PSYCHIATRIC NURSING I.

Mental Health & Mental Illness Mental Health (WHO): Actualization Contributes to community Tolerance Stays productive/Meaningful life Mental Illness (APA 2013): o Syndrome o Significant disturbance in cognition, emotion, regulation, or behavior. o Dysfunction in psychological, biological, & developmental process. o Significant distress in social, occupational, & other important activities. II. Theoretical Frameworks A. Psychoanalytic Sigmund Freud (Father of Psychoanalysis) (+) Neurosis vs (-) Psychosis Goal: give insight/bring repressed exp. into conscious awareness. Structure of personality: 1. Id: Pleasure Principle; birth 2. Ego: Rational Self; Reality Principle 3. Superego: Perfection Principle; 3-6 y/o o Ego Ideal: Reward o Conscience: Punishment; Guilt 3 Level of Awareness 1. Conscious 2. Preconscious 3. Unconscious Stages of Psychosexual Development 1. Oral (Birth-18mos.): gratification of basic oral needs. 2. Anal (18mos.-3yrs.): independence & control. 3. Phallic (3-6yrs.): sexual identity; Oedipus(M) & Electra(F) complex. 4. Latency (6-12yrs.): relationship with the same sex. 5. Genital (13-20yrs.): libido; relationship with the opposite sex. B. Developmental (Psychosocial) Erik Erikson Goal: analyze issues. Stages of Personality Development 1. Trust vs Mistrust (Birth-18mos) 2. Autonomy vs Shame & Doubt (18mos-3yrs) 3. Initiative vs Guilt (3-6yrs) 4. Industry vs Inferiority (6-12yrs) 5. Identity vs Role Confusion (12-20yrs) 6. Intimacy vs Isolation (20-30yrs) 7. Generativity vs Stagnation (30-65yrs) 8. Ego Integrity vs Despair (65yrs-Death) C. Interpersonal Harry Stack Sullivan Goal: re-educate interpersonal skills. Stages of Personality Development 1. Infancy (Birth-18mos): oral gratification 2. Childhood (18mos-6yrs): delay in personal gratification 3. Juvenile (6-9yrs): relationship with peer 4. Preadolescence (9-12yrs): relationship with the same sex 5. Early Adolescence (12-14yrs): relationship with the opposite sex 6. Late Adolescence (14-21yrs): lasting intimate opposite sex relationship D. Cognitive-Behavioral Existential (?)

Beck & Albert Ellis Goal: change belief. E. Behavioral Albert Bandura (Social Cognitive) o Concepts: 1. Observational Learning: Bobo Doll experiment Basic Models: 1. Live model 2. Verbal instructional model 3. Symbolic model 2. Mental States Intrinsic reinforcement: e.g. pride, satisfaction. Conditions for Effective Modelling: 1. Attention 2. Retention 3. Reproduction 4. Motivation Self-Efficacy Theory: belief in ones capabilities. Sources: 1. Mastery experiences 2. Social modeling (vicarious exp.) 3. Social or Verbal persuation 4. Psychological responses (physiologic arousal) o Basis: 1. Process of modeling 2. Concept of disinhibition: forgets diet when with friends. 3. Concept of elicitation: does unwanted activities if the crush is doing it. 4. Self-efficacy Burrhus Frederic Skinner (Operant/Instrumental Conditioning) o past exp.; repeatedly reinforced o Components: 1. Reinforcement (+ & -) 2. Punishment (+ & -) o Principles: (behaviors) 1. Learned 2. Consequences 3. Reinforcers 4. Positive reinforcers ( ^ recurrence) 5. Negative reinforcers (remove=recur) 6. Continuous reinforcement (fast=doesnt last long) 7. Random intermittent reinforcement (slow=continuous) Ivan Pavlov (Classical Conditioning) 1. Unconditioned stimulus 2. Unconditioned response 3. Conditioned stimulus 4. Conditioned response o Principles: a. Acquisition b. Extinction c. Generalization d. Discrimination F. Humanistic Abraham Maslow (Hierarchy of Needs) G. Neurobiological 1. Cerebrum Dominant/Left hemisphere: L.A.R.W.M. Nondominant/Right hemisphere: C.I.A. Lobes: a. Frontal: O-BM-Me-Em-Mo

o Integrative function: AR-At-PS-De b. Parietal: Ta-To-SO c. Temporal: S-H-Me d. Occipital: Co-LG-VI 2. Diencephalon a. Thalamus: RA-SB-EA b. Pineal gland c. Hypothalamus: Tr-Ac-En-Sd o Mamillary bodies: emotional response to odor. 3. Brainstem a. Midbrain o Reticular Activating System (RAS): Ma-S-Co-Aw o Extrapyramidal system: In-Mo-Co b. Pons: primary motor pathway o Locus ceruleus c. Medulla oblongata 4. Limbic system a. Hippocampus b. Amygdala 5. Cerebellum: Co-Mo-PA 6. Neurotransmitters a. Amines i. Monoamines o Norepinephrine: (E/I)At-Le-Me-Sl-Wa-Mo o Dopamine: (E)Co-CM-Mo-RER o Serotonin: (I) o Melatonin ii. Acetylcholine: (E/I) iii. Amino acids o Glutamate: (E) o GABA: (I) b. Peptides i. Endorphins & enkephalins: (I) ii. Substance P: (E)Pain c. Others i. Adrenaline: (E)Fight or flight ii. Epinephrine: (E) Fight or flight Defense Mechanisms 1. Compensation 2. Denial 3. Displacement 4. Rationalization 5. Reaction formation 6. Regression 7. Identification 8. Intellectualization 9. Introjections 10. Isolation 11. Projection 12. Repression 13. Sublimation 14. Suppression 15. Undoing 16. Conversion 17. Dissociation 18. Substitution III. General Assessment 1. Psychiatric History d. Patients profile e. Chief complaints f. History of present illness

g. Past history h. Family history i. Developmental history j. Social history 2. Mental status examination a. General description i. Appearance ii. Motor activity: echopraxia; psychomotor retardation & agitation;automatism; waxy flexibility iii. Speech patterns: aphasia iv. General attitude b. Emotional state i. Mood: elated; euphoric; labile; despairing ii. Affect (behavioral expression) c. Thinking/Thought process i. Form of thought o Flight of ideas o Associative looseness o Circumstantiality o Tangentiality o Neologism o Concrete thinking o Clang associations o Word salad o Perseveration o Echolalia o Mutism o Poverty of speech (alogia) o Thought blocking ii. Content of thought o Delusions: persecutory; grandiouse; reference; control/influence;somatic; nihilistic o Suicide/homicide; obsession; paranoia; magical thinking; religiosity; phobia; poverty of content; hypochondriasis; thought broadcasting & insertion d. Experience/Perceptual disturbances i. Hallucinations; auditory; visual; tactile; olfactory; gustatory ii. Illusions iii. Depersonalization iv. Derealization e. Sensorium & cognition i. L.o.C. ii. Orientation iii. Memory: confabulation; recent; remote; immediate iv. Capacity for abstract thought v. Judgment vi. Insight IV. Building the Nurse-Client Relationship Personal qualities of the nurse o Therapeutic use of self (Travelbee) o Awareness of self Joharis window 1. Open 2. Blind 3. Hidden 4. Unknown Components: 1. Rapport 2. Trust 3. Respect

4. Genuineness 5. Empathy 6. Acceptance 7. Concreteness Phases: 1. Pre-interaction 2. Orientation 3. Working 4. Termination Ethical & legal basis o Tort 1. Unintentional a. Negligence b. Malpractice Elements: i. Duty ii. Breach of duty iii. Injury/Damage iv. Causation 2. Intentional a. Assault b. Battery c. False imprisonment o Ethical issues Utilitarianism Autonomy Beneficence Nonmaleficence Justice Veracity Fidelity Therapeutic communication Therapeutic Impasses 1. Resistance 2. Transference 3. Countertransference V. Therapeutic modalities 1. Client unit a. Group psychotherapy or therapy: same cases; help each other b. Family or family systems therapy: families & couples c. Individual psychotherapy: one on one 2. Approach a. Psychoanalysis: bring out into consciousness b. Cognitive Behavior therapy: thoughts>feelings>behaviors c. Gestalt therapy: personal responsibility & challenges d. Reality therapy: choice theory; control himself e. Interpersonal psychotherapy: interpersonal behavior f. Milieu therapy: therapeutic communities; manipulate environment 3. Other strategies a. Promote self-esteem i. Replace (-) thoughts with neutral/(+) ii. Enhance sense of self iii. Promote use of personal resources iv. Assist to express thoughts & feelings v. Provide opportunities for (+) socialization b. Assertiveness training c. Social Skills training