyperalertness
o incoherent speech
a.n.g./n.a.l.
PSYCHIATRIC NURSING
Wernicke's Encephalopathy
ƒ An inflammatory hemorrhagic degenerative condition of the brain
ƒ caused by B1 deficiency
ƒ Symptoms include:
 double vision
 involuntary and rapid eye movements
 lack of muscular coordination
 decreased mental function
Nursing Diagnosis: Ineffective individual coping
Principles of Nursing Care:
ƒ Well lighted room
ƒ Diet as tolerated
ƒ Monitor vital signs
ƒ Administration of glucose
ƒ Vitamins
Alcohol Detoxification:
ƒ Drug of Choice: Disulfiram (Antabuse) - delays the metabolism of alcohol
ƒ Avoid alcohol-containing products
ƒ 3 S’s of detoxification:
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
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Safety
Sedation
Supplement (Multivitamins, Vitamin B-complex, Vitamin C)
DRUG-RELATED DISORDERS
Cocaine-Related Disorders
(Stimulants)
ƒ Cocaine is a white powdered stimulant substance
ƒ Usually sniffed, snorted, smoked in a pipe or injected into a vein or
subcutaneous tissue.
ƒ Poor man’s cocaine:
 Shabu (sha-boo)
ƒ Signs of use:
 panic attacks
 insomnia
 loss of appetite
 impaired thinking
 cocaine psychosis
 agitation
 dilation of the pupils
 diaphoresis
 increase VS
ƒ Classic sign: Perforated nasal septum
ƒ Can cause a sudden heart attack even in healthy young people.
Cannabis-Related Disorders (Cannabinoids)
Marijuana
ƒ Can act as stimulant or depressant and is often considered to be a mild
hallucinogen with some sedative properties
ƒ Is not physically addicting but may lead to psychological dependence
ƒ Plant : cannabis sativa
ƒ Active component is Tetrahydocannabinol
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PSYCHIATRIC NURSING
ƒ Routes of use:
 Orally (capsules, tablets, on sugar cubes)
 With food
 Smoked in a pipe or rolled as cigarette.
ƒ Acts within 15 minutes
ƒ Effects lasts approximately 2 to 4 hours
ƒ Physiologic symptoms include
 increased appetite
 excitement
 drowsiness
 lowered body temperature
 depression
 unsteady gait
 reduced coordination and reflexes
 inability to think clearly
 impaired judgment
ƒ Classic sign: bloodshot eyes
ƒ In large doses, it may cause:
 Hallucination
 Suicidal ideations
 Delusions of invulnerability
Long-term Goals:
ƒ Community resources
ƒ Other coping means aside from denial
ƒ Personal responsibility for not drinking / drugs taking
ƒ Isolation
ƒ Nutrition
ƒ Group therapy
SCHIZOPHRENIA AND OTHER PSYCHOSES
SCHIZOPHRENIA
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•
•
•
•
•
•
•
Is a serious psychiatric disorder
One of the most profound disabling illness
Not a single disease entity but a combination of disorders
"split mind"
characterized by:
o impaired communication
o loss of contact into reality
o deterioration from a previous level of functioning
Nursing Diagnosis: Altered thought process
Most acceptable theory: Biologic Theory
Manifestations: Eugene Bleuler
• Associative looseness
• Autism
• Apathy
• Ambivalence
• Auditory hallucination
Types
Distinguishing features
Disorganized Peculiar / bizarre behavior
Incoherence
Stereotyping
Paranoid
Prognosis: Poor
Defense Mechanism:
Regression
Hallucinations
Ideas of reference
Delusion of persecution
Suspiciousness
Prognosis: Good
Defense Mechanism:
Projection
a.n.g./n.a.l.
Nursing Interventions
ƒ Assist with ADL
ƒ Encourage activity
ƒ Present reality
ƒ Priority: safety of others
ƒ Deal with the HID
ƒ Offer sealed foods /
unopened medicines
ƒ Never displace outbursts of
emotions
ƒ Explain procedures in
simple ways
ƒ Never argue with the patient
PSYCHIATRIC NURSING
Catatonic
Wax flexibility
Stupor
Negativism – mutism, rigidity,
lack of response
ƒ Priority: nutrition &
circulation
ƒ Provide distraction
ƒ Encourage activity
Prognosis: Good
Defense Mechanism:
Repression
Undifferentiated
• Patients whose manifestation cannot be easily fitted into one or the
other type
Residual
• Patients with minimal symptoms
General Nursing Interventions:
ƒ Establish:
 a trusting relationship and provide acceptance
 a clear, consistent and open communication
ƒ Set limits
ƒ Decrease environmental stimuli
ƒ Observe for suicidal ideation
ƒ Administer medications, as ordered.
MOOD DISORDERS
Precipitating Factors
ƒ Loss of a loved one
ƒ Major life events
ƒ Role strain
ƒ Decreased coping resources
ƒ Physiological changes
Common Types of Mood Disorder
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ƒ Bipolar I Disorder: May experience one or more of symptoms of manic
episode
ƒ Bipolar II Disorder: May experience one or more symptoms of major
depressive episode with hypomania
ƒ Major Depressive Disorder: May be coded as mild, moderate or severe
with or without psychotic features.
ƒ Dysthymic Disorder
 Lesser severe than major depression
 No symptoms such as impaired communication, delusions and
hallucinations
ƒ Cyclothymic Disorder
ƒ DNOS (Depression Not Otherwise Specified) - lasts for 2 days-2 weeks
Clinical Symptoms of Major Depressive Episode
ƒ Affect flat
ƒ Weight change (gain or loss)
ƒ Energy loss
ƒ Sad feelings / Social withdrawal
ƒ Obvious sleep disturbances
ƒ Memory loss
ƒ Emotional blunting
a.n.g./n.a.l.
Kind firmness
Activity
Non-stimulating
Never give anything that
requires attention
Risk for injury:
Directed at others
Individual therapies
Lithium
Diet
Monotonous
Priority NDx
Nursing
Management
Risk for injury: selfdirected
Group therapy
Antidepressants
ECT
Suicide
ƒ thought or act of taking one’s own life
ƒ ultimate form of self-destruction
ƒ "cry for help“
ƒ reunion wish or fantasy
ƒ progressive failure to adapt feelings of anger or hostility
ƒ a way to end feelings of hopelessness and helplessness
ƒ an attempt "to save face" or seek a release to a better life
Nursing Diagnosis: Risk for injury-Self directed
Summary:
Appearance
DM
Matter of fact
Risk Factors
ƒ Sex (more female attempts suicide but more male commits suicide)
ƒ Unsuccessful previous attempt
ƒ Identification with a dead family member
ƒ Chronic
ƒ Illness (e.g. Cancer)
ƒ Depression/Dependent personality
ƒ Age (18-25 and 40)/Alcoholism)
ƒ Lethality of previous attempt/Looses
Clinical Symptoms of Manic Episode
ƒ Talkative or pressured to keep talking
ƒ Inflated self-esteem or grandiosity
ƒ Psychomotor agitation
ƒ Exhibit flight of ideas
ƒ Decreased need for help
ƒ Distractibility
Mania
Elated
Projection
Attitude therapies
Depression
Sad
Introjection
PSYCHIATRIC NURSING
Nursing care:
ƒ Safe environment
ƒ Always take overt or covert threats or attempts
seriously
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ƒ Ventilation of feelings
ƒ Encourage activities
ƒ Monitor closely (one-on-one, 24/7)
ƒ Empathy (show acceptance & appreciation)
CONDITIONS COMMONLY DIAGNOSED IN THE ELDERLY
Alzheimer’s Disease
A chronic, progressive degenerative cognitive disorder.
Marked by Dementia
Main Pathology: presence of senile plaques - destroys neurons (decreased
acethylcholline)
Signs and Symptoms:
ƒ Aphasia – deterioration of language function
ƒ Apraxia – impaired motor function
ƒ Agnosia – inability to recognize objects / people
ƒ Executive functioning - loss of abstract thinking
DEATH/D YING: Elizabeth Kubler-Ross
Stages:
Denial - "NO NOT ME"
Anger - "WHY ME"
Bargaining - "IF ONLY"
Depression - stage of silence
Acceptance - "Yes, it's me"
Nursing Diagnosis: Ineffective individual coping
Nursing Care:
ƒ Be physically present
ƒ Be non-judgmental
ƒ Encourage verbalization of feelings
ƒ Allow the patient to cry
ƒ Recognize your own thoughts about death and dying
3 PHASES:
ƒ Forgetfulness - difficulty of remembering appointments
ƒ Advance - difficulty of remembering past events but not recent events
ƒ Terminal - death occurs in 1 year
Nursing Diagnosis: Altered thought processes
Nursing Care:
ƒ Priority: safety & security
ƒ Always reorient the client (clock & calendar)
ƒ Use color instead of numbers & letters
ƒ Consistency – 1 nurse to lessen confusion
---END---
CONCEPTS ON DEATH AND DYING
a.n.g./n.a.l.
PSYCHIATRIC NURSING
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