PSYCHIATRIC NURSING LECTURE 2:

Basic Concepts and Nurse Patient Relationships

DEFENSE MECHANISMS
unconscious intrapsychic adoptive efforts to resolve emotional conflict and cope
with anxiety
automatic

pathology is determined by the frequency of use

DEFENSE MECHANISMS

DENIAL failure to acknowledge an intolerable thought , feeling, experience or

reality

DISPLACEMENT redirection of emotions or feelings to a subject that is more

acceptable or less threatening

PROJECTION attributing to others ones feelings, impulses , thought or wishes

UNDOING an attempt to erase an act , thought , feeling or desire

COMPENSATION an attempt to overcome real or imagined shortcoming

SYMBOLIZATION a less threatening object or idea is used to epresent another

SUBSTITUTION replacing desired , impractical , unattainable object with one
that is acceptable

INTROJECTION a form of identification in which there is a taking into oneself

the characteristic of another(love object)

REPRESSION unacceptable thoughts is kept from awareness(unconscious)

SUPPRESSION- consciously putting a disturbing thought or incident out of

awareness

REACTION FORMATION expressing attitude directly opposite to

unconscious wish or fear

REGRESSION returning to an earlier developmental phase in the face of stress

DISSOCIATION detachment of painful emotional conflicts from consciousness

IDENTIFICATION conscious patterning of ones self from another person

CONVERSION emotional problems are converted into symptoms

FANTASY conscious distortion of unconscious feelings or wishes

INTELLECTUALIZATION - over use of intellectual concepts by an individual

to avoid expression of feelings

RATIONALIZATION justifying ones actions which are based on other motives

SUBLIMATION - rechanneling of unacceptable instinctual drives with one hat is

aceptable

NURSE PATIENT RELATIONSHIP

SULLIVANS THEORY ON INTERPERSONAL RELATIONSHIP

DEVELOPED BY PEPLAU INTO NURSE- PATIENT RELATIONSHIP

SERIES OF INTERACTION BETWEEN THE NURSE AND PATIENT IN

WHICH THE NURSE ASSISTS THE PATIENT TO ATTAIN POSITIVE
BEHAVIORAL CHANGE

T RUST

R APPORT

U NCONDITIONAL POSITIVE REGARD

S ETTING LIMITS

T HERAPEUTIC COMUNICATION
PHASES

PRE-INTERACTION SELF AWARENESS

ORIENTATION PHASE DEVELOP A MUTUALLY ACCEPTABLE

CONTACT

WORKING IDENTIFICATION AND RESOLUTION OF THE PATIENTS

PROBLEMS

TERMINATION ASSIST PATIENT TO REVIEW WHAT HE HAS

LEARNED AND TRANSFER HIS LEARNING TO HIS REL. W/ OTHERS
WHEN TO TERMINATE NPR

GOALS ACCOMPLISHED

EMOTIONALLY STABLE
GREATER INDEPENDENCE

ABLE TO COPE WITH ANXIETY, LOSS , FEAR AND SEPARATION

COMMON PROBLEMS - NPR

TRANSFERENCE DEVELOPMENT OF EMOTIONAL ATTITUDE + OR

TOWARDS THE NURSE

RESISTANCE DEVELOPMNET OF AMBIVALENT FEELINGS

TOWARDS SELF EXPLORATION

COUNTER TRANS FERENCE TRANSFERENCE AS EXPERIENCED BY

THE NURSE
PRINCIPLES OF CARE

ACCPETS PATIENT AS UNIQUE WITH INHERENT VALUE AND WORTH

PATIENT IS VIEWED AS HOLISTIC HUMAN BEINGS WITH

INTERDEPENDENT AND INTERRELATED NEEDS

FOCUS ON STRENGTHS AND ASSETS

NON JUDGEMENTAL ASSISTANCE TOWARDS COPING

EXPLORE THE PATIENTS BEHAVIOR AND THE NEED IT IS DESIGNED

TO MEET AND THE MESSAGE IT IS COMMUNICATING
LEVELS OF INTERVENTION
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PRIMARY INTERVENTIONS AIMED AT THE PROMOTION OF MENTAL

HEALTH AND LOWERING THE RATE OF CASES BY ALTERING THE
STRESSORS

SECONDARY INTERVENTIONS THAT LIMIT THE SEVERITY OF THE

DISORDER

CASE FINDING AND PROMPT Tx

TERTIARY REDUCING THE DISABILITY AFTER A DISORDER

PREVENTION OF COMPLICATION AND ACTIVE PROGRAM OF

REHABILITATION
CHARACTERISTICS OF A PSYCHIATRIC NURSE-major roles of a nurse socializing agent
and patient advocate

EMPATHY- ability to see beyond outward behavior and sense accurately another
persons inner experience

GENUINENESS/CONGRUENCE ability to use therapeutic tools appropriately

UNCONDITIONAL POSITIVE REGARD - respect

THERAPEUTIC COMMUNICATION

CLARIFICATION

LIMIT SETTING

MUST HAVE CONSISTENCY AND IS NON JUDGEMENTAL

EMPATHETIC / ENCOURAGE EXPRESSION

ANSWERS NEEDS

REFLECTIVE AND INSIGHTFUL

THERAPEUTIC COMMUNICATION

FOCUS ON FEELING TONE ,NEEDS ,MOTIVATION

CRITERIA OF SUCCESSFUL COMMUNICATION FEEDBACK ,
APPROPRIATENESS, FLEXIBILITY AND EFFICIENCY
TECHNIQUES OF COMMUNICATION

TO INITIATE A CONVERSATION

giving broad openings

giving recognition / acknowledgement

TO ESTABLISH RAPPORT

GIVING INFORMATION

USE OF SILENCE

TO GATHER INFORMATION

FOCUSING

VALIDATING

REFLECTING

RESTATING

TO CLOSE A CONVERSATION

summarizing

TREATMENT MODALITIES
common psychotherapeutic interventions applied to psychiatric nursing
BIOLOGICAL

EMOTIONAL PROBLEM IS AN ILLNESS

cause may be inherited or chemical in origin

FOCUS OF TREATMENT IS MEDICATIONS AND ECT*

REMOTIVATION THERAPY

TREATMENT MODALITY THAT PROMOTES EXPRESSION OF FEELINGS

THROUGH INTERACTION FACILITATED BY DISCUSSION OF NEUTRAL
TOPICS

STEPS :
climate of acceptance
creating bridge to reality
sharing the world we live in
appreciation of works of the world
climate of appreciation
MUSIC THERAPY

INVOLVES USE OF MUSIC TPO FACILITATE EXPRESSION OF

FEELINGS,FACILITATE RELAXATION AND OUTLET OF TENSION
PLAY THERAPY

enables patient to experience intense emotion in a safe environment with the use
of play

children express themselves more easily in play. revealing as reflection of childs

situation in the family

provide toys and materials facilitate interaction observe and help child resolve
problems through play
Group therapy

Treatment modality involving three or more patients with a therapist to relieve

emotional difficulties, increase self esteem, develop insight , LEARN NEW
ADAPTIVE WAYS TO COPE WITH STRESS and improve behavior with
others( RELATIONSHIP WITH OTHERS CAN BE WORKED THROUGH)

IDEAL 8 10 MEMBERS
MILIEU THERAPY

CONSISTS OF TREATMENT BY MEANS OF CONTROLLED

MODIFICATION OF THE PATIENTS ENVIRONMENT , FACILITATE POSITIVE
BEHAVIORAL CHANGE

INCREASE PATIENTS AWARENESS OF FEELINGS, INCREASE SENSE OF

RESPONSIBILITY AND HELP ETURN TO COMMUNITY

clients plan social and group interaction

token programs , open wards and self medication

FAMILY THERAPY

A METHOD OF PSYCHOTHERAPY WHICH FOCUSES ON THE TOTAL

FAMILY AS AN INTERACTIONAL SYSTEM

PROBLEM IS A FAMILY PROBLEM

focus on sick members behavior as source of trouble / symptom serve a function

for the family

members develop sense of identity

points out function of the sick member for the rest of the family
PSYCHOANALYTIC

focuses on the exploration of the unconscious, to facilitate identification of the

patients defenses

ANXIETY RESULTS BETWEEN CONFLICTS OF ID AND EGO(DEFENSE

MECHANISMS FORM TO WARD OFF)

BECOMES AWARE OF UNCONSCIOUS THOUGHTS AND

FELINGS.UNDERSTAND ANXIETY AND DEFENSES
HYPNOTHERAPY

VARIOUS METHODS AND TECHNIQUES TO INDUCE A TRANCE STATE

WHERE PATIENT BECOMES SUBMISSIVE TO INSTRUCTIONS
BEHAVIOR MODIFICATION

A THERAPEUTIC INTERVENTION INVOLVOING THE APPLICATION OF

LEARNING PRINCIPLES IN ORDER TO CHANGE MAL-ADAPTIVE BEHAVIOR

PSYCHOLOGICAL PROBLEMS ARE A RESULT OF LEARNING

DEFICIENCIES CAN BE CORRECTED THROUGH LEARNING

BEHAVIOR MODIFICATION

OPERANT CONDITIONING

USE OF REWARDS TO EINFORCE POSITIVE BEHAVIOR

PERCEIVED AND SELF REINFORCEMENT BECOMES MORE

IMPORTANT THAN EXTERNAL

DESENSITIZATION

SLOW ADJUSTMENT OR EXPOSURE TO FEARED OBJECTS(USED IN

PHOBIAS)

PERIODIC EXPOSURE,UNTIL UNDESIRABLE BEHAVIOR DISAPPEARS

OR LESSENS
AVERSION THERAPY

AN EXAMPLE OF BEHAVIOR MODIFICATION IN WHICH PAINFUL

STIMULUS IS INTRODUCED TO BRING ABOUT AN AVOIDANCE OF ANOTHER
STIMULUS WITH THE END VIEW OF FACILITATING BEHAVIORAL CHANGE
TOKEN ECONOMY-REWARDING DESIRED BEHAVIOR
COGNITIVE THERAPY SHORT TERM STRUCTURED THERAPY ORIENTED

TOWARDS PRESENT PROBLEMS ABD SOLUTIONS AMIN FOCUS OF

DEPRESSIVE DISORDERS
HUMOR THERAPY TO FACILITATE EXPRESSION AND ENHANCE
INTERACTION
ACTIVITY THERAPY GROUP INTERACTION WHILE WORKING ON A TASK
TOGETHER
BIOLOGICAL THERAPY

ELECTROCONVULSIVE THERAPY

mechanism of action unclear

voltage 70 150 volts

about .5 2 seconds

6 12 treatments

intervals of 48 hours

indicators of effectiveness occurence of generalized tonic clonic seizures

indications depression , mania and catatonic schizophrenia

contraindications:fever , IICP, fracture,retinal det.,preg,TB w/ hemm. , cardiac d/o
consent needed
medications given :

AT SO4-decrease secretions

anectine ( Succinylcholine )- promote muscle relaxation

Methohexital Sodium ( Brevital )- serves as an anesthetic agent

common complications:

loss of memory

headache

apnea

fracture

respiratory depression
Psychopharmacology

classification , action and indication(complimentary data)

contraindications
common side/adverse effects
considerations , care and client teaching

common examples
I.ANTI PSYCHOTIC MEDICATIONS / NEULOLEPTICS

formerly called major tranquilizers. used to relieve psychotic

symptoms( delusions , hallucinations and looseness of association)

blocks activity of the CNS receptors and sympathetic nervous system

ALSO ACTS AS ANTI EMETIC , ANTI CHOLINERGIC AND

ANTIHISTAMINIC

C/I : hypersensitivity , glaucoma , convulsive d/o/ , pregnancy and lactation,

elderly clients

(CNS)extrapyramidal symptoms

PSEUDOPARKINSONISM-tremor , mask like facies drooling , restlesssness

AKATHISIA- restlessness

DYSTONIA-grimacing , torticoilis , intermittent muscle spasms

TARDIVE DYSKINESIA-lip smaking and tongue and mouth

movements,disappears during sleep , usually irreversible

NEUROLEPTIC MALIGNANT SYNDROME hyperthermia , rigidity ,tremors,

automatic hyperactivity

SEIZURES
leukopenia , agranulocytosis (blood dyscrasia)
photosensitivity ands orthostatic hypotension
blurred vision , glaucoma
dry mouth, NAVDA

check CBC & BP may cause leukopenia and orthostatic hypotension

report elevated temp , muscle rigidity and sore throat, avoid sunlight exposure
nay require several weeks of therapy to obtain desired effects
take with food or milk to reduce stomach irritation
watch out for s and sx of adverse rxns
teach the importance of follow up and compliance to medications
no activity that requires alertness for 2 weeks from start of therapy

common medications:
Phenothiazines:
Chlorpromazine ( Thorazine )
Prochlorperazine ( Compazine )
Fluphenazine (Prolixin)
OTHERS

CLOZAPINE
(CLOZARIL ) 300 450(SEIZURES)

CARBAMAZEPINE (TEGRETOL)50 200 MG / 24 HOURS(SEIZURES)

BUTYROPHENONE

HALOPERIDOL ( HALDOL ) 2 40 MG/24HRS

ANTIPARKINSONIAN MEDICATIONS

ADJUNCT TO ANTI-PSYCHOTIC AGENTS. TO BALANCE DOPAMINE

/ACETYLCHOLINE IN THE BRAIN

GLAUCOMA , TACHYCARDIA , HPN , CARDIAC Dx , ASTHMA,

DUODENAL UCER

BLURRED VISION,PHOTOSENSITIVITY ,HA ,

DROWSINESS,ORTHOSTATIC HYPOTENSION, CHF, HALLUCINATIONS

BEST TAKEN AFTER MEALS

AVOID DRIVING BLURRING OF VISION
CHECK BP-HYPOTENSION
ALCOHOL INCREASES INCREASES SEDATIVE EFFECTS
AVOID SUDDEN POSITION CHANGE
DRUGS IS NOT WITHDRAWN ABRUPTLY

COMMON DRUGS:

ANTICHOLINERGICS

ARTANE AND COGENTIN

ANTIHISTAMINE

BENADRYL

DOPAMINE RELEASING AGENT

SYMMETREL
ANTI ANXIETY

EXERT A GENERAL DEPRESSSING EFFECT ON TH E CNS.HAVE

MUSCLE RELAXANT AND ANTI CONVULSANT EFFECTS.GIVEN FOR
INSOMNIA AND AXIETY

CALLED MINOR TRANQIULIZER

MAY LEAD TO DEPENDENCE
IF BP BELOW 20 mmHG SYSTOLIC FROM BASELINE HOLD AND
NOTIFY PHYSICAN
WITHDRAWAL 8 MONTHS AND IN HIGH DOSES

GLAUCOMA , HYPERSENSITIVITY, LIVER AND KIDNEY

DYSFUNCTION,HYPERSENSITIVITY,
PSYCHOSESELDERLY , PREG AND LACT

DIZZNESS , DROWSINESS AND

CONFUSION(DISORIENTATION)DERMATITIS ,ECG CHANGES AND
ORTHOSTATIC HYPOTENSION,TINNITUS AND MYDRIASIS

ADMINISTER SEPARATELY INCOMPATIBLE WITH OTHER DRUGS

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AVOID DRIVING , ALCOHOL AND CAFFEINE . FOOD ALTERS EFFECTS

BEST TAKE BEFORE MEALS
CAREFUL SUPERVISION OF DOSE AND COMPLIANCE

DIAZEPAM (VALIUM)
HYDROXYZINE HCL ( ATARAX)
ALPRAZOLAM ( XANAX
CHLORAZEPATE ( TRANXENE)
LORAZEPAM ( ATIVAN)
HYDROXYZINE PAMOATE ( VISTARIL0
OXAZEPAM ( SERAX)
CHLORDIAZEPOXIDE ( LIBRIUM)
ANTIDEPRESSANTS

TREATMENT OF MELANCHOLIA,DEPRESSED MOOD ,MOOD SWING .

TRICYCLICS PREVENTS REUPTAKE OF NOREPINEPHRINE

SSRIS-INHIBITS UPTAKE OF SEROTONIN,STIMULANT

COUNTERACTING DEPRESSION ,INCREASING MOTIVATION

MAOIS -INTERFERES WITH MONOAMINE OXIDASE ALLOWING

INCREASED CONCENTRATION OF NEUROTRANSMITTERS
ANTIDEPRESSANTS

TRICYCLICS- HYPERSENSITIVITY LIVER DISEASE AND GLAUCOMA

SSRIS-SAME

MAOS-HYPERTENSION,LIVER DISEASE AND CARDIOVASCULAR

DISEASE
ANTIDEPRESSANTS

MAOIS HYPERTENSIVE CRISIS ,PHOTOSENSITIVITY, WEIGHT GAIN

AND SEXUAL DYSFUNCTION

SSRIS - NERVOUSNESS,INSOMNIA , DROWSINESS, ANXIETY,

TREMOR

TRICYCLICS SEDATION , ANTICHOLINERGIC EFFECTS(DRY

MOUTH , BLURRED VISION),CONFUSION,PHOTOSENSITIVITY,ORTHOSTATIC
HYPOTENSION, BONE MARROW DEP.,URINARY RETENTION
ANTIDEPRESSANTS

MAOIS INCREASED APPETITE ,ADEQUATE SLEEP

AVOID TYRAMINE RICH FOODS:AVOCADO,BANANA,CHEDDAR AND

AGED CHEESE,SOYSAUCE AND PRESERVED FOODS

TAKES 3-4 WKS TO WORK, 2-3 WEEKS BEFORE INITIAL THERAPEUTIC

EFFECTS BECOME NOTICEABLE

AVOID STIMULANTS

AVOID TRICYCLICS UNTIL 3 WKS AFTER STOPPING MAOI

USE SUNBLOCK

BEST TAKEN AFTER MEALS

REPORT HEADACHE INDICATIVE OF HYPERTENSIVE CRISIS

ANTIDEPRESSANTS
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TRICYCLICS INCREASED APPETITE ,ADEQUATE SLEEP

SUICIDE RISK IN 10 14 DAYS

SUNBLOCK REQUIRED

INCREASE FLUID INTAKE

TAKE DOSE AT BEDTIME,BEST GIVEN AFTER MEALS

SUGARLESS CANDY/GUM

DELAY OF 2-6 WKS (2-3WKS)BEFORE NOTICEABLE EFFECTS

CHECK BP HYPOTENSION

CHECK HEARTRATE CAUSES CARDIAC ARRYTHMIAS

ANTIDEPRESSANTS

SELECTIVE SEROTONIN REUPTAKE INHIBITORS

TAKE IN AM TO AVOID INSOMNIA

TAKES AT LEAST 4 WEEKS TO WORK

CAN POTENTIATE EFFECTS OF DIGOXIN,COUMADIN AND VALIUM

USED FOR ANOREXIA, NOT SUICIDAL OR HOMICIDAL

COMMON EXAMPLES

TRICYCLICS

IMIPRAMINE (Tofranil)

AMITRIPTYLINE (Elavil)

SSRIS

Fluoxetine ( Prozac)

Paroxetine ( Paxil)

Sertraline ( Zoloft)

MAOIS

Tranylcypromine (Parnate)

Phenelizine ( Nardil)

Isocarboxazid (Marplan)
ANTI - MANIC

MOOD STABILIZING DRUG, FOR THE CONTROL OF MANIC EPISODES

IN THE SYNDROME OF MANIC DEPRESSIVE PSYCHOSIS- LITHIUM
CARBONATE

CARDIOVASCULAR DISEASE, RENAL DISEASE, BRAIN DAMAGE,

CLIENTS RECEIVING DIURETICS, CLIENTS ON LOW SODIUM DIETS,
PREGNANCY AND LACTATION

NAVDA (LITHIUM TOXICITY), dizziness , headache, FINE HAND

TREMORS, IMPAIRED VISION,MUSCULAR WEAKNESS
ANTI - MANIC

INCREASE FLUID INTAKE 3LPD AND SODIUM INTAKE 3 GM./DAY

BEST TAKEN AFTER MEALS

MONITOR FOR TOXICITY

AVOID ACTIVITIES THAT INCREASE PERSPIRATION

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TAKES 10-14 DAYS BEFORE THERAPEUTIC EFFECT BECOMES
EVIDENT

ANTIPSYCHOTIC GIVEN DURING THE FIRST TWO WEEKS TO

MANAGE THE ACUTE SYMPTOMS OF MANIA.UNTIL LITHIUM TAKES
EFFECT

NORMAL - .5 1.5 mEq /L

MONITOR SERUM LEVELS 2-3 TIMES WEEKLY WHEN STARTED AND

MONTHLY WHILE ON MAINTENANCE

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