NCM 105
Psychiatric-mental health nursing
Lectured by: Raquel S. Antonio RN, MAN
Historical overview of psychiatric care
Primitive beliefs
1. People with mental illness has
been dispossessed by his or her
soul
2. People with mental illness are
possessed by evil spirits
Hippocrates (460-375 BC)
1. Associated insanity and mental
illness with an irregularity in the
interaction of the four body fluids
or humors (blood, black bile,
yellow bile, and phlegm)
2. Disequilibrium of these humors
led to being treated with potent
cathartic agents
(Chapter 2 of Townsend)
HISTORICAL OVERVIEWOF PSYCHIATRIC
CARE
3. Classification of mental disorders into
mania, melancholia and phrenites
4. existence and knowledge of epilepsy ,
hysteria, post partum psychosis and acute
brain syndromes(delirium tremens)
5. Rejected the influence of the Gods as a
causative of mental disorders
6. Influence the social attitudes.
GALEN
- a Roman Physician who expanded the
approach of Hippocrates
1. Studied the anatomy and physiology
of the nervous system
2. Developed a theory of the rational soul mentally ill led by Chiaruggi in Italy
as divided into external and internal
facts.
3. System consist of judgment,
perception, imagination and movement
Historical overview of psychiatric care
Middle Ages
1. Middle Eastern Islamic countries another 12 women
start to believe that people with
mental illness are actually ill
2. Establishment of special units
within general hospitals
16th and 17th Centuries
1. Mental institutions did not exist
in the US, and care for the
mentally ill is a family
responsibility
2. Those without family became the Spearheaded a movement to stimulate a
responsibility of the community public interest in building state mental
and are incarcerated hospitals
(Chapter 2 of Townsend)
Historical overview of psychiatric care
18th Century
1. First hospital for the mentally ill
was established in the US
2. Benjamin Rush – the father of
American Psychiatry, introduced
more humane treatment but also
used methods like bloodletting,
purging, various types of
restraints, and extremes of
temperatures, urge the building
of Psychiatric hospitals; first
American textbook was
published
19th Century
1. Establishments of the asylum Historical overview of psychiatric care
thanks to Dorothea Dix, a former
New England schoolteacher, who After WWII
lobbied on behalf of the mentally
ill
2. Humanistic therapeutic care
3. Asylums became overcrowded
over time and conditions
deteriorated and therapeutic
care reverted to custodial care.
(Chapter 2 of Townsend)
Historical overview of psychiatric care
18th Century
Humanitarian care approach of the
(1759-1820)
Philippe Pinel (1745-1826)
A French philosopher and has made
influence that the destructive behavior of
mentally ill was due to theirfilthy living
conditions and cruel treatment
Unchained 12 men then a year after
DANIEL TUKE (1827-1895)
Built a private asylum for mentally ill for
better humane treatment
Historical overview of psychiatric care
Dorothea Dix (1802-1807)
Advoacate the public on the needs of the
mentally ill
Historical overview of psychiatric care
1873
1. Linda Richards – graduated from
New England Hospital for Women
and became known as the first
American Psychiatric Nurse
2. She was instrumental in the
establishment of a number of
psychiatric hospitals and the first
school of psychiatric nursing at
the McLean Asylum in Waverly ,
Massachusettesm in 1882
3. Focus: training in how to provide
custodial care in psychiatric
asylums
(Chapter 2 of Townsend)
1. US government passed the
National Health Act of 1946
2. This legislation provided funds
for the education of
psychiatrists, psychologists,
social workers, and psychiatric
nurses
3. Introduction of antipsychotic
medications
1955
1. Incorporation of psychiatric
nursing curicula
2. Incorporation of nursing
interventions in the somatic
therapies (insulin shock and
electroconvulsive therapy)
(Chapter 2 of Townsend)
Historical overview of psychiatric care
20th Century onwards
Diagnostic and Statistical Manual (DSM) I
– 1952
DSM II - 1962
DSM III – 1980 1. A positive attitude toward self
DSM III-R – 1987 2. Growth, development, and the
ability to achieve self-
DSM IV – 1994 actualization
DSM IV-TR – 2000 3. Integration
DSM V – soon to be released (May 2013) 4. Autonomy
(The Internet) 5. Perception of reality
Mental health 6. Environmental mastery
Maslow – a “healthy” or “self-actualized” (Chapter 2 Townsend; pages 1 to 2,
individuals possessed the following Student Guide)
characteristics
Mental health
1. An appropriate perception of
reality The American Psychiatric Association
(APA) (2003) – a state of being that is
2. The ability to accept oneself, relative rather than absolute. The
others, and human nature successful performance of mental
functions shown by productive activities,
3. The ability to manifest fulfilling relationships with other people,
spontaneity and the ability to adapt to change and to
cope with adversity
4. The capacity for focusing
concentration on problem solving Robinson (1983) –
5. A need for detachment and 1. A dynamic state in which Mental illness
desire privacy thought, feeling, and behavior
that age-appropriate and APA (2000)
6. Independence, autonomy, and a congruent with local and cultural
resistance to enculturation norms is demonstrated
(Chapter 2 Townsend; pages 1 to 2, 2. It is viewed as the successful
Student Guide) adaptation to stressors from the
internal or external environment,
Mental health evidenced by thoughts, feelings,
and behaviors that are age-
Maslow – a “healthy” or “self-actualized” appropriate and congruent with
individuals possessed the following local and cultural norms
characteristics (Robinson)
7. An intensity of emotional (Chapter 2 Townsend; pages 1 to 2,
reaction Student Guide)
8. A frequency of “peak” Mental health
experiences that validates the
worthwhileness of, richness, and WHO
beauty in life
1. A state of complete physical,
9. An identification with humankind mental, and social wellness and
not just merely the absence of
10. A democratic character structure disease or infirmity
and strong sense of ethics
2. Emphasis is on health as a
11. Creativity positive state of well-being
12. A degree of nonconformance 3. People in a state of emotional,
physical, and social well-being
(Chapter 2 Townsend; pages 1 to 2, fulfill responsibilities, function
Student Guide) effectively in life, and are
satisfied with their interpersonal
Mental health relationships and themselves
Jahoda (1958) – identified six indicators (pages 2 to 3, Videbeck)
that are a reflection of mental health
Mental health
Factors that influence:
1. Individual make-up
2. Interpersonal
3. Social/cultural, or environmental
(pages 2 to 3, Videbeck)
Mental illness
Horowitz has identified two elements that
are associated with individuals’
perceptions of mental illness, regardless
of cultural origin
1. Incomprehensibility – relates to
the inability of the general
population to understand the
motivation behind the behavior
2. Cultural relativity – considers
that some behaviors that are
considered “normal” and
“abnormal” is defined by one’s
cultural or social norms
(Chapter 2, Townsend)
1. Mental disorder is a clinically
significant behavioral or
psyschological syndrome or
pattern that occurs in an
individual and is associated with
present distress (i.e., painful
symptom) or disability (i.e.,
impairment in one or more
important areas of functioning)
or with a significantly increased
risk of suffering death, pain,
disability, or an important loss of
freedom
(pages 2 to 3, Videbeck)
Mental illness
APA (2000)
2. General criteria to diagnose
mental illness:
a. Dissatisfaction with one’s
characteristics, abilities, and
accomplishments
b. Ineffective or unsatisfying
relationships
c. Dissatisfaction with one’s place
in the world
d. Ineffective coping with life
events
 e. Lack of personal growth
(pages 2 to 3, Videbeck)
Mental illness
Factors contributing to mental illness:
1. Individual
2. Interpersonal
3. Social/cultural or environmental
(pages 2 to 3, Videbeck)
DSM-IV-TR
Diagnostic Statistical Manual 4th Edition
Text Revision
Multiaxial evaluation system
Endorsed by the APA to facilitate
comprehensive and systematic evaluation
with attention to the various mental
disorders and general medical problems,
and level of functioning that might be
overlooked if the focus were on assessing
a single presenting problem
5 Axes (Axis I, II, III, IV and V)
(Chapter 2 of Townsend; pages 2 to 3,
Videbeck)
DSM-IV-TR
Axis I – Clinical Disorders and other
Conditions That May Be a Focus of Clinical
Attention. This includes all mental
disorders: depression, schizophrenia,
anxiety and substance abuse disorder
(except personality disorders and mental
retardation)
Axis II – Personality Disorders and Mental development
Retardation. These disorders usually
begin in childhood or adolescence and
persist in a stable form into adult life; “psychodynamic nursing”, the
also for reporting prominent maladaptive interpersonal development of the nurse
personality features and defense
mechanisms
(Chapter 2 of Townsend; pages 2 to 3,
Videbeck)
DSM-IV-TR
Axis III – General Medical Condition.
These include any current general medical The mental health nurse
condition that is potentially relevant to
the understanding or management of the Psychodynamic Nursing – being able to
individual’s mental disorder
Axis IV – Psychosocial and Environmental principles of human relations to the
Problems. These are problems that may
affect the diagnosis, treatment, and
prognosis of mental disorders named on
Axes I and II.
Axis V – Global Assessment of
Functioning. This allows clinician to rate
the individual’s overall functioning on the
Global Assessment of Functioning (GAF)
Scale. This scale represents in global
terms as a single measure of the
individual’s psychological , social, and
occupational functioning
(Chapter 2 of Townsend; pages 2 to 3,
Videbeck)
DSM-IV-TR
Note: A copy of the GAF can be seen in
Chapter of Townsend page 26
Note: DSM-IV-TR Classification of
Diseases are in pages 465 to 473 of
Videbeck 5th ed
DSM-IV-TR
Example of a Psychiatric Diagnosis:
Axis I 300.4 Dysthymic Disorder
Axis II 301.6 Dependent
Personality Disorder
Axis III 244.9 Hypothyroidism
Axis IV Unemployed
Axis V GAF = 65
(current)
(Chapter 2 of Townsend; pages 2 to 3,
Videbeck)
The mental health nurse
Peplau (1991) applied interpersonal
theory to nursing practice and, most
specifically, to nurse-client relationship
She provided a framework for
with the client in a given nursing situation
She states, “Nursing is helpful when both
the patient and the nurse grow as a result
of the learning that occurs in the
situation.”
(Chapter 2 of Townsend page 44 to 45)
understand one’s own behavior, to help
others identify felt difficulties, and apply
problems that arise at all levels of
experience
Roles of the Nurse
1. Resource person – provides
specific, needed information that
helps the client understand his or
her problem and the new
situation
2. Counselor – listens as the client
reviews feelings related to
difficulties he or she is
experiencing in any aspect of life
(Chapter 2 of Townsend page 44 to 45)
The mental health nurse
Roles of the Nurse
3. Teacher – identifies learning
needs and provides information
to the client or family that may
aid in improvement of the life
situation
4. Leader – directs the nurse-client
interaction and ensures that
appropriate actions are
undertaken to facilitate
achievement of the designated
goals
5. Technical expert – understands
various professional devices and
possesses the clinical skills
necessary to perform the
interventions that are in the best
interest of the client
6. Surrogate – serves as a
substitute figure for another
(Chapter 2 of Townsend page 44 to 45)
The interdisciplinary team
Multidisciplinary team
Functioning as an effective team member
requires the development and practice of
several core skill areas:
1. Interpersonal skills
2. Humanity
3. Knowledge
4. Communication skills
5. Personal qualities, such as
consistency, assertiveness, and
problem-solving abilities
6. Teamwork skills, such as
collaborating, sharing, and
integrating
7. Risk assessment and risk
management skills
(pages 72 to 73, Videbeck)
The interdisciplinary team
Pharmacist
Psychiatrist
Psychologist
Psychiatric Nurse
Psychiatric social worker
Occupational therapist
Recreation therapist
Vocational rehabilitation specialist
(pages 72 to 73, Videbeck)
The mental health/mental illness
continuum
Peplau (1991) applied interpersonal
theory to nursing practice and, most
specifically, to nurse-client relationship
development
She provided a framework for
“psychodynamic nursing”, the
interpersonal development of the nurse
with the client in a given nursing situation
She states, “Nursing is helpful when both
the patient and the nurse grow as a result
of the learning that occurs in the
situation.”
(Chapter 2 of Townsend; pages 2 to 3,
Videbeck)
The mental health/mental illness
continuum
Mental Health Continuum
Interpersonal Adequacy
Interpersonal Competency
Mental Illness Continuum
Interpersonal inadequacy
Interpersonal incompetency
(Chapter 2 of Townsend; Student Guide
page 3)
The mental health/mental illness
continuum
Interpersonal Adequacy
Interpersonal Inadequacy and
and competency
Incompetency
Mental Health Mental (Chapter 2 of Townsend; Student Guide
Illness
(Chapter 2 of Townsend; Student Guide
page 3)
The mental health/mental illness
continuum
Anxiety
- Peplau (1963) described four
levels of anxiety
1. Mild anxiety
2. Moderate anxiety
3. Severe anxiety
4. Panic
(Chapter 2 of Townsend; Student Guide
pages 8 to 11)
The mental health/mental illness
continuum
Anxiety
- Behavioral responses to anxiety
1. Mild anxiety – (coping
mechanisms) sleeping, eating,
physical exercise, smoking,
crying, pacing, yawning,
drinking, daydreaming, laughing.
Cursing, nail biting, foot
swinging, fidgeting, finger
tapping, talking to someone
whom one feels comfortable
(Chapter 2 of Townsend; Student Guide
pages 8 to 11)
The mental health/mental illness
continuum
Anxiety
- Behavioral responses to anxiety
2. Mild to Moderate Anxiety
a. Sigmund Freud (1961) identified continuum
the ego as the reality component
of the person that governs
problem solving and rational
thinking, and as the level of
anxiety increases, the strength
of the ego is tested, and energy
is mobilized to confront the
threat
b. Anna Freud (1953) identified a
number of defense
mechanisms employed by the
ego in the face of threat to
biological or psychological
integrity
pages 8 to 11)
The mental health/mental illness
continuum
Anxiety
- Behavioral responses to anxiety
3. Moderate to Severe Anxiety
a. If not resolved can contribute to
a number of physiological
disorders (pain, anorexia,
arthritis, colitis, ulcers, asthma,
etc…)
b. The presence of one or more
specific psychological or
behavioral factors that adversely
affect a general medical
condition (DSM-IV-TR)
(Chapter 2 of Townsend; Student Guide
pages 8 to 11)
The mental health/mental illness
continuum
Anxiety
- Behavioral responses to anxiety
4. Severe Anxiety
a. Extended periods can lead to
psychoneurotic patterns of
behaving
5. Panic Anxiety
a. At this level of extreme anxiety,
an individual is not capable of
processing what is happening in
the environment, and may lose
contact with reality
b. Psychosis may develop
(Chapter 2 of Townsend; Student Guide
pages 8 to 11)
The mental health/mental illness
Grief
1. Is a subjective state of
emotional, physical, and social
responses to the loss of a valued
entity
2. Stages (Kubler-Ross, 1969):
a. Denial
b. Anger
c. Bargaining
d. Depression
e. Acceptance
(Chapter 2 of Townsend)
The mental health/mental illness continuum

Anxiety and grief just two of the major responses to stress

Both are presented on a continuum

Disorders appear in the DSM-IV-TR are identified at their appropriate placement along the continuum

(Chapter 2 of Townsend)