PLT COLLEGE, INC.

Bayombong, Nueva Vizcaya

School of Health Sciences – College of Nursing

Psychiatric Mental Health Nursing

Psych Lecture Series # 4 (Prepared By: Prince Rener V. Pera, RN, MSN, EMT)

Ethical Issues of PMHN

Ethics- branch of philosophy that considers how behavioural principles guiding human
interactions can be analyzed and set.
Normative Ethics- set and define rules and procedures useful in providing guidance for human
decisions and actions.
Utilitarianism- “Greatest good for the greatest number.”
Deontology- looks at human duties to others and tries to analyze the principles on which these
duties are based. The following are the basic deontological principles:
a) Autonomy- refers to the client’s right to self-determination and independence
b) Beneficence- is the view that all treatments must be for the client’s good.
c) Fidelity- is an individual’s obligation to be faithful to commitments and contracts
d) Justice- ensures fairness, equity and honesty and decisions
e) Nonmaleficence- Do no harm, alleviate suffering, and promote healing
f) Veracity- Duty to be honest or truthful

American Holistic Nurse’s Association Code of Ethics

-We believe that the fundamental responsibilities of a nurse are to promote HEALTH, facilitate
HEALING, and ALLEVIATE suffering. The need for nursing is universal. Inherent in nursing is the
RESPECT for life, dignity and right for all persons.
Nurses and The nurse has the responsibility to model health behaviours. Holistic nurses
Self strive to achieve harmony in their own lives and assist others striving to do
the same.
Nurses and The nurse’s primary responsibility is to the client needing nursing care. The
the Client nurse strives to see the client as a whole, and provides care which is
professionally appropriate and culturally consonant. The nurse holds in
confidence all information obtained in professional practice, and uses
professional judgment in disclosing such information. The nurse enters into
a relationship with the client that is guided by mutual respect and desire
for growth and development.
Nurses and The nurse maintains cooperative relationship with co-workers in nursing
Co-Workers and other fields. Nurses have a responsibility to nurture each other, and to
assist nurses to work as a team in the interest of client care. If a client’s
care is endangered by a co-worker, the nurse must take appropriate action
on behalf of the client.
Nurses and The nurse carries personal responsibility for practice and for maintaining
Nursing continued competence. Nurses have the right to utilize all appropriate
nursing interventions, and have the obligation to determine the efficacy
Practice
and safety of all nursing actions. Wherever applicable, nurses utilize
research finding in directing practice.
Nurses and The nurse’s play s a role determining and implementing desirable standards
the of nursing practice and education. Holistic nurses may assume a leadership
Profession position to guide the profession toward holism. Nurses support nursing
research and the development of holistically oriented nursing theories. The
nurse participates in establishing and maintaining equitable social and
economic working conditions in nursing.
Nurses and The nurse, along with other citizens, has responsibility for initiating and
the Society supporting actions to meet the health and social needs of the public.
Nurses and The nurse strives to manipulate the client’s environment to become one of
the peace, harmony, and nurturance so that healing may take place. The nurse
 Environment considers the health of the ecosystem in relation to the need for health,
safety and peace of all persons.

Law has the relevance in nearly all aspects of nursing practice, but in no other area of nursing is
the law more intimately involved than in Psychiatric mental health nursing. Psychiatric client
may:
 Be placed in treatment against their will
 pose a risk for themselves
 have been judged to have committed a crime while legally insane
 Be unable or unwilling to consent to treatment
 Be incapable of fully understanding medication risks
 require restraints for safety of self and others
 make threats that obligate their caretakers to warn potential victims
 Undergo forensic evaluation that requires the nurse to testify in court.

Rights of the Client

1. Right to Privacy- right of the client to keep personal information secret. Thus, any client
has the right to keep the fact that he is in treatment to himself. He may not wish for his
spouse, employers, friends, or others to know that he is receiving care. Except for the
following premises:
- A nurse may confide to other health care team members about client’s care but not
to other members who has no direct involvement with the care or services of the
client.
- Nurse may discuss information to a specific person provided that there is verbal
consent from the client or nurse may secure a signed ROI Form (release of
information)
- Nurses cannot disclose information to persons who cannot be positively identified
(Ex. through telephone)
- Information can be divulged to insurance carriers, employers provided that there is
authorization from the client.
- Confidentiality can be breached in situations where the nurse has reason to suspect
child abuse, elder abuse or that an individual may be at risk to harm specific other
person (Tarasoff Duty to Warn)

2. Right to Keep Personal Items- when a client enters a health care facility, he is entitled the
right to his personal property. When storage of items becomes difficult, the client can be
asked to leave extras at home. However, if client has items of value, the nurse is obligated
to document the items and store them in the safe or other secure place. In situations
where the nursing staffs have professional justification to remove potentially harmful
objects, the nurse must recognize that the objects are still owned by the client and can be
removed only during the time of hospitalization.

3. Right to enter into Legal Contracts- a client maintains his legal rights as a citizen. Thus if
an adult, the client has the right to vote, get married, sign for a mortgage, write a
personal last will and testament, and manage personal financial affairs or control
personal funds. Except again if the patient is really competent to judge and discern things
for himself. At times, competence judgements are required to assess whether an accused
person can stand trial or was sane at the time the crime was committed.
 Probate Proceedings- carried out to establish a judicial ruling that an individual is
or is not competent to manage activities. These are court proceedings wherein a
judge hears evidence on the individual’s ability to function and makes a judgment
of competence or incompetence.
 Incompetence- legal term reflecting that the individual has mental disorder, which
makes him unable to compose good judgments.
 M’ Naghten’s Rule/ Test- legal definition of lack of guilt of a crime by virtue of
insanity.
4. Right of Habeas Corpus- permits a speedy legal hearing and evaluation for any individual
who claims he is being detained illegally. In such a hearing, a judge hears evidence and
makes determination of whether or not the individual may be released or detained for
psychiatric treatment.

5. Right to Informed Consent- Clients have the right to be given clear information about
treatment, risks, benefits and alternatives. They may have the right to refuse treatments
that are offered them. To give consent, an individual must be alert and oriented, must
understand the procedure and must be freely accept the treatment without coercion.

Professional Negligence

-Negligence means either behaving in a way that a prudent individual would not have
behaved or failing to use the diligence and care expected of a reasonable individual in
similar circumstances. Negligence that results in harm to a client or that allows a client
to harm someone else may involve the nurse in a malpractice lawsuit.

1. Failure to prevent Dangerous Client Behaviour

-Mental health professionals have increasingly been held to high standards of
accountability in predicting and preventing client danger. Thus, in situations in which a
client discloses that he is likely to inflict harm on himself or on others, the mental
health professional is obligated to take action to prevent that harmful action.

2. Sexual Involvement with Clients

-Intimate or sexual relationships with clients are discouraged. Such prohibitions are part
of virtually all codes of behaviour for other mental health professionals, and sexual
liaisons between therapist and client are prohibited. Violation may result to suspension
or revocation of professional license.

3. Failure to Honour Individual Rights

-Client may bring suit against mental health professional for wrongful commitment to a
psychiatric hospital, failure to obtain appropriate consent, wrongful restraint, or a variety
of other perceived assaults on personal autonomy.

4. Control of Violent or Self- Destructive Behaviors

- When violent or self-destructive behaviour is overt or thought highly probable, the
nurse’s primary focus is on protecting the client and those around him. Seclusion (Putting
someone in a usually empty or padded room or cell by themselves), or physical restraints
(apparatus that significantly inhibit mobility) are treatments that could violate Least
restrictive alternative principle. This principle is a legal doctrine that requires that clients
be treated with the least amount of constraint of liberty consistent with their safety.
Seclusion and Restraint be used only when required to prevent imminent harm to self or
others, or when all other options for behavioural control have been exhausted. Use of
restraints and seclusion requires a physician’s order every 12 hours and should be
assessed and closely supervised by the nurse every 2-4 hours

Criteria used to determine whether to decrease or to end the use of Restraints

a) Client is able to verbalize feelings and concerns rationally
b) No verbal threats
c) decreased muscle tension, and:
d) stated ability to be in control

5. Tort
- Wrongful act that result in injury, loss or damage. Torts may be unintentional or
intentional.
a) Unintentional Tort
1. Negligence- an unintentional tort that involves causing harm by failing to do what is
reasonable and prudent person would do in similar circumstances.
2. Malpractice- type of negligence that refers specifically to professionals such as nurses
and physicians. For a malpractice suit to be successful, that is, for the nurse, physician,
and/or hospital/ agency to be liable, the client or family needs to prove the following
elements:
 Duty- a legally recognized relationship existed (nurse-client, physician-client)
 Breach of duty- the medical professional failed to conform to standards of care,
thereby breaching or failing the existing duty.
 Injury or damage- the client suffered some type of loss, damage or injury.
 Causation- the breach of duty was the direct cause of the loss, damage, or injury.
b) Intentional Tort
1. Assault- involves any action that causes a person to fear being touched in a way that is
offensive, insulting, or physically injurious without consent or authority. (Ex. making
threats to restrain client in order to give the client an injection for failure to cooperate)
2. Battery- involves harmful or unwarranted contact with the client; actual harm or injury
may or may not be occurred. (Ex. performing perineal care without any need to do so)
3. False Imprisonment- unjustifiable detention of client (Ex. Seclusion or Restraint)

You Say: “It’s Impossible”

God Says: All things are possible (Luke 18:27)
You Say: “I’m too tired”
God Says: I will give you rest (Matthew 11:28-30)
You Say: “Nobody really loves me”
God Says: I love you (John 3:16 & John 3:34)

--May We all have a New Year full of blessings—

princerenerpera
 PLT COLLEGE, INC.
Bayombong, Nueva Vizcaya
School of Health Sciences – College of Nursing

Psychiatric Mental Health Nursing

Psych Lecture Series # 5 (Prepared By: Prince Rener V. Pera, RN, MSN,EMT)

Stress, Crisis and Anxiety

Stress- a stimulus or situation that produces distress, and creates physical and physiological
demands on an individual, requiring coping and adapting.

Sources of Stress

 Traumatic Events- extreme danger, natural disasters, man-made disasters, physical

assaults
 Life Changes- Death of spouse, divorce, marital separation, jail term, death of relatives,
illness, marriage, fired from job, marital reconciliation, retirement, sex difficulties.
 Daily Hassles- misplacement of items, debt concerns, too many interruptions and
responsibilities, not enough time for family and arguments
 Conflicts- dilemmas, independence versus dependence, intimacy versus isolation,
cooperation versus competition, impulse expression versus moral standards.

General Adaptation Syndrome- a theory developed by Hans Selye which describes stress as
wear and tear on the body occurring regardless whether the stressor is positive or
negative. Selye formulated the concept of Adaptive Energy which is a human resource
which allows response to stress. A drain of this adaptive energy would mean illness or
death. The phases of GAS are as follows:

1. Alarm Reaction Stage- stress stimulates the body to send messages from the
hypothalamus to the glands to prepare for potential defense needs.

2. Resistance Stage- Are adaptive responses that attempt to limit the damage of stress
wherein the digestive system reduces function to shunt blood to areas needed for
defense. The lungs take more air, and heart beats faster and harder so it can circulate
highly oxygenated and nourished blood to the muscles to defend the body by flight, fight
or freeze behaviours. If the person adapts to stress, the body relaxes and the systemic
responses abates.

3. Exhaustion Stage- occurs when the person has responded negatively to anxiety and
stress; body stores are depleted or the emotional components are not resolved, resulting
in continual arousal of the physiologic responses and little reserve capacity.

ALARM REACTION RESISTANCE EXHAUSTION STAGE

Shock Counter Shock Shock Counter Shock
Depressed Nervous Excretion of Normal State Depressed Nervous Excretion of
System Epinephrine of V/S and System Epinephrine
Decreased Muscle etc. Decreased Muscle
Tone Tone
Hypotension Elevated Systolic Hypotension Elevated Systolic
BP/ Equal or BP/ Equal or
lower diastolic lower diastolic
BP BP
Hemoconcentration Glycogenolysis Hemoconcentration Glycogenolysis
Decreased Plasma Gluconeogenesis Decreased Plasma Gluconeogenesis
Glucose Glucose
Protein Catabolism Mobilization of Protein Catabolism Mobilization of
free fatty acids free fatty acids
Hypothermia Hyperthermia Hypothermia Hyperthermia
Other researchers most notably Engel, observed and recorded psychosocial responses to stress.
He identified 2 major responses to stress:
1. Fight or flight response and;
2. Conservative- withdrawal State

Fight or Flight Response

Body Part or System Adaptation to Stress

Hypothalamus Sympathetic Nervous System is stimulated
Sympathetic Nervous System Adrenal Medulla is stimulated
Adrenal Medulla Epinephrine and Norepinephrine are released
Eyes Pupils dilate
Lacrimal Glands Tear secretion increases
Respiratory System Bronchioles and pulmonary blood vessels dilate; respiratory
rate increases
Cardiovascular System Force of Cardiac contraction increases
Cardiac output increases
Heart rate increases
Blood pressure increases
Gastrointestinal System Gastric motility decreases
Secretions decreases
Sphincters contract
Liver Glycogenolysis and gluconeogenesis increase
Glycogen synthesis decrease
Urinary Tract Ureter motility increases
Bladder muscle contracts
Bladder sphincter relaxes
Sweat Glands Secretion increases
Fat Cells Lypolysis is initiated
When a continuing “fight or flight” response becomes sustained-stress response, the whole
body is affected. The hypothalamus stimulates the pituitary gland, which in turn directs the
release of various hormones; including adrenocorticotropin, which stimulates the adrenal cortex;
vasopressin, growth hormone, thyrotropin, and gonadotropins.

Sustained-Stress Response

COPING Mechanisms to Stress (Erikson’s Model)

 Coping Strategies for Stress Reduction

 Seek out a supportive person

 Strive for self-discipline
 Vent strong emotions
 think through options and use problem solving techniques
 Perform physical activities and exercise to release energy
 Use relaxation techniques, such as; listening to music, taking a warm shower or bath, meditating,
performing imagery or visualization exercises and using progressive muscle relaxation techniques

Psychological Variables that Affect/ Influence Stress

1. Control- the belief that one has some power over stressors can lessen the intensity of the
stress response
2. Predictability- stressors that can be predicted lessen the impact of the stress response
( as compared to the response to unpredictable stressors)
3. Perception- an individual’s view of the world and perception of the current stressor
either increases or decreases the intensity of the stress response
4. Coping Responses- the availability and effectiveness of defense or coping mechanism s
may increase or decrease the stress response.

Defense Mechanisms as Emotion- focused Coping

- These defense mechanisms do not alter the stressful situation, they just simply change
the way the person perceives or thinks about it. Thus all defense mechanisms involve an
element of self deception.
1. Repression- Impulses or memories that are too frightening or painful are excluded from
conscious awareness.
2. Rationalization- this serves in 2 purposes; it eases our disappointment when we fail to
reach a goal (“I didn’t want it anyway!”), and it provides us with acceptable motives for
our behaviour.
3. Reaction Formation- individuals conceal a motive from themselves by giving strong
expression to the opposite motive.
Anxiety
- State where a person has strong feelings of unknown/ nonspecific worry or dread
- Neurotransmitter alterations in the brain, especially in the limbic system, have been
implicated in stress, anxiety, and some related anxiety disorders.
a) GABA (Gamma-aminobutyric Acid) is an inhibitory neurotransmitter associated
with the relaxation response; because medications used to treat anxiety enhance
GABA, researchers believe that a relative deficiency or imbalance in GABA is
directly related to anxiety.
b) Serotonin- deficit or imbalance of this neurotransmitter in the amygdale is thought
to be significant also in anxiety.
c) Norepinephrine- is an excitatory neurotransmitter responsible for cardiovascular
changes in stress and anxiety.
Stages of Anxiety
1. Mild Anxiety- Tension of day-to-day living; individual has an alert perceptual field; can
motivate learning. (Ex: Anxiety felt when missing the bus)

Responses:
Wide perceptual field Restlessness
Sharpened senses Fidgeting
Increases Motivation GI “Butterflies”
Effective Problem solving Difficulty sleeping
Increased learning ability Hypersensitivity to noise
Irritability

Nursing Interventions:
Use cognitive strategies; stress management education, and problem solving approach

2. Moderate Anxiety- focus is on immediate concern; perceptual field is narrowed;

individual exhibits selective inattention.

Responses:
Cannot connect thoughts Diaphoresis
Increased use of automatism pounding pulse
Muscle tension Headache
Dry mouth High voice pitch
Faster rate of speech frequent urination

Nursing Interventions:
Use relaxation techniques; assist in using problem solving approaches; teach coping
strategies; and encourage catharsis

3. Severe Anxiety- Focus is on specific detail; perceptual field is greatly narrowed and
unable to easily solve problems. (Ex. Anxiety felt when witnessing a car accident)

Responses:
Cannot complete tasks severe headache
Cannot solve problems effectively nausea, vomiting and diarrhea
Behaviour geared towards anxiety trembling
relief and usually ineffective rigid stance
Doesn’t respond to redirection vertigo
Feels awe, dread, or horror pale
Crying and with ritualistic behaviour tachycardia and chest pain

Nursing Interventions:
Structured tasks and exercise to stimulate large muscle groups could be beneficial

4. Panic- Individual experiences a sense of awe, dread, and/or terror; individual loses
control; there is a disorganization of the personality. (Ex. anxiety felt when experiencing
an earthquake and being unable to cope?)

Responses:
Perceptual field is focused on self may bolt and run
Cannot process any environmental stimuli or totally immobile and mute
Loss of rational thoughts dilated pupils
Doesn’t recognize potential danger increased blood pressure and pulse
Can’t communicate verbally
Possible delusion and hallucination
May be suicidal

Nursing Interventions:
Decrease environmental stimuli; stay with the client; use quiet voice when conversing;
and assist with relaxation breathing.

PRAYER is the MOST POWERFUL against TRIALS

the MOST EFFECTIVE MEDICINE against SICKNESS
and the MOST VALUABLE GIFT to someone we CARE

Always be reminded by your COMMITMENT STATEMENT!!!

Godbless always!

Sir Prince 