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PSYCHIATRIC NURSING

An Introduction
Geralyn B. Chacapna, RN
INTRODUCTION
 Mental Health
 Mental Illness
 Population at Risk
 Psychiatric Nursing
 The Nurse’s Role
 The Nursing Process
Mental Health/Illness Continuum
Stress
Mental Health Mental Illness

ADAPTIVE MALADAPTIVE
Healthy Neurosis Psychosis
Reality Oriented Denies Reality
Interacts Hallucination and delusion
Socially acceptable behavior Bizarre behavior
Mental Health
World Health Organization:
"Mental health is a state of well-being where a
person can realize his or her abilites to cope
with normal stresses of life and work
productively.”
Mental Illness
 A mental disorder or condition manifested by
disorganization and impairment of functions
that arises from various causes such as
psychological, neurobiological and genetic
factors.
Classification of Mental Illnesses
 The Diagnostic and Statistical Manual of
Mental Disorders, 4th Edition, Text Revision
(DSM-IV-TR).
 Diagnostic criteria are listed for each of the
psychiatric disorders.
 A multiaxial system- people are evaluated
from multiple aspects or points of function.
DSM-IV-TR Multiaxial Evaluation System
 Axis I - Clinical disorders and other conditions
that may be a focus of clinical attention
 Axis II - Personality disorders and mental
retardation
 Axis III - General medical conditions
 Axis IV - Psychosocial and environmental
problems
 Axis V - The measurement of an individual’s
psychological, social, and occupational
functioning on the GAF Scale
Population at Risk for Mental
Illness
1. With familiar or genetic predisposition to mental
illness
2. With poor access to health care
3. Disadvantaged
4. Misusing substance
5. Undergoing lifestyle changes
6. Victims of violence
7. Elderly poor
Psychiatric Nursing
 Psychiatric nursing or mental health nursing is
the specialty of nursing that cares for people of all
ages with mental illness or mental distress.
 An interpersonal process that promotes and
maintains behavior that contributes to integrated
functioning; uses theories of human behavior as a
science and the purposeful use of self as an art.
What do psychiatric nurses do?
 Ensure safety and security
 Care for biophysical needs
 ADL’s
 Nutrition, exercise
 Medication management
 Assist in creating a healthy social world
 Moderate stimulation to optimal level for
individual needs
Nursing Approach/Model
Components:
 Nurse-Client Interactive Relationship – mutuality,
collaboration, and problem-solving; tools:
communication and nurse-client relationship
 Environmental Management – provide
therapeutic environment by serving as advocates
and role models, by offering social support and by
engaging clients in collaborative problem-solving of
here-and-now problems of daily living
 Nursing Process
THE NURSE in
Psychiatric Nursing
“Self-awareness: Basis for personal
development and practice”
The Johari Window
1 2
Public Self Semi-Public Self (blind
area)
3 4
Private Inner
Self (unconscious self)
 This illustrates dimensions of the self as known to the
person and as known to others
THE SELF
Components:
B. Cognitive processes – thought, perception,
and memory
C. Affect – feelings, emotions
D. Beliefs, attitude, and values
THERAPEUTIC USE OF SELF
 The nurse calls upon her thoughts, feelings,
behaviors, knowledge, and skills to promote
growth in the client.
 Critical element: Self-awareness
 Trust is the basis for relating.
Therapeutic/One-to-One Nurse-
Client Relationship
 Definition: A PROFESSIONAL interpersonal
experience between a client and nurse
 Framework: Caring
 Factors:
 Empathy
 Understanding
 Acceptance: “Being is not doing”
 Connection/Involvement
 Hope: “What is wanted will happen”
 Enabling
Empathy in Nursing
Components:
2. Awareness
3. Objectivity
4. Acceptance
5. Validation
6. Clarification
PHASES OF THE NPI:
 The therapeutic relationship can be divided into three
phases.
*Pre-interaction – gather data about client/patient;
self-awareness; common fears:
3. Fear of rejection

4. Feelings of helplessness

5. Fears of verbal or physical aggression

6. Fear of mental illness


PHASES:
 Orientation phase - getting to know each other and
clarifying purpose of relationship and roles
 Working phase - essentially the time when the bulk
of the therapeutic work is done
 Resolution phase - this is where the patient becomes
more independent and eventually is able to end the
therapeutic relationship with the nurse.
Communication
 Definition: a complex process of exchanging
verbal and nonverbal messages and interpreting
their meaning
 Therapeutic communication serve two broad
purposes:
3. Promoting greater self-awareness
4. Enhancing self-disclosure with associated
benefits of increased self-acceptance and
closeness to others
Communicating with the Anxious
Patient
Anxiety
 A diffused apprehension that is vague in nature
and is associated with feelings of uncertainty and
helplessness
 Extremely common in our society
 Mild anxiety is adaptive and can provide
motivation for survival
Hildegard Peplau’s four levels of
anxiety
 Mild - seldom a problem
 Moderate - perceptual field diminishes
 Severe - perceptual field is so diminished that
concentration centers on one detail only or on many
extraneous details
 Panic - the most intense state
REMINDERS
 Decide what the anxiety level is before
deciding how to communicate
 Empathy focuses on feelings and needs, and
this tends to increase anxiety
 Structure increases emotional security and
tends to decrease anxiety
 Communication strategies shift constantly
depending on anxiety level
Severe/Panic level of anxiety
 Results in breakdown or compromised ego
function
 Need to restore ego functioning by reducing
anxiety
 Recognize reality of crisis state, help
determine source
 Provide security, decreased stimuli, focus on
safety
Goals of Communication when someone
has severe/panic level anxiety
 Decreasing anxiety to a moderate level
 Reduce stimulation

 Provide structure

 Provide security

 Helping person regain self control


 Limit setting

 Confine activities away from others

 Provide specific direction about what can and cannot

be allowed
 Support the natural desire to be ‘in control”
Therapeutic interventions for
specific problems
 Hallucinations
 Confirm reality for them, but not for you
 Provide noncompeting, single focus stimuli
 Delusions
 Do not address the thoughts, focus on the feelings
 Address security needs and trust
Verbal Communication
 Opening Discussion: Use broad openings: “Tell me
about your family”, “Describe what a typical day is
for you”, “What things would you like to talk about
today?”
 Clarification of Content:
3. Encouraging cues: nodding, saying “Uhmm, go
on…”
4. Paraphrase: “When you say ‘ugly feelings’ does this
mean you feel unattractive?”
5. Restating: “You are saying that your parents often
made you feel ugly and worthless.”
6. Clarifying: “How many times has this happened?”
Verbal Communication
 Asking for examples: “You say you have ‘ugly
feelings’, can you give me an example of what was
happening when you felt like this?”
 Response to Feelings:
3. Directly inquire about feelings: “How did that make
you feel?”, “What were you feeling then?”
4. Reflecting: “You were feeling really lonely”
5. Exploring: “Tell me more…”
6. Summary and Validation: “You’ve been saying
than… You’ve felt….Is that a correct summary of
our talk today?”
Eliminate These Blocks to
Effective Communication:
1. “Why”
2. Agreeing and Disagreeing
3. Answerable by yes or no
4. Leading questions
5. False reassurance
6. Judgmental
7. “All”, “Often”, “Generally”, “Usually”
8. “Only”
Eliminate These Blocks to
Effective Communication:
1. “Always”
2. Words with superlatives, e.g. “Most”, “Best”
3. “-time” (sometimes, all the time)
4. “-body” (everybody, somebody)
5. Negative words: limit, inhibit, suppress, avoid,
never, stop, restrict, intimidate
Non-Verbal Communication
 Kinesis – body language
 Paralanguage – pitch and tone
 Proxemics - distance:
1. 3 feet – social distance
2. 1 foot – personal distance
3. Skin to skin – intimate
THE NURSING
PROCESS
The Nursing Process
 Definition: The underlying scheme that
provides order and direction to nursing care.
 Steps:
1. Assessment
2. Nursing Diagnosis
3. Intervention
4. Planning
5. Implementation
6. Evaluation
1. Assessment
 Data Collection – must  Recording – need for
be accurate, descriptive narrative data
comprehensive,  Sources of Data – the
organized, and updated client as primary source;
regularly secondary: family, friends,
 Assessment Skills – use health professionals.
of observation and  Analysis and Validation of
communication skills Data
PSYCHOSOCIAL AND
NEUROLOGICAL ASSESSMENT
 COMPONENTS:
1. History
2. Cerebral function/mental status
 HISTORY: Present Problem; Past Psychiatric
History; Influence of Chemicals; Family History
and Profile; School and Vocational History;
Psychosocial History (Developmental Task
Attainment, Peer and Family Relationships, Sexual
History, Significant Life Stressors/Events,
Customary Coping Patterns, Support System,
Interest and Leisure Activities, Cultural and Ethnic
Background and Beliefs)
PSYCHOSOCIAL AND
NEUROLOGICAL ASSESSMENT
 CEREBRAL FUNCTION/MENTAL
STATUS: LOC, General Appearance, Speech,
Affect and Mood, Intellectual Performance,
Thought Content, Behavior, Judgment, Insight,
Perception, Cranial Nerves, Sensory
Perception, Cerebellar Function, Motor
System, Reflexes
MNEMONICS
 Always send mail through post office
 A – Affect (blunt, flat, expanded mood, euphoric)
 S – Speech
 M – Motor (catatonic, waxy flexibility, echopraxia)
 T – Thought Processes (blocking, ideas of reference)
 P – Perception
 O – Orientation (TIME, PLACE, PERSON)
SPEECH
1. Blocking: cessation of speech, loses train of
thought
2. Mutism: absence of speech
3. Echolalia: verbal repetition of what is heard
4. Verbigeration: repetition of same words,
sentences, or phrase several times
5. Perseveration: inability to shift from one task to
another (verbal or motor)
SPEECH
1. Pressured Speech: increased quantity of speech in
a given time
2. Neologism: invention of words
3. Looseness of Association: point of conversation
shifts abruptly without any connection to previous
topic
4. Flight of ideas: speech jumps from one topic to
another rapidly but there is a relation between
5. Circumstantiality: excessive associated ideas
THOUGHT CONTENT
1. Suicidal ideation
2. Violence
3. Recurring thoughts or dreams/obsessions
4. Superstitions
5. Delusions
6. Illusions
7. Worthlessness
8. Paranoid ideas
1. Ideas of reference
2. Ideas of influence
2. Nursing Diagnosis
 Includes:
2. The client problem or potential problem
3. The cause or related influencing factors
4. The resulting signs or symptoms exhibited
by the client
3. Intervention
 Priority setting – life-threatening problems are
given priority (suicidal ideation, refusal to eat
due to suspicion or guilt feelings,
impulsiveness with the potential for injury,
overactivity to the point of exhaustion)
MASLOW’S HIERARCHY OF
NEEDS
4. Planning
 Coordinating with patient, significant others
including the family and support system,
involved members of the health team.
5. Implementation
 Actual nursing actions:
2. Assume responsibility for the client’s needs
until he is able to assume responsibility for
self
3. Manipulation of environment to promote
health
4. Helping the person towards some goal
6. Evaluation
 Also involves data collection
 Changes are made as needed throughout the
care plan, and revisions are communicated to
other staff members for implementation and
further evaluation.