Documente Academic
Documente Profesional
Documente Cultură
Subita Fageria
Lecturer
Deptt. of B. Sc. (Nursing
Biyani Nursing College, Jaipur
2
Published by :
Think Tanks
Biyani Group of Colleges
While every effort is taken to avoid errors or omissions in this Publication, any
mistake or omission that may have crept in is not intentional. It may be taken note of
that neither the publisher nor the author will be responsible for any damage or loss of
any kind arising to anyone in any manner on account of such errors and omissions.
Preface
I am glad to present this book, especially designed to serve the needs of
the students. The book has been written keeping in mind the general weakness
in understanding the fundamental concepts of the topics. The book is self-
explanatory and adopts the “Teach Yourself” style. It is based on question-
answer pattern. The language of book is quite easy and understandable based
on scientific approach.
This is to help the students for clearing their doubts and for guidance and to
understand the subject why easily in a settled manner. This book covers the
diagnosis and management of both medical & nursing including the
psychopharmacology & general therapies of psychiatric disorders.
Any further improvement in the contents of the book by making corrections,
omission and inclusion is keen to be achieved based on suggestions from the
readers for which the author shall be obliged.
I acknowledge special thanks to Mr. Rajeev Biyani, Chairman & Dr. Sanjay
Biyani, Director (Acad.) Biyani Group of Colleges, who are the backbones and
main concept provider and also have been constant source of motivation
throughout this Endeavour. They played an active role in coordinating the various
stages of this Endeavour and spearheaded the publishing work.
I look forward to receiving valuable suggestions from professors of various
educational institutions, other faculty members and students for improvement of
the quality of the book. The reader may feel free to send in their comments and
suggestions to the under mentioned address.
Author
4
Mental Health/
Psychiatric Nursing
Course Description
This course is designed to help students develop the concept of mental health and mental
illness, symptoms, prevention, treatment modalities and nursing management of mentally
ill.
General Objectives:-
Upon completion of this course, the students will be able to:
1. Describe the concept of mental health and mental illness and the emerging trends
is psychiatric nursing.
2. Explain the causes and factors of mental illness, its prevention and control.
3. Identify the symptoms and dynamics and abnormal human behavior in
comparison with normal human behavior.
4. Demonstrate a desirable attitude and skills in rendering comprehensive nursing
care to the mentally ill.
Course Content
Unit I Introduction
Meaning of mental health and mental illness
Definition of terms used in psychiatry.
Review of mental mechanisms (ego mechanisms)
Review of personality and types of personality.
Unit-VII Bio-Psychosocial
Psychopharmacology
Definition, classification of drugs, antipsychotic, antidepressant, antimanic,
antianxiety agents.
Role of nurses in psychopharmacology
Psychosocial therapies
Definition of psychosocial therapies.
Types of therapies; individual and group therapy, behavior therapy, occupational
therapy.
Role of nurse in these therapies.
Somatic therapy
History, technique of electro convulsive therapy (ECT) indications,
contraindications.
Role of nurses before, during and after electroconvulsive therapy.
Mental Health & Psychiatric Nursing 7
Unit I
Introduction
According to Kerl Malinger: The adjustment of human beings to the world and
to each other with a maximum of effectiveness and happiness."
According to WHO: "The capacity of an individual to form harmonious
relationships with other and to participate in or contribute constructively to
change in social environment".
Thus, Mental Health is positive state in which the person is responsible, self-
directive and displays self-awareness.
Q.3 How will you differentiate the mentally healthy people from mentally ill
people?
Ans.:
S.No. Mental Health Mental illness
1 Positive attitudes towards self Negative attitude towards self
acceptance and self awareness acceptance & self awareness
(Optimistic) (pessimistic)
2 Able to solve problems by self with Avoid problems than solve
creativity
3 Positive self concept relate well to - Poor self concept
people and their environment - Feels inadequate
4 Able to cope up stress and reality Not able to cope thus stressful
perception situations
5 Able to make decision and sound Poor decision making & judgments
judgment. power
6 Able to establish and maintain healthy Relationship with friends & family
relationship are disturbed.
7 Accepts the authority and Unable to assume authority &
responsibility responsibility
8 Able to work effectively and Mostly dependent work
independently
9 Differentiate and analyze the Unable to analyze
situations
10 Has good sense of humar Easily get irritated
10
Conversation
Identification
Defense Origin in habit training Introjections
mechanism (1-3 yrs) Reaction formation
and their Transference
origin. Sublimation
Repression
Origin in later period of child- Suppression
hood (13-6) Regression
Rationalization
Incorporation
Other commonly use defense Intellectualization
mechanism Symbolization
Undoing
Q.5 How mental mechanism help the person to react appropriately to the
situation?
Ans. It is one of the coping mechanism used to reduce anxiety & fear.
It assist the client to identify the source of anxiety and explore the methods to
reduce anxiety.
It also keeps an individual temporarily free or away from the problem.
They protect the individual against psychological threats related to ego.
Helps the people to other people's behaviour and the factors associated with
their nature.
It helps the people to lead a satisfactory & productive life which prevents
mental illness, promote mental health of individual in specific family &
community in general.
For example:-
A graduate nurse is expected to do comprehensive nursing care, if
she fails to do so and the tutor identifies it and scolds, she cries like a child to overcome
her failure instead of putting more efforts and succeeding in it. Here, the nurse uses
regression mental mechanism.
According to Taylor : Personality refers to "the Aggregate of the physical & mental
qualities of the individual as these interact & function in characteristic fashion with his
environment.
Personality is expressed through the behaviour of a person. The characteristic
behaviour which is a combination of physical and mental characteristics of an
individual, differentiate one individual from another with his/her unique ident.
Heredity
Embryonic factors
I. Biological Factors Fetal factor
Antenatal factor
Unit II
History of Psychiatry
Mental disorders was known as " UNMADA" & fainting was known as " Murkh"
16
Past Situation :
1. In 1946, bhore committee report recommend preparation of psychiatry
nurses.
2. In 1965, INC - Psychiatric Nursing or a compulsory course in BSc. (N)
3. In 1975, MSc. (Psychiatric Nursing) started in RAK New Delhi
4. In 1983, DPN in Ranchi
5. In 1986, Psychiatric Nursing In GNM
Mental Health & Psychiatric Nursing 17
Present situation:
1. 22000 bed in 42 mental hospital
2. 2000-3000 bed in general hospital
3. I bed for 32,000 population
4. No. meaningful available for rural population
5. 1000-1500 psychiatrist in India.
6. Every year 150 are being trained.
7. All the same time number of psychiatric nurses only 900-950
8. About 60 seat are available for DPN & may not be filled each year.
9. 1 Nurse for every 1,00,000 population.
18
Unit III
Q.2 How many types of basic techniques included in Mental Health Assessment?
Ans. Three types of basic techniques included in mental health assessment:
1. History taking
2. Mental status examination
3. Psychological tests
I. Identification data:
Name of the patient …………………….
age………..
Sex…………………
Bed no. …………………….
Mental Health & Psychiatric Nursing 19
b) Childhood history
c) Adolescence
d) Adulthood
e) Late maturity
2. Educational history
3. Play history
4. Occupational history
5. Sexual & menstrual history
Personal hygiene
Posture
Facial expression
Gestures
2. Talk or speech :
a) Speech activity :-
i. Unusual pattern
ii. Unusual words
b) Tone and volume of speech
c) Speech pattern
d) Coherence
3. Mood or affect :-
A. objective mood
a) Appearance
b) Intensity of happiness
c) Consistency of word
d) Emotional Expression
B. Subjective mood
4. Thought process :
1. Thought at formation level
2. Stream of Thought
3. Thought at content level.
5. Perception :
a) Illusion
b) Hallucination
6. Cognitive function:
22
1. Level of consciousness
2. Attention
3. Concentration
4. Memory – immediate/Recent memory/remote memory
7. Orientation: time, place, person
8. Intelligence: average/confused
9. Insight: Present/Partial/Present/Absent
10. Judgment: Personal/social
11. Abstract ability:
12 General Information
13 Psychosocial factor
Stressor
Coping skills
Relationship
Socio-cultural aspects
Adaptability
Spiritual areas
2. listening
3. Validating
4. Providing information
5. Restating
6. Clarifying
7. Paraphrasing
8. Pin pointing
9. Linking
10. Questioning
11. Focusing
12. Sharing summarizing
13. Reflecting
14. Confronting
24
Unit-IV
Community Mental Health
Q.3 What are the facilities (Services) available in the community to strengthen
their mental Health ?
Ans.: varied community facilities are available to provide mental health care for total
population and self involvement for their future life.
1. Day hospital centre: Patient receives a full range of treatment, services during
day time and return home at the end of day. Patients develop routine &
discipline in life.
2. Half way house: These are for those who no longer need full services of a
hospital but are not yet ready for a completely independent living, still he may
require supervision for medication & carrying domestic activities
3. Quarter way house:-
Chronically ill patients are kept in quarter way homes.
These patients are enough improved to live in family but their family
members reject them
This home try to make these patients self dependent. It reduces gap
between hospital life & community life.
Ex. 13 & 14 ward at NIMHANS, Banglore.
4. Group homes:-
15-20 recovered mentally ill patients (client) will be placed in this
home.
They stay together & provides moral, emotional, & social support to
each other.
5. Foster homes
26
Q.4 What are the role of nurse in community mental health services?
Ans. Nurse can play an important role in linking the community services to the
hospital. The following roles of nurse in community mental health services:-
Mental Health & Psychiatric Nursing 27
1. Consultative role
2. Clinician role/Practitioner role
3. Therapeutic role
4. Researcher role
5. Educator role
6. Liason role
7. Coordinator role
8. Domiciliary role
9. Manpower facilitator
10. Social skill training
11. Manger/administration role
12. Preventive role
13. Other role :
Assertiveness training to improve self confidence
Conducts groups meeting.
Carryout community outreach services.
Provide crisis intervention services.
1. Primary Prevention:
Means reducing incidence of mental illness by controlling the factors
which cause mental illness.
It includes two component:
Health promotion
Specific protection
2. Secondary prevention :
28
Unit V
Psychiatric Nursing Management
4. Ward management
5. Role of nurse in psychotropic drugs
6. Role of nurse in psychotherapy :-
a. Nurse as a Psychotherapist
b. Nurse as a parent substitute
c. Nurse as a role model
d. Nurse as a resource person
e. Nurse as a supporter
f. Nurse as a socializing agent
g. Nurse as a communication
h. Nurse as a counselor
i. Nurse as a catalyst
j. Nurse as a Occupational Therapist
k. Nurse as a administrator
l. Nurse as a interpreter
m. Nurse as a teacher or technician
n. Role of nurse before during and after electro convulsive therapy (ECT)
1. Genuineness
2. Respecting the client
3. Empathy
4. Self-discipline
5. Sincerity
6. Role model
7. Good communication skills
8. Good observer
9. Show love & affection
10. Active listeners
11. Good speaker
12. Exploration of the problem (catharsis)
13. Immediacy
14. Trustful
15. Professionalism
16. Caring
Q.8 What are phase involved in establishing and maintaining the therapeutic
relationship?
Ans. T-NPR involves series of phases:-
T-NPR Phases
Phases of T-NPR :-
Quality Pre- Introductory/ Working phase Termination phase
Interaction Orientation (Resolution/End phase)
phase phase
Definition Begins when a Begin when It starts when nurse and Begins during orientation
nurse assigned nurse goes to patient are able to phase.
a patient before patient, overcome barrier of In this nurse develop pact
the nurse first introduce herself orientation phase. Nurse with patient
contact with & get & patient actively works
client. introduction on meeting the goals.
about him.
a) General ability: Ability to listen, interpret speak & express through writing.
b) Special ability:
Ability to observe or interpret observation
Ability to ascertain
Ability to recognize when to speak, silent smile, interact
Ability to wait, proceed, speed
Ability to maintain T-NPR
C) Element:
Stimulus
Need for information, comfort, advice etc.
Ans.
Communication
Formal Informal
Communication Communication Verbal Nonverbal
Communication Communication
Spoken/oral Written
Mental Health & Psychiatric Nursing 39
Unit IV
CAUSES OF
ABNORMAL
BEHAVIOR
Mental Illness
Panic dis.
Dissociative disorder Conversion disorder
Dissociative Amnesia Somatoforms disorder Panic disorder
Dissociative Fugue Body dimorphic disorder Phobia
Q.3 What is the different between the organic psychosis and functional psychosis?
Ans.
7 Prognosis: Prognosis :
- Bad prognosis - Good prognosis
- Recurrence common - Recurrence less
Mental Health & Psychiatric Nursing 47
Personality disorder
Stereotype 1 Echoprexia
Activity 2. Echolalia
Illusion Hallucination
1. Autistic thinking
2. Derestic Thinking Structure Speed of association Type of Association
of Association
1. Magical
Thinking
1. Neologism Flight of ideas Motor aphasia 2. Poverty of
2. Word salad Clang association Sensory aphasia content
3. Circumstantiality Blocking of through Nominal aphasia of speech
4. Tangentiality Thought retardation Syntactical 3. Overvalued
5. Perseveration Poverty of speech aphasia ideas
6. Irrelevant answer 4 Delusion
7. Lossening of association 5. Obsession
8. Derailment 6. Phobia
7. Hypochondriasis
52
V. Disorder of affect
Types of Delusion :
1. Bizarre delusion
2. Delusion of grandeur
3. Delusion of self accusation
4. Delusion of control
5. Delusion of persecution
6. Delusion of reference
7. Delusion of jealousy/infidelity
8. Encapsulated delusion
9. Nihilistic delusion
10. Delusion of worthlessness and property
Mental Health & Psychiatric Nursing 53
Negative symptoms :
Apathy
Blunted affect
Diminished Emotional Responsiveness
Stereotype thinking
56
Social withdrawal
Lack of spontanity
Avolition
Detachment
Primary/Fundamental Symptoms (Bleuler 4 A's)
Secondary/accessory symptoms
Social withdrawal
Persistent sadness
Hypochondrial ideas
C. Depressive stupor :
Intense form of depression
Clouding of consciousness
Marked ideas of death
2. Poverty of ideas :
Retarded thinking
Difficulty in thinking
Death of thought
Delusion of nihilism
Suicidal of ideas
Feeling of hopelessness
3. Decrease Psychomotor activity :
Reduce energy level
Negativism
Delusion of guilt
Frustration in day to day activity
Ans.: I. Classification
Mood disorder
F 30 – Manic episode
F 31 – Bipolar affective disorder
F 32 – Depressive episode
F 33 – Recurrent depressive disorder
F 34 – Persistent mood disorder
F 38 – Other mood disorder
F 39 – Unspecified mood disorder
3. Drugs :
a) Sedatives –– if patient agitated
b) Hypnotics - if insomnia present
62
c) Tranquillizers:
– Meprobamate 200-400 mg
– Chlordizepoxide 10-20 mg
– Diazepam 5-10 mg T.D.S. If patient is anxious
d) Neuroleptics - if patient agitated and anxious
– Chlorpromazine hydrochloride
e) Antidepressant drugs :
– Tricycle & Tetracyclic compounds
Such as immipremine, hydrochloride
– amitryptiline Hydrochloride
– Trimipramine
– Mianserin
MAO (Mono amino oxide) inhibitors like phenelezine. It is more powerful anti
depressant drug
Recently more specific drugs are :
– Aminiptine
– Fluoxetine
– Amoxopine
– Tradozone
Psychotherapy :
Cognitive & behaviour therapy
Analytical psychotherapy
Occupational psychotherapy
Work therapy
Art therapy
Music therapy
Interpersonal therapy
Mental Health & Psychiatric Nursing 63
Family therapy
Hysterionic behaviour
Suggestibility (susceptible against any suggestion)
Transformation of an unconscious conflict into physical symptoms
Emotional outbursts
Repressed anxiety
It is of two types:-
Hysteria
– Excessive consumption
– Alcohol related disability
– Problem drinking
– Alcohol dependence
–Ethyl
– Opium &
alohol – Amphetamines –Cannabis eg ganja, –Maprobamate
its
–sedative/ – Cocaine charas, bhang, –Diazepain
derivatives
hypnotics hashish –Chlordiazepoxide
Eg. Opium,
Eg. –other
heroin,
Barbiturates LSD: -
morphine,
Nindral Lysergic
Codeine
Dalmane Acid
– Synthetic
Doriden Diethylemide
Narcotics
Such as
methadone
Developme Disruptive Anxiety Eating General To disorder Elimination Speech Other disorder
ntal Behavioural Disorder disorders Identity disorder disorder
Disorders Disorder of disorder of
Childhood childhood
1. Mental retardation
2. Pervasive disorders-
a. autistic disorder 1. Attention 1. Separation 1.Anorexia 1.Trans 1.Eneuresi Stuttering
b. childhood autism deficit anxiety nervosa Sexuliasn s
c. childhood psychosis hyperactive disorder 2.bulimia 2. Gender 2.Encopre
d. pseudo defective psychosis disorder 2. avoidant nervosa identity sis
3. Specific development (ADHD) Disorder 3. pica disorder of
disorders- 2. conduct 3. Overanxious 4. rumination childhood
a. Specific reading disorder disorder disorder disorder of
b. Specific arithmetic infancy
disorder
c. specific development
disorder of speech &
language
d. Specific developmental
disorder of motor function.
Sexual dysfunction
Not caused by organic Gender Disorder of Sexual
Disorder identify sexual orientation
disorder or preference disorder
Trans
Sexual inadequacies sexualism Homosexuality
Fetishism
Transvestism
Exhibitionism
In male In female Voyuerism
Paedophillia
Erectile Frigidity Sadism
Impotence Vaginismus :- Masochism
Premature Involuntary
Ejaculation Contraction of
vaginal introits
at penetration
Mental Health & Psychiatric Nursing 69
Unit VII
Bio Psychosocial Therapies
Antipsychotic Drugs
Contraindication:-
1. Children under 3 Yrs. Of age
2. Comatose patient
Mental Health & Psychiatric Nursing 71
3. Drug hypersensitivity
4. Severe depression
5. Other contraindications :
History of epilepsy
Pregnancy
Parkinson disease
Peptic ulcer
1. Parkinsonism :
It occurs in 40 percent of patient with EPS
It occurs one week after treatment
It is of two types :
(A) Akinetic form :
a. Impairment in masticating movement
b. Weakness
c. Muscle pain
d. Fatigue
(B) Agitating form:
72
a) Muscle rigidity
b) Motor retardation
c) Mask like face
d) Shuffling gait
e) Slurred speech
f) Salivation
g) Tremors
Antiparkinsonian Drugs
Q.6 Write down about indication, Contraindications and action of anti manic
drugs?
Ans. Anti manic drugs are also called mood stabilizers.
Indications :
1. Mania
2. Manic Depressive Psychosis (MDP-Bipolar disorder)
3. Hypomania
4. Recurrent depression
5. Alcoholism
6. Schizo – affective disorder
Contraindication :-
1. Side – effect of renal, CVS, liver and respiratory system
2. Thyroid disorder (Hypothyroidism)
3. Diuretic potent
4. Dehydration
5. Child below 12 yrs. Age
6. Parkinsonism
7. Obesity
8. High grade fever
Mode of action:
It reduces the level of nor-epinephrine and serotonin or catecholamine.
Q.9 What are the indications, contraindications and mode of action of anti
depressant drugs?
Ans: It is also called mood elevators.
Indications:
1. Major depressive illness
2. MDP depressive phase of bipolor disorder
3. Anxiety
4. Psychotic depression
5. Obsessive compulsive disorder
6. Migraine headaches
7. Panic disorders
8. Eating disorder (bullemia)
9. ADHD in children
10. Sleep apnoea
11. Cataplexy
Mental Health & Psychiatric Nursing 77
Contraindications:
1. Increase manic and psychotic episode of MDP.
2. CVS problem (arrhythmias)
3. Liver problem
Mode of action:
It acts by accelerate (increase level of) receptors of nor epinephrine and serotonin in the
central nervous system and reduce anxiety.
Indications :
1. Anxiety disorder/Panic disorder
2. Insomnia
3. Obsessive compulsive disorder
4. Depression
5. Alcohol withdrawal symptoms.
78
6. Convulsions
7. Induce sleep pre-operatively.
Contraindications:
Patent with renal, liver, respiratory impairment and hepatic failure.
Mode of action: It acts by increasing GABA activity that can cause decrease activity of
neurotransmitter in brain results in decrease neural activity.
Headache
Hypotension
Bodyache
Impotence
Confusion
Tremors
Convulsion
Ataxia
ANS :
Dry mouth
Tinnitus
Note : EPS (Extra Pyramidal Syndrome) : In antipsychotic drugs
Note :
Bradycardia : In Antimanic drugs
Palpitation : In anti anxiety drugs
3. Hematopoietic System :
Agranulocytosis
Leukopenia
Leukocytosis
4. Endocrine System :
Amenorrhea
Breast enlargement
Impotency
Change in Libido
Mental Health & Psychiatric Nursing 81
Galactcorrhoea
Gynaecomostia
Hyperglycemia
5. Gastro Intestinal tract :
Constipation
Diarrhea
Anorexia
Nausea
Vomiting
Weight gain
Jaundice
Q.13 Write in detail about nursing care of patient receiving psychotropic drugs?
Ans.: Psychotropic drugs are used to treat the signs and symptoms of mental illness. But
all behavioural problem are not treated by the drugs. The treatment is based on the
thorough psychiatric evaluation of the patient.
Before administering any drug, the nurse should know about the drugs that is half
life period and after dose, the side effect of drug, age of the patient, to know the liver
metabolites and kidney excretion etc
Nurse's Role:
I. General Role :
1. No drug should be administered without prescription
2. Do not leave the patient alone until the drug is swallowed
3. Do not allow patient to carry medicine to another patient.
4. Keep safety measures.
5. Give a glass of water after medicine.
6. Do not leave the drug tray within reach of patient.
7. All medicine given must be recovered on patient chart.
8. Do not force the patient orally.
9. Check drug daily for any change for colour order.
10. Drug bottle should be properly labeled .
11. Drug cupboard are always to be kept locked when not in use.
12. Nurse should know side effect indication and contraindication of drug.
13. Nurse must know the legal aspect.
3. While administrating drug, if any doubt arises without hesitation nurse should
consult with doctor.
4. Observe drowsiness, sore throat, fever
5. Record blood pressure.
6. Provider good oral hygiene to reduce dry month.
7. Weight recording and low salt in case of anti-psychotic/anti manic drugs.
8. Discourage the patient to take antacids as they cause decrease absorption.
9. Maintain intake/output chart
10. Advice to protect the skin.
11. Record in client's chart about which drug administered; if any side effects
observed.
12. Nurse need to have an effective drug attitude.
13. Nurse has to be familiar with regular usage of drugs, their actions, side effects and
they hold responsibility while administering to avoid errors.
14. Uses a variety of techniques with different clients in different situations.
15. While administering the drug, confirm the client by calling their name.
16. While administering lithium, complete investigation as urine analysis, BUN
creatinine electrolytes, 24 hrs creatinine clearance, thyroid test etc should be
checked.
17. Every 3 month, lithium level to be checked.
18. Blood level of lithium is tested 12 hrs after last dose. The therapeutic level should
always be maintained 0.6-1.4 m Eq/lt.
19. While administering MAOI, caution should be taken food substances, as cheese,
pickle, beer, red, wine chicken, liver, overripe fruit, banana peel, yoghurt and
some medications as cold medication, nasal and sinus decongestants, narcotics,
local anesthetics, epinephrine, cocaine, amphetamine should be avoided
84
Goals of psychotherapy:
1. To achieve remission of symptoms
2. To modify disturbed pattern of behaviour
3. To strengthen the ego
4. To improve growth & development of the client.
5. Modify environment causing maladaptive behaviour.
6. Improve IPR skills.
Mental Health & Psychiatric Nursing 85
Indicated of Psychotherapy
1. First choice for neurotic illness
2. Very useful in psychosomatic illness.
3. Schizophrenia
4. Mania, depression
5. Alcoholism
6. Drug addiction
7. Sexual deviation
8. Personality & character disorder
9. Childhood disorder
10. Marital disharmony
Contraindications
1. Severe psychotic illness
2. Unresponsive, unmotivated and in cooperated patient.
3. Violent/ excitement
4. Unconscious patient
5. Assaultive and destructive behaviour
6. Negativism
7. Organic Psychosis
8. Psychotic Depression
9. Group psychotherapy in hysteria and hypochondriasis.
Advantages:
86
o Attractive
o Patience
– Nurse should maintain T-NPR
– Accept the patient as unique individual
– Nurse should encourage the patient for involvement in psychotherapy
– Nurse must know proper knowledge of different types of psychiatric illness
– In occupational therapy, nurse help the patient to teach new skills related to as a
job.
– Demonstration to the nursing students.
4. Reality therapy
5. Uncovering or insight psychotherapy
6. Supportive psychotherapy :
o Mental ventilation
o Environmental modification
o Persuasion
o Re-education
o Re-assurance
o Suggestion
Q.18 Define group therapy. Write in detail about the objective, types of groups,
steps & merits and demerits of group therapy.
Ans.: Definition : Group therapy is a mean of psychotherapy of psychological problem
in which a group of patients is provided psychotherapy by a group of psychiatrist as well
as the patient interact with each other & help in problem solving.
Description:
1. Group therapy is less time consuming
2. Group consist of 8-10 patient.
3. Session of psychotherapy are held once in a week & generally continue for 12-18
months.
4. Duration of session longer than individual therapy. It is one or two hour.
5. It uses many type of psychotherapy technique.
6. The patient in group generally have some problem eg. alcoholic patient.
Objective:
1. The member of group gain personal insight
2. The group member Improve their IPR
Mental Health & Psychiatric Nursing 91
3. The patient can change their destructive behaviour & can modify their
behavior.
4. The patient can share their intimate feelings, ideas, experiences.
5. It provide an environment of mutual respect that further improve respect & self
understanding.
Types of Groups
7. Heterogeneous group: The group member does not have similarity on basis
of sex, age, socio-economic in society. It is just opposite to homogenous
group.
8. Open or close group: In open group member are free to join or leave the
group at any time. Closed group have certain number, certain duration. Patient
can not join or leave the group any time.
9. Group according To mental illness: The group classified according to their
nature of illness.
Psychotic group
Neurotic group
10. Psychodrama group : The group acts event from the life of one member.
Sexual disorder
Thumb sucking/nail biting/tics
Migraine
Anorexia nervosa
Bulimia nervosa
Obesity
Psycho – somatic disorder
Contra Indications:
Psychotic disorder that have acute pervasive symptoms and in which reinforcement is not
applicable
Steps: it has 3 steps
1. Training of relaxation technique before the main therapy.
2. Hierarchy formation - Patient is asked to construct a hierarchy of anxiety
causing stimulus.
3. Systemic desensitization:-
It is done in two ways:
(a) SD-1 the stimulus is confronted in imagination
(b) SD-2 The stimulus is confronted in reality
96
Definition:
Any activity which engages a person's resources of time, energy & is composed of
skills and value.
–"REED & SENDER SON".
Any goal directed activity meaningful to the individual providing feedback to him
about his worth & value as an individual & about his inter relatedness to other-
–"JOHNSON".
Objectives:
The major goals of patient in rehabilitation:
1. To assess need of patient
2. To identify the skills of the patient
3. To remove or modify mal adaptive behaviour
4. To improve mood & reduce, anxiety
5. To role performance
6. To stimulate self confidence
7. To give opportunity for self expression
8. To reverse psychopathology
9. To increase socialization & communication
10. To improve old skills & acquire new ones.
Mental Health & Psychiatric Nursing 97
Basic Requirement:
1. Knowledge levels of patient
2. Background of patient
3. Psychological problem/diagnosis.
4. Capacity or skills of patient.
5. Therapeutic nurse patient Relationship.
6. Interest of patient.
7. Continuous evaluation of progress.
Implementation of plan
Alcohol dependence
Homosexuality
Child disorder
Principle: Principle of this therapy is the pairing of the pleasant stimulus (eg - alcohol)
with an unpleasant response. This pairing convert the pleasant into unpleasant stimulus
after the therapy is over.
20-40 session are given.
Duration of session is about 1 hour
Booster sessions are given after completion of treatment.
E.g. : Pairing of alcohol [pleasant] with drug appmorphine disulfirum (unpleasant)
Thumb sucking (pleasant) with low voltage. Electric current (unpleasant)
Conduct disorder
Role identify difficulty
Depression
Anorexia nervosa
Relapse in schizophrenia
1. Psychodynamic: This approach is based on this concept that the entire family
problem arise from past experiences of each member & unconscious conflicts. The
therapist helps to gain insight that how their own problems, unconscious conflict
effect the inter relations.
2. Systemic Approach: It concentrates on the present problems rather than past
experiences. This therapy has 5-10 session with interval of month long. The
therapist arrange family interview to assess the family disagreement, ways of
communication.
3. Structural approach: The term family structure refers to the hierarchy in the family
& to a set of unspoken rules regarding task & responsibility.
Eg. Usually in every family both parents have more authority & responsibility. In
this therapy, the therapist identifies the rules which be family tension & try to
bring about changes.
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4. Elective family therapy: It is a short term method planned to bring about restricted
changes in the family. It also concentrates on the present situation of family & the
way of communication.
1. Occupational therapy
2. Recreational therapy
3. Play therapy
4. Biblio therapy
5. Dance– therapy
6. Art therapy
7. Education therapy
Q.24 Define ECT. What are the types of ECT techniques/methods, indication
contraindications, complications of ECT?
Ans. Electro Convulsive Therapy:
It is a painless form of electric therapy primarily used for patients with depression and
schizophrenic disorders.
Definition: ECT is a physical/somatic therapy in which with the help of two electrodes,
current is passed through the temporal region in between the two hemisphere of the
brain, to produce a grand mal type of seizures.
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Cerleti and bini are the first neuropsychiatric who used ECT in 1937.
Method/Techniques of ECT :
ECT can be given by direct or indirect method.
I. Direct ECT
ECT has been used directly on the patient. The patient is administered atropine
subcutaneously (SC) 0.6 mg to 1.0 mg, half an hour before the treatment or IV
immediately before the treatment minor tranquilizers like calmpose is also used.
A gland mal seizure is induced in the patient by passing an electric current through
the temporal lobe Atropine prolongs the period of disorientation after the seizures.
It also reduces vomiting. Immediately after The ECT treatment appropriate
resuscitative and other emergency management equipment and supplies are kept
ready A skilled person & nurse to resuscitate the patient should be available.
ECT given by this technique causes a lot of anxiety to the patient.
II. Indirect/Modified ECT : ECT is modified with the use of anesthesia, muscle
relaxant & oxygenation. Anesthesia is necessary to allay anxiety & achieve the
maximum effect, avoid compilation, modify the force of convulsion.
Placement of Electrode :
The location of electrode depends on the unilateral or bilateral ECT.
Bilaterally, ECT involves the placement of electrodes in the bitemporal
region.
To minimize post convulsive confusion & amnesia, unilateral ECT has
been devised in which electrodes are placed so as to avoid the dominant
temporal area.
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Amount of current :
The nature and range of a stimulus intensity setting varies from device to device.
70 to 1.50 volts for .1 to 1 sec. will produce a convulsive effect.
The actual amount, range from 200-600 milliamphers
X-ray of the chest haemogram urine analysis and ECG should be given whenever
indicated.
4. Removal of denture if any is desirable
5. Mouth gag is put resting on the 3rd molar to prevent the tongue bite, cheek bite
and lip bite.
6. Physical restraints may be necessary to prevent powerful jerky movement of the
body.
7. The patient lies down comfortable on a bed in a supine position.
The patient must be observed for at least half an hour after the treatment is
given.
The production of gland mal seizure is necessary.
In direct ECT, the tonic phase i.e. muscle contraction last for 10 sec.
approximately. The clonic phase i.e. movement or convulsions last for 25-
30 sec. approximately. Then patent goes into relaxation phase.
Pulse & respiration recorded every 15 min.
The patient should be prevented from fall & injury.
If the patient become excited & rowdy IM inj. 8-10 ml of paraldehyde or
50-100 mg. if chlorpromazine or diazepam 5-10 ml have to be given to
control the patient.
Indication of ECT :
The indication of ECT depends upon the availability and non-availability of psychotropic
drugs. The common condition for ECT are :
1. Major depressive episode is primary indication – 80 90 patient.
2. Involutional melancholia – 80-90 %
3. Depression
Suicidal & stuporous patient
Endogenous depression of moderate to severe degree.
Delusional & psychotic depression
Unipolar - bipolor depression
Post partum depression
Depression of old age as long as there is no atherosclerosis & brain
changes.
4. Manic phase (mania)
1. Severe attack
2. Delirium Mania
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Contraindication
No absolute contraindication
Impairment of memory may vary from mild tendency to forget name to sevre confusion.
Resuscitation tray
Mouth wipes.
B.P. apparatus, sterile syringe, spirit swab
3. Recovery Room
Observation of vital sign
Mouth wipe & toilet facilities
4. Role of nurse before ECT
Thorough physical examination
Informed consent
NBM (Nothing by mouth) before treatment
Remove metallic articles from body.
Remove lipstick, nail polish
Loosen the tight cloth
Empty bowel & bladder
Maintain personal hygiene
Give premedication, atropine, calmpose
Nurse should display a warm supportive attitude.
Take the patient to the waiting room
5. Role of nurse during ECT
Transfer the patient on a well padded bed placed in supine position.
Place tongue depressor in between teeth
Give short acting anesthetic to the patient
Support the shoulder or arm
Restraint the thigh with the help of sheet
Hyperextension of head with support to the chin give few breath of O2
(Oxygen)
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Unit-VIII
Forensic psychiatry/legal aspects
Q.1 How a mentally ill patient get admitted in a mental hospital and how he get
discharged?
Ans. Admission and discharge of the clients in a psychiatric unit/mental hospital is
based on section 31,34 of Indian lunacy Act (ILA) 1912 later it was modified on
1st October, 1931.
Admission and discharge can be made in one of following:
1. Admission procedure on voluntary basis :
(a) For major client and desires to have admission into the mental
hospital based on his suffering:-
He will approach medical superintendent of hospital, along with two
visiting medical officers (who are appointed by state govt.) will observe
the case, at their own discretion, they can admit the case into the hospital,
provided the client has to submit the filled up performa stating that he is
interested to be admitted.
(b) For minor cases: the nearest guardian has to apply request for admission,
medical officer within 24 hours of receipt such application can admit the
case cast into the hospital.
Discharge Procedure :
(a) For major client: If he feels his condition is better, he can ask for discharge by
writing a written notice of 24 hours.
(b) For minor client: If minor attains "major" and "cured", he has to write an
application. The medical superintendent will observe and decide whether he
can be discharged or not, within a month.
Admission is made, if the family members or the relatives of the patient have
to submit the request or petition for admission of the client into mental
hospital.
The petitioner must be a major and personally observed the client within 14
days of making the petition. Petition Has to be written on a special form,
denoting all the particulars of an individual which has to be supported by two
medical certificate (one form greeted govt. medical officer and other from
registered medical practitioner) Both medical officers have to be
independently examine the "alleged lunatic" at different times and within 7
days of applying for reception order and have to certify that the lunatic needs
admission and detained under care and treatment.
The medical practitioner has to be very careful in giving a certificate in order
to avoid legal complications for a wrong certification.
Discharge Procedure:
In this clause, the clients can be admitted for a period not exceeding 90 days.
If relative feels that medical officer is misusing the lunatic, he can obtain
permission from magistrate for discharge. The magistrate will verify the
condition of the client through personal inquiry and if he satisfies, thinks that
the client condition was improved, he recommends for discharge.
The petitioner has to apply to the superintendent of the mental hospital for
discharge. If the person is not dangerous and is fit to live safely, he can be
discharged.
in-charge feets that it is necessary to bring the legal authorities into the scene,
he can apply to the magistrate or relatives can approach magistrate to issue an
reception order for treatment. This order is valid for 6 months. In these cases
only one medical certificate is required.
Discharge: After recovery, if medical officer feels he can be fit to live safely
in the society, he will discharges.
If the mentally ill patient is very dangerous, and the medical officer in charge
think that patient needs hospitalization, he can admit the patient but within 72
hours. The patient need to be examined by the magistrate to produce a
reception order.
Discharge procedure
If the client condition improves, he can be able to take care and found to be
sound, he will be discharged.
1. Those who suffering with unsound mind and incapable of making their
defense.
2. Those who committed the crime, but were acquitted on the ground of
unsound mind at time of committing suicide.
3. Those who contacted the disease after imprisonment.
Discharge procedure: The visitors of the hospital has to report every 6 month once about
the client's mental status and authority which has ordered detention. As soon as the client
is fit to lead normative life they have to inform about the same to authority concerned.
The person will be handed over to the prison officer for the further legal action.
Chapter I – Terminologies
It contain some terms, preliminary conditions and its definition. Some of the terms used
are:
Asylum.
Cost maintenance
Lunatics
Criminal Lunatics
Reception order etc.
State govt. will appoint board of visitors (at least 3 member’s one medical officer not
necessary to have psychiatrist. Other two may by PSW or politicians)
Chapter V
Lunatic properties, court amendments for assessing, disbursement of properties
Fine of Rs.500/- will be collected by manager of lunatic appointed by court, if he
is not maintaining properly.
Chapter VI
Establishment of Asylums
Board of visitors has to conduct monthly visits and periodically they have to observe
standard diet, medical checkup, parameters etc. and report it to govt.
Q.3 Write a short on Indian mental Health Act, 1987 (IMHA, 1987) ?
Ans.: IMHA, 1987 is an amendment of Indian lunatic Act, 1912
Mental Health Act was introduced in Rajya Sabha in 1981, mental health bill no. XLI act
14 came into practice as a MHA from 22nd may 1987. Later government of India issued
order that came in force with effect from April, 1 1993 in all state and union territories of
India. It includes ten chapters. This act is applicable throughout India.
Objectives:
1. To formulate rules and regulation for the procedure related to admission and
discharge of the client in psychiatric hospital units
2. To regulate establishment & maintenance charges of psychiatric hospitals
3. To provide facilities for establishing the guardianship of mentally ill, who are
incapable of managing their own affairs.
4. Discarding custodial care, safeguarding mental patient from community and
incorporating better provision relating to treatment & care.
5. Judicial safeguard for patient right to prevent any dignity or cruelty to mentally ill.
6. Introduces humanitarian consideration
7. To establish and coordinate the central and state authorities for mental health
services.
8. To regulate the power of government for establishing, licensing and controlling
psychiatric hospitals.
Mental health act is divided in the ten chapters consisting 98 sections.
Cost of maintenance:
A mentally ill person admitted in psychiatric hospital shall mean the cost of such items as
per state government by general and special order specify in this behalf.
Licensing authority: State govt. will appoint and authorized an inspective officers, who
will have an authority to inspect any psychiatric hospital within the state and gives license
under section 8.
Reception order: Order made provision for the admission and detention of mentally ill
persons in a psychiatric unit.
Chapter III
It provides guidelines for establishment and maintenance of psychiatric hospital.
There is a provision of licensing authority who will process application for licenses.
Valid license has to be reviewed every 5 yrs.
Chapter IV
It describes the procedures for admission and detention of the clients in psychiatric units
Chapter V
It deals with inspection, discharge, leave of absence and removal of mentally ill person.
Chapter VI
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Judicial inquisition regarding alleged mentally ill persons possessing property, custody of
his persons and management of his property court may appoint guardian to look after self
and property.
Chapter VII
It deals with liability to meet the cost of maintenance of mentally ill person detained in
psychiatric hospital or nursing homes.
Chapter VIII
It aimed at protection of human right of mentally ill person. No, mentally ill
person during treatment will be subject during treatment to any indignity.
Mentally ill persons under treatment cannot be used for research purpose, Unless it
benefit him.
Consent has to be obtained either from client or from relatives for discharge.
No communication or no letter has to be sent to mentally ill cannot be read or
interpreted or detained or destroyed.
Chapter IX
It deals with penalties and procedures for establishment of maintenance of psychiatric
hospital or psychiatric nursing home.
Chapter X
It deals with provision for miscellaneous action.
It deals with clarification pertaining to certain procedure to be followed by the medical
officer incharge of the psychiatric hospital.
The Medical Officer prepares the report of hospital operations every 6 months once and
will send it to the authorities.
Incharge Medical Officer is responsible for the supply of requisites (like food, sanitation
etc) in the psychiatric hospitals,
Q.4 what are the legel responsibilities of a nurse in care of mentally sick patient?
Ans.: Legals responsibilities/legal aspect :
A psychiatric nurse have many responsibilities while caring a psychiatric patient.
She is responsible for providing quality nursing care to reduce malpractice
litigation. Quality nursing care can only be legally proved by its accurate,
complete documentation. So a psychiatric nurse has some legal responsibilities are
as following :
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3. The information can be shared with the parents who have a legal duty to act in
their children's best interest
4. Patient's permission should be obtained before information in sought from
other persons.
5. Patient should know from the start that information can be shared among the
members of health care team.
6. Rules of confidentiality can be breached in following condition:
In patient's interest
In the public interest
For legal representatives
7. The patient should be told in advance about the special condition in which all
the information may be revealed such as group therapy and family therapy.
Census report
Inter department report
Special report on unusual condition of patient.
Reports on mistakes.
Reports on complaints
Evaluation on report etc.
a. Psychotherapeutic Intervention
b. Health Education
c. Self care activities
d. Somatic therapies
e. Therapeutic environment
f. Psychotherapy
Standard VI : Evaluation of her nursing action.
Standard VII: Peer Review
Standard VIII: Continuing Education/Action
Standard IX : Interdisciplinary collaboration
Standard X : Utilization of community health system
Standard XI : Research
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Unit IX
Psychiatric emergencies and crises
intervention
Q.1 Define psychiatric emergencies, write the classification of psychiatric
emergencies.
Ans: Emergency: It is situation in which immediate action is essential for the survival
of system.
Psychiatric Emergency : It is explained as a disturbance is behaviour, affect and
thought (BAT) to that extent, that it needs immediate therapeutic intervention.
It is defined as a sudden onset of an unusual disorder and socially inappropriate
behaviour caused by an emotional situation.
-"Bimla Kaooor, 2002"
Psychiatric Emergency
Ans. Nurse have to assume overall in-charge for interventions and seeks guidance from
the psychiatrist whenever necessary.
Handle the case tactfully
Provide calm & watchful environment
Emergency cases has to be shifted as early as possible where he will be
safeguarded against injury either to himself or to the others.
Protect other patient.
Encourage verbal expression of feeling.
Provision of care in meeting the client's need accordingly.
Use communication techniques
Always remain with patient.
Build trusting relationship with patient.
Talk in simple language and slow volume.
Do not threaten theater the patient but set limit on his behaviour
Remain aware of pt's right, feeling & dignity
Constant observation on patient activity
Crises intervention
Education to family and friends of patient.
Q.3 Define suicide, what are the risk factors of suicide? Classify the suicide and
how the patient with suicidal ideation be managed?
Ans. Suicide:
It is commonest psychiatric emergency
It is act of killing on self.
Patient's threats, gestures are always taken seriously.
Definition of suicide:
"Aggression towards the self following the internalization of frustration or disappointment
related to loved one".
According to Clayton
"Ultimate act of self destruction"
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Mild depression
Classification of suicide :
In 1951 E-mail Durkheim classified social categories of suicide:
1. Egoistic suicide: one who may lose social integration with their social group.
2. Altruistic suicide: Results from a response to a cultural expectation e.g. sathee
sahagamanam which has followed in ancient India.
3. Anomic suicide: Occurs in response to the changes occurs in individual life. For
e.g.: divorce, loss of job.
4. Sam sonic suicide of revenge:
Experiencing as being unfriendly for e.g.: if the husbands is unfaithful to his wife.
She may attempt to commit suicide to take revenge from him.
5. Continuous survey
6. Provide calm & safe environment to the patient.
7. ECT for major depression
8. Antidepressant for OPD patient.
9. Keep strict observation to prevent repeat attempt.
Nursing management :
1. Make a treatment plan
2. Conduct suicide assessment, lethality plan
3. Engage the client in purposeful activities by diverting the mind.
4. Careful observation of client is needed in vulnerable time.
5. Provide symptomatic psychotherapeutic treatment.
6. Administer the drug, if any prescribed.
7. Report to the team members if any clues related to suicide are identified.
8. Encourage the client to develop optimistic ideas or sense of hope and self
control.
9. Motivate the client to express his repressed feelings
10. Involve the family members in provisions of care and guide them to provide
situational support.
11. All psychiatric drugs should be kept under lock
12. Patient should not left alone.
13. Constant observation on patient activity.
14. Give the patient opportunities to express feeling.
15. Remove object which might be used as a means of suicide.
16. Teach better problem solving techniques, alternative expression, sense of
achievement in personal life, decision making ability and importance of
positive self esteem.
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17. Encourage the client to explore his hobbies one by one, restart it
constructively.
18. Staff has to be aware of problems raised by the client.
19. If client leave ward without intimation take immediate action.
20. Discharge plan has to be made in advance, inform follow up visits.
Q.4 Define crisis, what are the types of crisis situation? Which types of techniques
used in crisis intervention and describe nurses role in crisis intervention?
For e.g.:
Suicide
Addicts
Human being
Imbalance state
Felt need was not fulfilled
To restore equilibrium
Role of nurse in crisis intervention: Nurse has the following role in the crisis
intervention: -
Establish trusting relationship with patient.
Actively listen the problem of patient and his family it is challenging but very
important skill.
Encourage an honest disclosure, ensure confidentiality.
Do not attempt to avoid emotional reaction such as anger or crying.
A change in environment may serve to alleviate stress and may produce a sense of
comfort.
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