Psychiatric nursing

Mental Health
Balance in a persons internal life and
adaptation to reality
State of wellbeing in which a person is able to
cope with normal stresses of daily life and
realize his/her potential (WHO, 2005)
In short is the SUCCESSFUL ADAPTATION TO
STRESSORS!!!
Mental Illness
State of imbalance characterized by a
disturbance in a persons thought, feelings and
behavior
In short is the MALADAPTIVE RESPONSE TO
STRESSORS!!!
Poverty and abuse are the major factor that
increase the risk of development of mental
illness at home
Factors that can lead to mental
disorders
Dissatisfaction with ones characteristics,
abilities and accomplishments
Ineffective or unsatisfying relationships
Dissatisfaction with ones place in the world
Ineffective coping with life events
Lack of personal growth
DSM-IV-TR
Diagnostic and Statistical Manual of Mental Disorders
Fourth Edition, Text Revision
Axis I
Major psych disorders and other clinical disorders except those
belonging to Axis II: depression, schizophrenia, anxiety and substance
related d/o
Axis II
Mental retardation and personality disorders
Axis III
Current/General medical conditions that are potentially relevant to
understanding or managing the persons mental disorders
Axis IV
Psychosocial and environmental problems that may affect the
diagnosis, treatment and prognosis of mental d/o
Axis V
Global assessment of functioning w/c rates a persons overall
psychological functioning on a scale of 0 to 100

Example of Psychiatric Diagnosis using
DSM-IV
Psychiatric Diagnosis
Axis I Dysthymic Disorder
Axis II Dependent personality disorders
Axis III Hypothyroidism
Axis IV Unemployed
Axis V GAF: 60 (current)
DSM-V
DSM-5
It has 3 sections:
Introduction and directions for usage
Diagnoses and disorders (20 disorders)
Unclassified conditions to undergo further research
Major changes:
Direct and specific diagnosis; no more axials
From roman numeral IV to standard 5
From disorder otherwise classified to DISORDERS NOT
ELSEWHERE CLASSIFIED
THEORIES AND MODELS IN PSYCH
Psychoanalytic theory
By Sigmund Freud
Personality Processes
Id: pleasure principle
Ego: reality principle
Superego: conscience/moral principle


Age Stage
Birth to 18 months Oral Stage
18 months to 3 years Anal
3 y/o to 6 y/o Phallic
6 y/o to 12 y/o Latency
13 to 20 years Genital
Psychoanalytic theory
Psychosocial Theory
By Erik Erikson
Stage Virtue
Trust vs. Mistrust (infant)
Hope
Autonomy vs. shame & doubt (Toddler)
Will
Initiative vs. Guilt (Preschool)
Purpose
Industry vs. Inferiority (School Age)
Competence
Identity vs. Role confusion (adolescent)
Fidelity
Intimacy vs. Isolation (young adult)
Love
Generativity vs. Stagnation (middle adult)
Care
Integrity vs. Despair (old adult)
Wisdom
Trust vs. Mistrust
Task: to develop basic trust in the mothering figure and be
able to generalize it to others
Autonomy vs. Shame & Doubt
To gain some self-control, ability to delay gratification and
independence within the environment.
Initiative vs. Guilt
To develop a sense of purpose and the ability to initiate and
direct own activities.
Industry vs. Inferiority
To develop a sense of self-confidence by learning,
competing, performing successfully and receiving
recognition from significant others, peers and
acquaintances.
Psychosocial Theory
Identity vs. Role confusion
Task: formulating a sense of self and belonging
Intimacy vs. Isolation
To form an intense, lasting relationship or a commitment
to another person, cause, institution or creative effort
Generativity vs. stagnation
To achieve the life goals established for oneself, while also
considering the welfare of future generation
Integrity vs. Despair
To review ones life and derive meaning from both positive
and negative events, while achieving a positive sense of
self-worth

Psychosocial Theory
Cognitive Model
By Jean Piaget
Sensorimotor (birth-2yrs)
Develops a sense of self. Concept of object permanence
(tangible objects dont cease to exist just because they are
out of sight)
Preoperational (2-6yrs)
Able to express self with language. Understand meaning of
symbolic gestures.
Concrete operational (6-12yrs)
Apply logic thinking. Understand spatiality and reversibility.
Increasingly social and able to apply rules, thinking is still
concrete (take things literally)
Formal operational (12-15yrs and beyond)
Child learns to think and reason in abstract terms. Further
develops logical thinking and reason and achieves cognitive
maturity.
EGO DEFENSE MECHANISM
Compensation overachievement in one area to
offset real or perceived deficiencies in another
area
Conversion expression of an emotional conflict
through the development of a physical symptom
Denial failure to acknowledge an unbearable
condition; failure to admit the reality of a
situation
Displacement feelings are transferred,
redirected or discharged from the appropriate
person or object to less threatening person or
object
Fixation immobilization of a portion of the
personality resulting from unsuccessful
completion of tasks in a developmental stage
Identification modeling action and opinions of
influential others while searching for identity
Intellectualization acknowledging the facts but
not the emotions
Introjection accepting another persons
attitudes, beliefs and values as ones own
Projection unconscious blaming of
unacceptable inclinations or thoughts on an
external object
Rationalization excusing own behavior to avoid
guilt, responsibility and conflict
Reaction Formation acting the opposite of one
thinks or feels
Regression moving back to previous developmental
stage to feel safe and have needs met
Repression an involuntary, automatic submerging of
painful, unpleasant thoughts and feelings into the
unconscious
Suppression conscious exclusion of unacceptable
thoughts and feelings from conscious awareness
Substitution replacing the desired gratification with
one that is more readily available
Sublimation substituting a socially acceptable activity
for an impulse that is unacceptable
Undoing exhibiting acceptable behavior to make up
for or negate unacceptable behavior
PATHOLOGIC BEHAVIORS
Agnosia
Inability to recognize
objects and people
Agraphia
Loss of ability to write
Alexia
Loss of ability to read
Alogia
Decrease in amount
and content of
speech/inability to
speak


Ambivalence
Presence of two
opposing feelings
Amnesia
Inability to recall past
events
Anhedonia
Loss of interest in
pleasurable things

Retrograde amnesia
Loss of memory of
the distant past
Anterograde amnesia
Loss of memory of
the immediate past
Apathy
Dulled emotional
state

Apraxia
Inability to carry out
purposeful motor
activities
Avolition
Lack of motivation
Blunted affect
Severe reduction in
emotional reaction

Circumstantiality
Indirect speech
characterized by over
inclusion of details after
which the client
eventually gets through
the intended purpose of
his/her message
Clang association
Association of words by
sound rather than by
meaning
Confabulation
Filling in of memory gaps
Dj vu
Feeling of having been to
a place w/c one has not
yet visited

Delusion
Fixed false belief that
isnt seen in reality
Depersonalization
Feeling of strangeness
towards ones self


Dysarthria
Inability to articulate
Echolalia
Echoing of phrases
Echopraxia
Pathologic imitation of
posture/action of others

Expressive
aphasia/Brocas aphasia
characterized by the loss of
the ability to produce
language (spoken or
written).
Receptive
aphasia/Wernickes
Aphasia
have serious
comprehension difficulties
and be unable to grasp the
meaning of spoken words.
Global aphasia
has difficulty speaking and
understanding words. In
addition, the person is
unable to read or write.

Flat Affect
Absence or near absence
of emotional reaction
Flight of Ideas
Shifting from a topic to the
next in a somewhat related
way
Hallucination
False sensory perception in
the absence of external
stimuli
Illusion
Misperception of an actual
external stimuli
Inappropriate affect
Disharmony between the
stimuli and the emotional
reaction
Jamais vu
Feeling of not having
been to a place which
one has visited
Looseness of
association
Shifting from one topic
to another in a
completely unrelated
way
Neologism
Pathologic coining of
new words with personal
meaning

Tangentiality
Inability on the speaker
to achieve the desired
goal of the
communicated message
Perseveration
Persistence of a
response to a previous
question
Verbigeration
Meaningless repetition
of words or phrases

Word salad
Incoherent mixture of
words and phrases
Waxy flexibility
Ability to assume various
positions without
resistance


ASSESSMENT
Sensory Perception
Illusion
Hallucination
G: gustatory
O: olfactory
V: visual
A: auditory
T: tactile (common in alcohol withdrawal)
Appearance and Motor Behavior
Thought Process
Circumstantial thinking
Flight of ideas
Ideas of reference
Loose association
Tangential thinking
Thought blocking (pt. is
silent; usually seen in
schizophrenic patients)
Thought broadcasting
Thought insertion


Thought withdrawal (false
belief thought has been
taken out of the
patient)
Word salad
Clang association
Delusion
Neologism
Mood and Affect
Blunt affect little or slow to respond
Broad affect full range; exaggerated affect
Flat affect poker face; no reaction
Inappropriate affect incongruent
Labile affect unpredictable, rapid change of
affect
Restricted affect one expression
Injury towards self/others
Suicidal ideation/plan/method/access/time &
place
Time and place: isolated places at early in the
morning or during endorsement

Sensorium and intellectual process:
Orientation/memory/concentration/
abstract or intellectual function

Judgment (Decision) and Insight
(Lesson Learned)
Self-concept
Roles and Relationship
Physiologic, self care, hygiene
THERAPEUTIC RELATIONSHIP
Nurse-Patient Relationship (NPI)
Involves mutual learning
A corrective emotional experience
Personal attributes (use of self) and clinical
techniques (therap comm) = change of
patients insight and behavior
Friendliness
Caring
Interest
Understanding
Congruency
Consistency
Treating the patient as
human being
Suggesting without
telling
Approachability
Listening
Keeping promises
Providing schedule of
activities
Honesty
1. Trust is built when the nurse
exhibits the following behavior:
2. Genuine Interest
3. Empathy ability of the nurse to perceive the
meanings and feelings of the client and to
communicate that understanding to them
4. Acceptance
5. Positive Regards unconditional and
nonjudgmental attitude
6. Self-awareness and therapeutic use of self
the nurse must know and understand his or her
self
Therapeutic Nurse-Patient
Relationship
By Hildegard Peplau
Phases:
Pre-orientation: before meeting the client
Orientation: begins when the nurse and client meets and
ends when the client begins to identify his/her problems
Identification: begins when the client works
interdependently with the nurse, expresses feelings and
begins to feel stronger
Exploitation: client makes full use of the services offered
Termination/Resolution: client no longer needs
professional services and gives up dependent behavior;
end of NPI
THERAPEUTIC COMMUNICATION
Using Silence
Providing general leads
Using open-ended questions
Using touch
Restating or rephrasing
Seeking clarification (overall meaning of the
entire message)
Clarifying time or sequence
Offering self
Giving information
Acknowledging
Listening
Presenting reality
Focusing: focus could be an idea or a feeling
Reflecting
Summarizing
Seeking consensual validation (verification of
the meaning of a specific words to patient)
NONTHERAPEUTIC
COMMUNICATION
Stereotyping
Agreeing and disagreeing
Being defensive
Challenging
Probing (ex. Is asking WHY?)
Testing
Changing topics and subjects
Unwarranted reassurance
Passing judgment
Rejecting
Giving common advice
LEGAL ASPECTS OF PSYCHIATRIC
NURSING
Exempting Circumstance
2 Types of Hospitalization
Voluntary Admission
Client admitted himself to hospital
Discharge: initiated by patient HAMA/DAMA
Civil rights: retained by patient
Justification: voluntarily sought out help
Involuntary Admission
Admission: application by others
Discharge: determined by court or hospital
Civil rights: retained none, some or all
Justification: mentally ill and dangerous to
self/others, requires treatment and the
patient cant meet their own needs.
Patients Rights
T Treatment
R Refuse treatment
I Informed consent
P Privacy &
Confidentiality
L Least restriction
E Enter contract
C Communicate
H Habeas corpus
(immediately
present the body)
E Education
K Keep personal
belongings
Tarassoffs Principle
Duty to warn a potential victim of a persons
dangerousness
Ex. If you as a nurse knows that a person is
dangerous to others you can apply this
principle by telling the authorities of such; or
warning a person who can be a victim.
PSYCHOTROPIC DRUGS
Antipsychotic drugs
(Neuroleptics)
For psychosis and hallucinations seen in
schizophrenia, schizoaffective disorders and
manic phase of bipolar disorder
Off label uses: for anxiety and insomnia
Mechanism of action
It blocks receptors for dopamine (decrease
dopamine)
Types
(Typical & Atypical)
Typical:
Phenothiazines:
azine (Chlorpromazine Thorazine; Fluphenazine Prolixin
given IM)
Thioxanthene
Thiothixene Navane
Butyrophenones
dol (Haloperidol (Haldol) & Droperidol (Inapsine))
Dibanzazepine
Loxapine Loxitane
Dihydroindolone
Molindone Moban
Atypical
zapine/ apine & ridone
Clozapine (clozaril)
Risperidone (risperdal)
Olanzapine (zyprexa) note: may also be given as a
mood stabilizer
Quetiapine (seroquel)
New Generation
Aripiprazole: Abilify

Types
(Typical & Atypical)
Side effects: EPS
Acute Dystonia
Akathisia
Bradykinesia
Pseudoparkinsonism
Other side effects
Neuroleptic Malignant Syndrome
Tardive Dyskinesia
Anticholinergic Side effect
EPS
Acute Dystonia
Manifestation:
Acute muscular rigidity
Dysphagia: stiff/thick
tongue
Opisthotonus: tightness in
entire body with head &
back and arched neck
Oculogyric crisis: eyes
rolled back in a locked
position
Torticolis: twisted head
and neck
Occurrence:
First week of treatment
Younger than 40 years old
Males
Receiving high potency
drugs like haldol and
navane
Management:
Give anticholinergic:
Cogentin (Benztropine) -
IM
Or Benadryl IM/IV

Akathisia
Subjective feeling of
restlessness
S & Sx:
Restless legs
Jittery
Anxiousness
Rigid posture or gait
Lack of spontaneous
gestures
Inability to sit still and
rest
Management:
Change medication
Addition of beta-blocker
(Inderal), anticholinergic
or benzodiazepene
Bradykinesia
Slowed movement
S & Sx:
Weakness
Fatigue
Painful muscle
Anergia
Management:
Give anticholinergic:
Cogentin or Benadryl
Pseudoparkinsonism
Manifestation
Stooped posture
Mask-like face
Decreased arm swing
Shuffling gait
Drooling
Tremors
Bradycardia
Coarse pill-rolling
movement of thumb and
fingers while at rest
Management:
Change medication
Add oral anticholinergic
Give amantadine
(dopamine agonist)
NMS
Potentially fatal
idiosyncratic reaction to
an antipsychotic drug
Occurrence:
1
st
2 weeks of therapy
After an increase in dosage
Dehydration
Poor nutrition
S&Sx
N: Nilalagnat
M: muscle cramps
S: sweating
Management:
Immediately d/c meds
Treat dehydration and
hyperthermia
May change medication
DOC: Dantrium & Parlodel
Antipsychotics should not
be adminitered at least
two weeks after symtom
resolution
Tardive Dyskinesia
A syndrome of
permanent involuntary
movement that is most
commonly caused by long
term use of typical
antipsychotic
Irreversible & no tx
S & Sx
Tongue protrution
Teeth grinding
Lip smacking
Facial twitching
Symptoms stop with sleep
Management:
No substantial
management available.
Vitamin E helps improve
condition in minority of
patients