REVIEWER NI EREN

Mental Health-Psychiatric Nursing Practice
I. Human Nature – Determinism
A.
Psycho Sexual Stages
Personality theories and determinants of
• Deterministic : Our behaviour is determined by
psychopathology:
irrational forces, unconscious motivations, and
Implications
for
mental
health-psychiatric
nursing practice.
biological and instinctual drives as these evolve
through key psychosexual stages in the first six
yrs of life.
• One can liberate from these – unconscious
1.
PSYCHOANALYTIC THEORY
becomes conscious
Sigmund Freud (1856— 1939)
II. Instincts
• Sigismund Schlomo Freud; 6 May 1856 – 23
• Life Instincts ( Eros)
September 1939)
> Maintain the survival of the individual and
•
Austrian neurologist,
•
father of psychoanalysis.
>Identified with libido (Sexual energy )
•
Oldest of eight children
> All pleasurable acts
humankind
• Married with 3 girls and 3 boys
• Death Instincts (Thanatos)
• Based theory on personal experiences
> Aggressive Drives
Fundamental
> Manifest themselves in one’s unconscious wish
Assumptions
of
Psychoanalytic
Approach
to die or to hurt oneself or others
• Unconscious factors motivate our behavior
III. Theory of Personality
• Experiences or events of first 6 yrs of life are
A. Functional or Dynamic (THE STRUCTURAL
determinants of later development of personality
THEORY)
• Unconscious motives and conflicts are central
•
Freud argued that the human mind and
personality are made up of three parts:
• Later personality problems will have its roots on
early repressed childhood conflicts
Id, Ego, Superego
BASIC CONCEPTS
Uncoscious,Preconscious , Conscious

Human Nature
•
ID -pleasure principle/primary process

Instincts
•
EGO -reality principle/secondary process

Anxiety
•
SUPEREGO -conscience

Theory of Personality – Functional or Dynamic
-ego ideal
– Structural or Topographical

Ego Defense Mechanisms
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1. Id (evil side) = reflects basic or innate desires
>It contains the commands and prohibitions that
such as pleasure- seeking behaviour, aggression,
we learn from parents, teachers, and others in
and sexual impulses.
authority during our childhood years.
•
•
Seek
instant
causes
>It both arises from, and allows resolution of, the
impulsive unthinking behavior, and has no
Oedipus complex that all humans have to
regard for rules or social convention.
negotiate at about the age of five
The
 According to Freud, the ego dwells in the
“it”
(or,
gratification,
the
id)
:
pleasure
principle/primary process
conscious mind and the id and superego are in
2. The ego ( the “ME/I” ): acts according to the
reality principle.
•
 Freud argued that our personality should be in
is the balancing or mediating force
between the id and superego.
•
:EGO

the area of our unconscious.
a state of dynamic equilibrium (balance)
B.
represents mature and adaptive behavior
• According to Freud, there are three levels of
consciousness:
reality principle/secondary process
• three levels of consciousness/awareness:
The “me” (or, the ego)
> The id is the original pleasure-seeking mind,
1.
with the demands, pressures, and frustrations
the
perceptions,
e.g.: Being aware of happy feelings
imposed by the outside world.
Thinking about a loved one.
> secondary process thinking, that realistic,
rational
cognitive
activity that we associate with waking life in
adulthood.
2. Preconscious – thoughts and emotions are not
currently in the person’s awareness, but he or she
can recall them with some effort.
e.g.: an adult remembering what he or she did,
3. The superego (Social Component ):
•
to
person’s awareness.
realistic one, driven by the need to compromise
goal-oriented,
Conscious-refers
thoughts, and emotions that exist in the
driven by instincts, and the ego is the newer,
pragmatic,
Levels of Conciousness
thought, or felt as a child.
is the part of person’s nature that reflects
moral and ethical concepts, values, and
parental and social expectations.
•
It is in direct opposition to the id.

The “over-me” (or, the superego) .
2. Unconscious
behavior.
exercises
moral
censorship
is
the
realm
of
thoughts and feelings that motivate a
person even though he or she is totally
unaware of them.
>The superego is an ideal ego that, as the
conscience,
mind-
on
•
According to Freud’s theories, a person
represses into unconscious the memory of
a traumatic events that are too painful to
remember.
2
The metaphor of an iceberg to help us in
understanding Freud's topographical theory.
•
Only
10%
of
an
iceberg
is
5. Compensation — It is an attempt to cover ones
visible
(conscious) whereas the other 90% is
beneath the water (preconscious and
unconscious).
•
The
deficiency e.g. If a student is not good in his
studies, may show his ability in sports.
6.Identification — It is a process which may
operate outside and beyond conscious awareness.
Preconscious
is
allotted
Hero worshipping by an individual is a sort of
approximately 10% -15% whereas the
identification
Unconscious is allotted an overwhelming
himself with a popular hero or an actor.
75%-80%.
where
an
individual
identifies
7. Displacement- redirecting of thoughts feelings
Ego Defense Mechanisms
and impulses directed at one person or object, but
- It operates on an unconscious level and they
tend to deny or distort reality
taken out upon another person or object. The
classic example is the man who gets angry at his
boss, but can’t express his anger to his boss for
Two characteristics
fear of being fired. He instead comes home and
kicks the dog or starts an argument with his wife.
a) Denying, falsifying and distorting realty
The man is redirecting his anger from his boss to
b) Operating unconsciously
his dog or wife.
Defense Mechanisms
8.Withdrawal — withdraw themselves from the
1.Projection —an individual puts the blame of his
own failure upon others and some unfavorable
factors of his environment. Blaming others for his
mistake .e.g. a student comes late to the class
circumstances that cause tension, frustration or
pain e.g. If a person is being humiliated or laughed
at, he may shut himself in a room and may not need
any one.
excuses by saying that the bus or train was late
9.Day-dreaming — It is a defense mechanism
or traffic jam.
which sometimes helps in making adjustment. e.g.
2.Sublimation
—unacceptable
desire
are
redirected into socially accepted channels. e.g.
Anger –Kick boxing-some people, poem writing,
engage in social services.
into the unconscious
Posttraumatic
Stress
of becoming a bride groom and feels satisfaction
in the imaginary world.
10.Denial – Simplest form of self defense
3.Repression — Pushes threatening thoughts back
-
A young man who has been jilted in love, dreams
eg. If a person is diagnosed as having cancer,
they will first get shock, then start denying
Disorder
(PTSD)
–
Common with veterans and victims of sexual abuse
4.Rationalization — An individual tries to justify
his failure by giving some excuses e.g. A student
makes use of rationalization, when he tries to
blame teachers for hard question paper.
reality saying perhaps that the diagnosis was not
proper.
11.Reaction Formation – It is the replacement in
consciousness of an anxiety producing impulse or
feeling by its oppsite eg. A person who hates
another cannot accept the painful fact of hating
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and so shows extraordinary love towards that
attempting to counteract the damage done by the
person
original comment, hoping the two will balance one
12.Introjection
–
taking
in
and
accepting
uncritically the values and standards of others eg.
If a child is constantly called stupid, the child
thinks that she is really stupid.
another out.
ERIK ERIKSON’S PSYCHOSOCIAL THEORY

Erikson
described
eight
psychosocial
stages of development. In each stage, the
13. Regression- is the reversion to an earlier stage
person must complete a life task that is
of development in the face of unacceptable
essential to his or her well-being and
thoughts
mental health.
or
impulses.
For
an
example
an
adolescent who is overwhelmed with fear, anger

This task allow the person to achieve life’s
and growing sexual impulses might become clingy
virtues: hope, purpose, fidelity, love,
and start exhibiting earlier childhood behaviors
caring, and wisdom.
he has long since overcome, such as bedwetting.
14. Acting Out- is performing an extreme
behavior. Instead of saying, “I’m angry with you,”
a person who acts out may instead throw a book
at the person, or punch a hole through a wall.
When a person acts out, it can act as a pressure
release, and often helps the individual feel calmer
and peaceful once again.
15.Dissociation- is when a person loses track of
time and/or person, and instead finds another
representation of their self in order to continue
in the moment. People who have a history of any
kind of childhood abuse often suffer from some
form
of
dissociation.
In
extreme
cases,
dissociation can lead to a person believing they
have
multiple
selves
(“multiple
personality
disorder”).
16. Compartmentalization- parts of oneself are
CRISIS AND CRISIS INTERVENTION
CRISIS - turning point in an individual’s life
that produces an overwhelming emotional
response.
separated from awareness of other parts and
CATEGORIES:
behaving as if one had separate sets of values.
1.
17. Undoing- is the attempt to take back an
unconscious
behavior
or
thought
that
is
unacceptable or hurtful. For instance, after
realizing you just insulted your significant other
unintentionally, you might spend then next hour
praising their beauty, charm and intellect. By
MATURATIONAL CRISIS - sometimes
called
developmental
crisis,
are
predictable events in the normal course of
life.
2. SITUATIONAL CRISIS - are anticipated
or sudden events that threaten the
individual’s integrity.
“undoing” the previous action, the person is
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gives the nurse an idea about the client’s
3. ADVENTITIOUS
CRISIS
(SOCIAL
CRISIS) – include natural disaster, violent
crimes
perception of his or her situation.
MENTAL STATUS EXAMINATION
CONTENT OF THE ASSESSMENT:
CRISIS INTERVENTION
1.


History
Directive interventions – are designed to

General Appearance and Motor Behavior
assess the person’s health status and promote

Mood and Affect
problem solving, such as offering the person

Thought Process and Content
new information, knowledge, or meaning;

Sensorium and Intellectual Processes
by

Judgmental and Insight
and

Self-concept
directing the persons behavior by offering

Roles and Relationships
suggestions or course of action.

Physiologic and Self-care concerns
raising
the
providing
person’s
feedback
self-awareness
about
behavior;
2. Supportive interventions – Aim at dealing with
the
person’s
understanding,
needs
such
as
for
empathetic
encouraging
the
GENERAL
APPEARANCE
The
serving as a sounding board for the person,
appearance, including:
MENTAL STATUS EXAMINATION
ASSESSMENT - first step of the nursing process
and involves the collection, organization, and
analysis of information about the client’s health.
MOTOR
BEHAVIOR
person to identify and discuss feelings ,
and affirming the person’s self-worth.
AND
nurse
assesses
the
client’s
overall

Hygiene and grooming

Appropriate dress

Posture

Eye contact

Unusual movements or mannerism

Speech (rate of the speech fast or slow,
PSYCHOSOCIAL ASSESSMENT - to construct a
responses a minimal “yes” or “no” without
picture of the client’s current Emotional state,
elaboration, tone audible or loud)
Mental capacity, and Behavioral function.
Automatisms: repeated purposeless behaviors
FACTORS INFLUENCING ASSESSMENT:

Client Participation/ Feedback

Client’s Health Status

Client’s
Experiences/Misconceptions
often indicative of anxiety, such as drumming
fingers, twisting locks of hair, or tapping the foot.
Psychomotor
Previous
about
Health Care

Client’s Ability to Understand

Nurse’s Attitude and Approach
OPEN – ENDED QUESTIONS: allows the client to
begin as he or she feels comfortable and also
retardation:
overall
slowed
movements
Waxy flexibility: maintenance of posture or
position over time even when it is awkward or
uncomfortable.
Neologism : invented words that have meaning only
for the client.
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MOOD : refers to the client’s pervasive and
Loose associations: disorganized thinking that
enduring
jumps from one idea to another with little or no
emotional
state.
EXPRESSED
EMOTIONS
evident relation between the thoughts.
AFFECT : is the outward expression of the client’s
Tangential thinking: wandering off the topic and
emotional state. FACIAL EXPRESSION
never providing the information requested.
BLUNTED AFFECT: showing little or a slow-to-
Tendency to speak about the topics unrelated
respond facial expression.
to the main topics.
BROAD AFFECT: displaying a full range of
Thought blocking: stopping abruptly in the middle
emotional expression.
of a sentence or train of thought; sometimes
unable to continue the idea.
FLAT AFFECT: showing no facial expression.
INAPPROPRIATE AFFECT: displaying a facial
expression that is incongruent with mood or
situation; often silly or giddy regardless of
circumstances.
Thought broadcasting: a delusional belief that
others can hear or know what the client is
thinking.
Thought insertion: a delusional belief that others
RESTRICTED AFFECT: displaying one type of
expression, usually serious or somber.
LABILE: when client exhibits unpredictable and
rapid mood swings from depressed and crying to
euphoria with no apparent stimuli.
Thought process: refers to how the client thinks.
Thought Content: is what the client actually says.
are putting ideas or thoughts into the client’s
head- that is, the idea are not those of the client.
Thought withdrawal: a delusional belief that
others are taking the client’s thoughts away and
the client is powerless to stop it.
Word salad: flow of unconnected words that
convey no meaning to the listener.
Confabulation: is a type of memory error in which
Circumstantial thinking: a client eventually answer
gaps in a person’s memory are unconsciously filled
a question but only after giving excessive
with fabricated, misinterpreted or distorted
unnecessary detail.
information.
Delusion : a fixed false belief not based in reality.
SENSORIUM AND INTELLECTUAL PROCESSES
Flight of ideas : excessive amount and rate of

ORIENTATION
speech composed of fragmented or unrelated

MEMORY
ideas.

ABILITY TO CONCENTRATE

ABSTRACT
Ideas
of
reference:
client’s
inaccurate
interpretation that general events are personally
THINKING
INTELLECTUAL ABILITIES
directed to him or her, such as hearing a speech
ORIENTATION
on the news and believing the message
recognition of person, place, and time
personal meaning.
had
&
-
Refers
to
the
client’s
Hallucinations = can involve the five senses and
bodily sensations.
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Auditory hallucination: hearing voices, are the
most common
Therapeutic use of self

the nurse can begin to use aspects of his
Visual hallucination = seeing things don’t really
or her personality, experiences, values,
exist, are second most common.
feelings,
skills,
JUDGMENT: refers to ability to interpret one’s
and
needs,
coping
perceptions, to establish
relationships with clients.
environment and situation correctly and adapt
one’s behavior and decisions accordingly.
intelligence,
JOHARI WINDOW
INSIGHT : is the ability to understand the true

nature of one’s situation and accept some personal
responsibility for that situation
about oneself

SENSORY- PERCEPTUAL ALTERATIONS - Some
clients experience HALLUCINATIONS (false
sensory perceptions or perceptual experiences
One tool that is useful in learning more
Which creates a “word portrait” of a
person in four areas and indicates how well
that person knows himself or herself and
communicates with others.
that do not really exist)
The four areas evaluated as follows:
SELF CONCEPT - the way one views oneself in
Quadrant 1: Open/ public self- qualities one knows
terms of personal worth and dignity.
about oneself and others also know.
ROLES
AND
RELATIONSHIP
-
People
functioning in their community through various
roles such as mother, wife, son, daughter,
teacher, secretary, or volunteer
PHYSIOLOGIC
AND
Quadrant 2: Blind/ unaware self – qualities known
only to others.
Quadrant 3: Hidden /private self – qualities known
only to oneself.
SELF-CARE
CONSIDERATION - When doing psychosocial
assessment, the nurse must include physiologic
functioning. Although a full physical health
Quadrant 4: Unknown – an empty quadrant to
symbolize qualities as yet undiscovered by oneself
or others.
assessment may not be indicated, emotional
problems often affect some areas of physiologic
function.
SELF – CARE CONSIDERATION - The nurse also
ask the client if he or she has any major or chronic
health problems and if he or she takes prescribed
medications as ordered and follows dietary
recommendations.
SELF AWARENESS

Is the process by which the nurse gains
recognition of his or her own feelings,
beliefs, and attitudes.
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