Psychiatric Mental Health Nursing
Eve Karpinski, APHN-BC, RN-BC
Question 1
 How stress are you now?
 1. Not at all.
 2. Mildly
 3. Moderately
 4. Severely
Stress
 The word stress lacks a definitive definition.
 Adaptation is defined as restoration of homeostasis to
the internal environmental system.
 Adaptation includes responses directed at stabilizing
internal biological processes and psychological
preservation of self-identity and self-esteem.
Stress as a Transaction Between the
Individual and the Environment
 Individual’s perception of the event
 Primary appraisal – a judgment about the situation in
one of the following ways:
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Irrelevant
Benign-positive
Stress appraisal
 Secondary appraisal – an assessment of skills,
resources, and knowledge that the person possesses to
deal with the situation
 Precipitating event – a stimulus arising from the
internal or external environment and perceived by the
individual in a specific manner
The physiological of stress
 . “Fight or Flight” Response
 When the body encounters a stressor, it prepares itself for “fight or
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flight.” Identify the adaptation responses that occur in the initial stress
response in each of the physical components listed.
Physical component Adaptation Response
Adrenal medulla
Eye
Respiratory system
Cardiovascular system
Gastrointestinal system
Liver
Urinary system
Sweat glands
Fat cells
Releases norepinephrine and epinephrine.
Pupils dilate.
Secretion is increased from lacrimal glands.
Bronchioles dilate.
Respiration rate is increased.
Increased force of cardiac contraction
Increased cardiac output
Increased heart rate
Increased blood pressure
Decreased gastric and intestinal motility
Decreased secretions
Sphincters contract
Increased glycogenolysis and gluconeogenesis
Decreased glycogen synthesis
Increased ureter motility
Bladder muscle contracts
Bladder sphincter relaxes
Increased secretion
Lipolysis
Stress Response
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Adrenal medulla
Eye
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Respiratory system
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Cardiovascular system
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Gastrointestinal system
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Liver
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Urinary system
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Sweat glands
Fat cells
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Releases norepinephrine and epinephrine.
Pupils dilate.
Secretion is increased from lacrimal glands.
Bronchioles dilate.
Respiration rate is increased.
Increased force of cardiac contraction
Increased cardiac output
Increased heart rate
Increased blood pressure
Decreased gastric and intestinal motility
Decreased secretions
Sphincters contract
Increased glycogenolysis and gluconeogenesis
Decreased glycogen synthesis
Increased ureter motility
Bladder muscle contracts
Bladder sphincter relaxes
Increased secretion
Lipolysis
When the stress response is sustained for an extended period of time the pituitary gland
is stimulated by the hypothalamus to release a number of
hormones. Match the ultimate physical effects listed below with the appropriate
hormone that triggers the response.
__________ 1. Adrenocorticotropic hormone (ACTH)
__________ 2. Vasopressin (antidiuretic hormone [ADH])
__________ 3. Growth hormone
__________ 4. Thyrotropic hormone (TTH)
__________ 5. Gonadotropins
a. Results in increased serum glucose and free fatty acids.
b. Suppression of sex hormones resulting in decreased libido and impotence.
c. Increased gluconeogenesis; immunosuppression; anti-inflammatory response;
increased sodium and water retention.
d. Increased basal metabolic rate.
e. Increased blood pressure (through constriction of blood vessels) and increased
fluid retention.
Stress Mastery
 Stress Mastery is the utilization of coping
strategies in the response to stressful situations.
 Adaptive coping strategies protect the individual
from harm and restore physical and psychological
homeostasis.
 Coping strategies are considered maladaptive when the
conflict being experienced goes unresolved or intensifies.
Effects of chronic Stress
 Increase Gluconeogenisis
 Decrease Immune
 Decrease inflammatory response
 Retention of sodium and water
 Decrease in libido, frigidity and impotence
 Increase in blood pressure
The Physiological of Relaxation
Unhealthy Coping Strategies
Healthy Coping Strategies
 Awareness
 Your own thoughts
 Relaxation
 Laughter
 Meditation
 Interpersonal
communication with caring
other
 Problem-solving
 Pets
 Music
 Aromatherapy
 Massage
 Journaling
 Personality is defined by the DSM-IV-TR as “enduring
patterns of perceiving, relating to, and thinking about
the environment and oneself that are exhibited in a
wide range of social and personal contexts.”
 Life-cycle developmentalists believe that people
continue to develop and change throughout life,
thereby suggesting the possibility for renewal
and growth in adults.
Theories
 Freud’s theory of psychosexual development
 Erikson’s eight development stages
 Harry Stack Sullivan’s interpersonal theory
 Mahler’s theory of object relations development
 Piaget’s cognitive development
 Kohlberg’s theory of moral development
 Nursing Peplau’s stages
Mental Health
 Defined as “The successful adaptation to stressors
from the internal or external environment, evidenced
by thoughts, feelings, and behaviors that are ageappropriate and congruent with local and cultural
norms.”
 Stages are identified by age. However, personality is
influenced by temperament (inborn personality
characteristics) and the environment.
 It is possible for behaviors from an unsuccessfully
completed stage to be modified and corrected in a
later stage.
Mental Illness
 Defined as “Maladaptive responses to stressors from the
internal or external environment, evidenced by thoughts,
feelings, and behaviors that are incongruent with the local
and cultural norms and interfere with the individual’s social,
occupational, or physical functioning.”
 Horwitz describes cultural influences that affect how individuals
view mental illness. These include
 Incomprehensibility – the inability of the general
population to understand the motivation behind the
behavior.
 Cultural relativity – the “normality” of behavior is determined
by the culture.
Psychological Adaptation to
Stress
 Anxiety and grief have been described as two
major, primary psychological response patterns to
stress.
 A variety of thoughts, feelings, and behaviors are
associated with each of these response patterns.
 Adaptation is determined by the extent to which
the thoughts, feelings, and behaviors interfere
with an individual’s functioning.
Anxiety
 A diffuse apprehension that is vague in nature and is
associated with feelings of uncertainty and
helplessness.
 Extremely common in our society.
 Mild anxiety is adaptive and can provide motivation
for survival.
Peplau’s four levels of anxiety
 Mild – seldom a problem
 Moderate – perceptual field diminishes
 Severe – perceptual field is so diminished that
concentration centers on one detail only or on many
extraneous details
 Panic – the most intense state
Behavioral Adaptation
Responses to Anxiety
 At the mild level, individuals employ various coping
mechanisms to deal with stress.
A few of these include eating, drinking, sleeping, physical
exercise, smoking, crying, laughing, and talking to persons
with whom they feel comfortable.
 Anxiety at the moderate to severe level that remains
unresolved over an extended period of time can contribute
to a number of physiological disorders – for example,
migraine headaches, IBS, and cardiac arrhythmias.
Extended periods of repressed severe anxiety can result in
psychoneurotic patterns of behaving – for example, anxiety
disorders and somatoform disorders.
Grief
 The subjective state of emotional, physical, and social
responses to the loss of a valued entity; the loss may be
real or perceived.
 Elisabeth Kübler-Ross
(5 Stages of Grief)
 Denial
 Anger
 Bargaining
 Depression
 Acceptance
Defense Mechanisms
 Compensation
 Denial
 Displacement
 Identification
 Intellectualization
 Introjection
 Isolation
 Projection
 Rationalization
 Reaction formation
 Regression
 Repression
 Sublimation
 Suppression
 Undoing
DSM-IV-TR Multiaxial Evaluation
System
 Axis I – Clinical disorders and other conditions
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that may be a focus of clinical attention
Axis II – Personality disorders and mental
retardation
Axis III – General medical conditions
Axis IV – Psychosocial & environmental problems
Axis V – Global assessment of functioning rated
on the Global Assessment of
Functioning (GAF) Scale, which
measures an individual’s
psychological, social, and occupational
functioning
Psychobiology
 The 101st Congress of the U.S. designated the 1990s
as the “Decade of the Brain,” with the challenge
for studying the biological basis of behavior.
 In keeping with the neuroscientific
revolution, greater emphasis is
placed on the study of the
organic basis for psychiatric
illness.
Implications for Nursing
 Emphasis in psychiatric nursing is on a smooth
transition from a psychosocial approach to a
biopsychosocial focus
 Psychiatric nurses must have a specialized knowledge
about
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Neuroanatomy and neurophysiology
Neuronal processes
Neuroendocrinology
Circadian rhythms
Genetic influences
Psychoimmunology
Psychopharmacology
Diagnostic technology
Neurotransmitters
play an important role in human emotions and
behavior and are the target for the mechanism of
action in many psychotropic medications.
Major categories of neurotransmitters
Cholinergics
Monoamines
Amino acids
Neuropeptides
 Pituitary gland
 Posterior lobe
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Vasopressin
Oxytocin
 Anterior lobe
 Growth hormone
 Thyroid-stimulating hormone
 Adrenocorticotropic hormone
 Prolactin
 Gonadotropic hormones
 Melanocyte-stimulating hormone
Circadian rhythms
Follow a near-24-hour cycle in humans and may influence
a variety of regulatory functions, including the
sleep-wake cycle, body temperature regulation,
patterns of activity such as eating and drinking, and
hormone secretion.
 Some mood disorders have been linked to increased
secretion of melatonin during darkness hours.
 Symptoms that occur in the premenstrual cycle have
been linked to disruptions in biological rhythms.
Sleep-wake cycle is one of the most common biological
rhythms that demonstrates circadian influence.
Sleep stages
0 – Alpha
1 – Beta
2 – Theta
3 – Delta
4 – Delta
REM - Beta
Neurochemical influences on sleep-wake cycle
Serotonin and L-tryptophan
Norepinephrine and dopamine
GABA
Acetylcholine
Ethical and Legal Issues in
Psychiatric/Mental Health
Nursing
Definitions
 Ethics - the science that deals with the rightness and
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wrongness of actions
Bioethics - term applied to ethics when they refer to
concepts within the scope of medicine, nursing, and allied
health
Values – ideals or concepts that give meaning to the
individual’s life
Moral behavior – conduct that results from serious critical
thinking about how individuals ought to treat others
Values clarification – a process of self-exploration
through which individuals identify and rank their own
personal values
 Values – ideals or concepts that give meaning to the
individual’s life
 Moral behavior – conduct that results from serious
critical thinking about how individuals ought to treat
others
 Values clarification – a process of self-exploration
through which individuals identify and rank their own
personal values
Ethical Considerations
Theoretical Perspectives
 Utilitarianism – an ethical theory that promotes actions based
on the end results that produce the most good (happiness) for
the most people
 Kantianism – suggests that decisions and actions are bound by
a sense of duty
 Christian ethics - do unto others as you would have them do
unto
you; alternatively, do not do unto others what you would not
have them do unto you.
 Natural law theories – do good and avoid evil. Evil acts are
never condoned, even if they are intended to advance the noblest
of ends.
 Ethical egoism – decisions are based on what is best for the
individual making the decision.
Ethical Dilemmas
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Ethical dilemmas occur when moral appeals can be
made for taking either of two opposing courses of
action.
Taking no action is considered an action taken.
Avoiding Liability
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Respond to the client
Educate the client
Comply with the standard of care
Supervise care
Adhere to the nursing process
Document carefully
Follow up and evaluate
Maintain a good interpersonal
relationship with client and family
Ethical Principles
 Autonomy – This principle emphasizes the status of
persons as autonomous moral agents whose rights to
determine their destinies should always be respected.
 Beneficence – This refers to one’s duty to benefit or
promote the good of others.
Nonmaleficence – abstaining from negative acts toward another;
includes acting carefully to avoid harm
Justice – principle based on the notion of a hypothetical social
contract between free, equal, and rational persons. The concept
of justice reflects a duty to treat all individuals
equally and fairly.
Veracity – principle that refers to one’s duty to be truthful always.
A Model for Making Ethical
Decisions
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Assessment
Problem identification
Plan
Implementation
Evaluation
Ethical Issues in Psychiatric/Mental
Health Nursing
 The right to refuse medication
The right to the least restrictive treatment alternative
Legal Considerations
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Nurse Practice Act defines the legal parameters of professional
and practical nursing.
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Types of Laws
 Statutory law
 Common law
 Civil Law – protects the private and property rights of individuals
and businesses
Tort
 Contracts
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 Criminal law – provides
protection from conduct
deemed injurious to the
public welfare
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Confidentiality and right to privacy
 Doctrine of privileged communication
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Informed consent
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Restraints and seclusion
 False imprisonment
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Commitment issues
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Voluntary admissions
Involuntary commitment
Emergency commitment
The mentally ill person in need of treatment
Involuntary outpatient commitment
The gravely disabled client
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Malpractice and negligence
Types of lawsuits that occur in psychiatric nursing
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Breach of confidentiality
Defamation of character
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Libel
Slander
Assault and battery
False imprisonment
Invasion of privacy