PLT College

Institute of Health Sciences- College of Nursing

Psychiatric Mental Health Nursing

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

PSYCHIATRIC TREATMENT
1. Milieu Therapy- intended to provide a structured environment which serves as an emotional
sounding board which would clarify and diagnose conflicts and consequences of actions and
would facilitate adaptive changes in behavior.

Milieu- from the French word w/c means middle place. It refers to the people and other social
and physical factors in the environment w/c client interact.

Components:
 Environment Manipulation
The Nurse has to meet the basic needs especially physiologic and emotional needs and
improve the interpersonal relationship of the patient
 Attitude Therapy
a) Passive friendliness- The patient initiates the relationship (for paranoid and suspicious
patients)
b) Active friendliness- The nurse initiates the relationship (for depressed clients)
c) Kind Firmness- It is used for patients who have suicidal tendencies; The patient’s
behaviors maybe allowed but have limits.
d) No demand- It is commonly used for manic/elated clients, ADHD, aggressive; it has a
structured limits
e) Matter-of- fact- it is commonly used for clients who are manipulative, demanding and
addicts.

2. Family Therapy - It involves participation of one or member of the family who seek help for
troubled family relationship(s) or the problems of individual members of the family.
- The focus of the treatment is the faulty interaction of the family member(s).
3. Psychotherapy- It is a treatment of the emotional conflict of the client.
It aims to develop independence in the client. (Solving problems in a mature level).

Types of Psychotherapy:
A. Supportive – It is indicated to client w/ poor insights.
The therapist assumes the role of offering directions and guidance.
a. Goal: To solve the current problem through medication, ECT, Group therapy

Forms of Supportive Therapy of Psychotherapy

 a) One on One/ Individual – It is a direct interview on the client by the therapist.
Goal: To help the client functions in a higher level, and understands himself and the
environment.
b) Group therapy – The group consists of a therapist with 10-12 members/patients.
Goal: To assess unity/cohesiveness of the group, and to note interaction; to increase the
acceptance of the other; and to increase social interaction. This form of therapy is done
through:
• Dance therapy • Play therapy
• Sports therapy • Music therapy
B. Uncovering – The therapist explores the unconscious mind of the patient.
PROCEDURE:
a) Psychoanalysis – The therapist has to trace the developmental tasks where the conflict
emanated from (e.g. Paranoid)
b) Narsoanalysis ( Narcotherapy ) – It can be done thought the ff:
• Sleep therapy
• Use of sedatives

4. Remotivational Therapy – It is a group interaction of 10-12 patients to reorient patient to reality

and improve social interaction. Any TOPIC may be reacted upon, except those that reflect the wounded
part of the client; examples of the topics that may be discussed or tackled: nature, sports, industry,
science, literature, occupation.

STEPS:
a) Climate of Acceptance – this is an orientation phase of the therapy to establish rapport w/ with
the client/patient
b) Bridge of reality – The therapist starts the topic with the visual aids presentation; asks
questions related to visual aids.
c) Sharing the world we live-in – The therapist present the topic; ask several questions regarding
the topic.
d) Appreciation of the work of the world – The therapist correlates topic to occupation to become
productive; ask thought provoking questions. Content sharing can be one of the activities.
e) Climate Appreciation – This is the Evaluation on the client by the therapist. The therapist asks
the client to summarize, to enable the patient to feel that he belongs to the group and to boost
his self –esteem and confidence.

5. Behavioral Therapy – A type of therapy that focuses on modifying observable behavior, including
emotion and verbalization, by manipulating the environment, the behavior, or the consequences of
the behavior. Behavioral approaches focuses on the effects rather than the cause, also used in
behavioral contracts to help reinforce positive behaviors and diminish maladaptive behavior.
6. Cognitive Therapy – A form of therapy most often used in depression that stems from the
individual’s negative self-concept, or exaggerated, prolonged guilt, that result in automatic thoughts of
self-deprecation.
Goal: To diminish depressive symptoms by helping the individual challenge and invalidate distorted
thoughts

a) Thought Stopping – A cognitive strategy used to treat individuals with depression characterized
by irrational, anxiety provoking, and “brooding type” behaviors.
b) Goal: Inhibit this maladaptive behavior by instructing the patient to shout the word “STOP”
after he /she expresses the illogical behavior. In this way, the patient learns to control his or her
thought and thus control the maladaptive behavior. (Applicable to obsessive-compulsive)

c) Thought Substitution/ Switching – A cognitive approach in w/c the patient is instructed to

substitute a positive or rational thought for negative, distorted thought.

d) Reframing/Relabeling – A cognitive technique in w/c the nurse/therapist renames or re-labels

seemingly dysfunctional behavior as reasonable and understandable behavior, to take away the
negative motive of the act.
Goal: To emphasize the positive aspect of interpersonal feelings and behaviors.

e) Rational-Emotive Therapy (RET) – A type of cognitive therapy base on the premise that an
individual’s values and belief control his or her behavior. Many beliefs and assumptions are
irrational and self-defeating, and people often evaluate their behavior by using this faulty
thought. Helps individual or groups examine one irrational thought and behavior through verbal
discussion and written assignments, followed by activities that allows individuals to challenge
their faulty beliefs by directly confronting the fear situations and nothing that the results are not
devastating.

f) Deep-Breathing Exercises- A simple, adaptive therapeutic technique for reducing anxiety in

individuals with mild to moderate levels of anxiety.

g) Benzon’s Relaxation Response- A simple, basic procedure (develop by M. Benzon) for eliciting
relaxation in person experiencing tension and mild to moderate level of anxiety.

h) Progressive Relaxation Technique- Another form of relaxation therapy (develop by Jacobson) in

which the situation that is generally met with stress and tension (e.g. taking an exam). The
individual is instructed to imagine with all the sense of mental picture or image of the feared or
troubling situation, based on past memory of the event.

i) Visual Imagery- Combines positive experience with actual or perceived negative events or
situation in an effort to desensitize the trauma of the negatives event and or correct distortion
surrounding the vents. It is often combined with relaxation techniques to enhance its
effectiveness.
j) Assertiveness Training- Assertiveness training a component of behavior therapy, is a process by
which as individual learns to communicate needs, refuse request, and express both positive and
negative feeling in an open, honest, direct, and appropriate manner.

k) Desensitization- The object of desensitization is to lessen the negative impact of a frightening or

troubling object, thought, or event by exposing the individual to the object, thought, or event
on a progressive, least to most threatening manner.

7. Psychoanalytic Therapy- A type of therapy (develop by Sigmund Freud and his followers) that
focuses in repressed, intrapsychic conflict that produced interaction among three theoretic
construct of the mind.
8. Gestalt Therapy- Gestalt, which means “the whole”, is based in Gestalt psychology. The therapist
helps the individual become aware of his or her “total self” and “the world” that surround him or
her.
9. Client-Centered Therapy- A psychoanalytic humanistic approach developed by Carl Roger in
which the therapist encourages expression of feeling through use of reflection and clarification.
10. Transaction Analysis (TA)- A type of therapy (develop by Berne) in which it is theorized that
individual are capable of responding from three distinct ego states (parent, child, and adult,
described below) and that successful interpersonal transaction depend on the use of appropriate
combination of these ego states between the communicator.
11. Psychodrama- A method of group psychotherapy (develop by Jacob Merono) in which the truth
is explored via improvised dramatizations of emotionally charged situation and conflict.
12. Somatic Therapy- It is an application of physical means of agent to control behavior.
A) ECT- Electroconvulsive Therapy (electrotherapy)
 It was introduced by Cerletti and Beni.
 It was an application of 70-150 volts with one (1) electrode to non-dominant side of the
brain and two (2) electrodes at the temporal site.
 The electrical current is applied from 0.11 second, producing 45 grand mal seizures
(tonic lasts for 10 seconds and clonic lats for 30-35 seconds).
 It is especially indicated to clients with severe depression. This therapy is given when the
client does not respond to pharmacological treatment. Has been effective also to
Schizophrenia and Manic patients.
Types of ECT
A) Non-modified
 No drugs are given
 Patient is monitored and NPO is given 2 to 4 hours prior to ECT
 Patient is awake
B) Modified
 Drugs are given 30 minutes to 1 hour prior to ECT
 NPO is given 6 to 8 hours before ECT
The drugs given prior to ECT (30 minutes to 1 hour) are the following:
1) Atropine Sulfate- It prevents bradycardia and reduces secretion.
 2) Succinylcholine (Anectine)- It is muscle relaxant; lessens muscle contraction
3) Sedative (minor tranquilizers)- It induces sleep.

NURSING CARE:
 Before and During ECT
1) Consent should be secured
2) Complete physical assessment (CP clearance, cardiac assessment, lab assessment)
3) Check vital signs
4) NPO
5) Remove all metals in his body
6) Loosen clothing of the client
7) Empty the bladder to prevent urinary incontinence
8) Position the client to supine with pillow under the back to prevent fracture of the
vertebrae
9) Restrain
 Post ECT
1) Flat on bed with head turned to side.
2) Assess for respiratory arrest (ready for respiratory stimulant). Narcan(naloxone) is
give to a patient to relieve respiratory arrest.
3) Restraining- It is a direct application of physical force without the permission of the
patient, using a mechanical device to control his activities.
4) Seclusion- It is an involuntary confinement or isolation of the person wherein he/she
is prevented to leave the hospital.

PHARMACOLOGY IN PSYCHIATRY

I. Antianxiety Drugs (Minor tranquilizer, anxiolytics)

- They reduce high levels of anxiety. They may help people with generalized anxiety disorder,
panic disorder, and other anxiety disorders. Benzodiazepines, a class of drugs that are most
widely prescribed antiaxiety drugs. Benzodiazepines can be addictive and may cause
drowsiness and impaired coordination during the day. Benzodiazepines act as CNS
depressant; basically reduce over activity of the CNS especially the limbic system (the
emotional brain).
Common Anxiolytics:
V- Valium (diazepam)
A- Ativan (lorazepam)
T- Tranxene (chlorazepate)
L- Librium (chlordiazepoxide)
E- Equanil (meprobamate HCl)
X- Xanax (alprazolam)
S- Serax (oxazepam)

General Side Effects:

 1. Habit forming. The use of drugs is strengthened through time.
2. Drug tolerance. To feel/experience the initial effects, one has to increase the dose of the
drug.
3. Withdrawal symptoms. These are exhibited by the patient in the following:
 Restless/nervousness
 Sleeplessness
 Dilated pupils
 Frequent yawning
 Watery eyes
 Tachycardia
 Excessive sweating

General Nurse Care: Taper the dose

II. Antipsychotics (Phenothiazines; Major Tranquilizer; Neuroleptics)

These drugs are indicated for mental illness in which the person loses contact with reality
and has difficult of functioning in daily life.
 Neuroleptics- They produces the extra pyramidal symptoms (EPS).
 Dopamine antagonist- It is a chemical that inhibits the entry of dopamine in the center
of emotion and personality (hypothalamus and medulla oblongata) and the basal ganglia
(for muscle coordination).

High Potency Typical Antipsychotics

S- Stelazine (Triluphenazine)
Ha- Haldol (Haloperidol)
N- Navane(Thiothixene)
T- Trilafon (Perphenazine)
Pro- Proxilin (fluphenazine)

Moderate Potency Typical Antipsychotics

Mo- Moban (Molindone)
Lo- Loxitane (Loxapine)
Se- Serentil (Mesoridazine)

Low Potency Typical Antipsychotics

Tho- Thorazine (chlorpromazine)
Me- Mellaril (thioridazine)
Ta-Taractan ( Thioridazine)

Aypical Antipsychotics
Clozapine (Clozaril)
Risperidone (Risperdol
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Ziprasidone (Geodon)
 NEW GENERATION ANTIPSYCHOTIC
Aripiprazole (Abilify)

Side Effects:
Anticholinergic Side Effects

B-lurring of Vision P-hoto Sensitivity W-eight Gain

U-rinary Incontinence N-ausea T-achycardia
C-onstipation D-ry skin G-ynecomastia
O-rthostatic Hypotension N-asal Com=ngestion S-exual Dysfunction

Extrapyramidal Symptoms
Anti-psychotic drugs affect the movement of voluntary skeletal muscles particularly the ff;

a) Akathisia- It refers to the motor restlessness.

s/sx: foot tapping, pacing around, and can’t sit still

b) Pseudoparkinsonism (Paralysis Agitans)- It is a drug induced; it is a chronic disorder

characterized by degeneration of basal ganglia.
s/sx: Mask-like face, Hand tremors, Rigidity of the extremities, Body weakness------AKINISIA
Drooling of saliva, Dysphagia, Shuffling gaits (tip-toed, stoop position)

c) Acute Dystonic Reaction (Dystonia) the earliest EPS appears 1-5 days after receiving drug.
s/sx: Stiffening of the muscle, Wryneck/ Torticollis (Twisted Head and Neck), Opisthotonus
Erect position, Oculogyric crisis (involuntary rolling back of the eyeballs)

d) Tardive Dyskinesia- It is irreversible and late appearing due to prolonged use of the drug
from 1-5 years.
Treatment: No antidote, just stop the drug.

e)Akinesia

f) Neuroleptic Malignant Syndrome- The major symptoms of NMS are rigidity; high fever;
autonomic instability such as unstable blood pressure, diaphoresis, and pal lor; delirium; and
elevated levels of enzymes particularly CPK. Clients with NMS usually are confused and often
mute; they may fluctuate from agitation to stupor.

Treatment to Extrapyramidal Symptoms

B – enadryl (diphenhydramine) ANTIHISTAMINE
L – arodopa (Levodopa) ANTIPARKINSON
A – kineton (Biperidine Hydrochloride) ANTICHOLINERGIC
C – ogentin (Benztropine Mesylate) ANTICHOLINERGIC
 K – emadrin (Procyclidine) ANTICHOLINERGIC
S – ymmetrel (amantedine hydrochloride) DOPAMINERGIC AGONIST
Or – phenadine
A-tivan (Lorazepam) BENZODIAZEPINE
V-alium (Diazepam) BENZODIAZEPINE
A – rtane (Trihexaphenydil) ANTICHOLINERGIC
P – ardole (Brocroptine Mesylate) ANTICHOLINERGIC
E – ldepryl (Selegline Hydrochloride) ANTIPARKINSON

III. ANTI-DEPPRESANT (MOOD ELEVATOR)

These are medications used to treat depression. They increase the level of neurotransmitters in the
synapse of the brain cell.

MAJOR CLASSES:
A. TRICYCLIC ANTIDEPRESSANTS (TCAs)
These are standard antidepressants w/c take effect w/in 2-4 hrs. Norepinephrine blocker is a
TCA that increases the serotonin level but not the level of norepinephrine.
COMMON TCA’s:
Tofranil (Imipramine)
Norpramin (Desipramine)
Elavil (Amitriptyline)
Pamelor(Nortriptyline)
Sinequan (Doxepin)
Surmontil(Trimipramine)
Vivactil (Protriptylin)
Ludiomil (Maprotiline)
Remeron (Mirtazapine)
Ascendin (Amoxapine)
Anafranil (Clomipramine)

TCA, si Ela at Pamela Surmontil

Sinama pa si Ana Ascendin
Nood ng Sine ni Nora
Prinoduce yan ng Viva, Panuorin sa Tofra

B. SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs)

These are drugs for DEPRESSION and ANXIETY that increase the serotonin levels in synapses of
the brain cells, resulting in elevation of mood; they usually take effect w/in 2-4 wks.
COMMON SSRI’s:
P – rozac (fluoxetine)
E – scitalopram (lexapro)
P – axil (paroxetine)
Z – oloft (setraline HCl)
 Ci – talopram (celexa)

C. MONOAMINE OXIDASE INHIBITORS (MAOIs)

They are enzymes w/c are responsible in the breakdown of serotonin; they also metabolize
tyramine, a vasoconstrictor, if not metabolized. They are potent antidepressants given only
when the client did not respond to TCAs and SSRIs. They act on the enzyme MAO to increase
the level of neurotransmitters specifically serotonin in the post synaptic cleft of the neurons.
COMMON MAOIs:
Pa – rnate (tranylcypromine
Ma – rplan (isocarboxacid)
Na – rdil (phenelzine Sulfate)
Ma-nnerix

NURSING CONCIDERATION WHEN TAKING MAOIs:

1. Avoid food rich in tyramine
 All Cheese except Cream, Cottage, White, Ricotta cheese
 Processed Foods ( Salami, sausage, sardines, smoked fish, Soy, chicken liver, pickles,
pepperoni, salami, mortadella)
 Pasteurized ( Yogurt, Yeast)
 Fermented ( Beer, Chianti Red Wine, Coffee, Chocolate)
 Some Fruits ( Banana, Avocado, Raspberries, Figs and over-ripe fruits)
2. Monitor presence of nausea and vomiting, head ache, blurring of vision, and dizziness.
3. Monitor BP accurately for the possibility of cerebral hemorrhage secondary to hypertensive
crisis.
MAOI+ Tyramine Rich Foods= Hypertensive Crisis
S/Sx: Increase BP, Diaphoresis, Chest Pain, Occipital Headaches, Nausea & Vomiting
Drug of Choice: Regitin

GENERAL NURSING CARE IN GIVING ANTIDEPRESSANTS:

1. Prevent suicide. Monitor client for 24 hrs in an irregular basis.
2. Be aware of the cues of suicide:
S - ex (male-action, female-attempts)
A – ge (Below 19 yrs/o and above 45 yrs/o)
D – epression biological Marker changes (sleeping and eating pattern)

P – revious attempts
E – thanol/ alcohol consumption
R – ational thinking lost
S – upport system lost
O – rganized plan
N – o spouse
S – erious sickness
IV. LITHIUM CARBONATE (MOOD STABILIZER, ANTIMANIC)
It is a white crystalline salt used for the treatment of bipolar disorder; it decreases the level of
norepinephrine to normal level w/o the experience of being elated. Lithium normalizes the reuptake
of certain neurotransmitters such as serotonin, norepinephrine, acetylcholine, and dopamine. It also
reduces the release of norepiniephrine through competition with calcium

COMMON ANTIMANIC DRUGS (Brand names)

Lithane Eskalith Lithonate
Lithobid Lithotab

Lithium Toxicity

Warning Signs:
Anorexia Hyperreflexia Muscle Twitching
Nausea & Vomiting Ataxia Vertigo
Hand tremor Tinnitus Weakness, Drowsiness

Signs of Lithium Intoxication:

Fever Irregular Pulse Seizures
Decreased Urine Output ECG Changes Coma
Decreased BP Altered LOC Death

Managing Lithium Toxicity:

1. Obtain History
2. D/C Lithium doses
3. Evaluate V/S
4. Obtain Lithium level
5. Obtain other blood works ( Electrolytes, BUN, Crea, U/A, CBC)
6. Evaluate Cardiac Status via ECG
7. If acute overdose, give emetics
8. Provide Hydration
9. In severe cases, implement Osmotic diuresis (Mannitol/Urea), Increase Lithium clearance,
provide intake of NaCl to promote lithium excretion and implement dialysis

NURSING RESPONSIBILITIES:
1. Maintain a therapeutic level of sodium and lithium in the blood. (Note: Blood is extracted 12 hrs
after taking lithium for sodium and lithium level determine.
2. For clients taking lithium and the anticonvulsants, monitoring blood levels periodically is
important.
3. The time of the last dose must be accurate so that plasma levels can be checked 12 hours after
the last dose has been taken. Taking these medications with meals will minimize nausea.
 4. The client should not attempt to drive until dizziness, lethargy, fatigue, or blurred vision has
subsided.

We need an opposition to remind us if we are making MISTAKES.

When we are not opposed, we tend to think that everything we do is RIGHT.
princerenerpera

PLT College Inc

Institute of Health Sciences- College of Nursing

Psychiatric Mental Health Nursing

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

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 for 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)

princerenerpera

PLT College Inc

Institute of Health Sciences- College of Nursing

Psychiatric Mental Health Nursing

Psych Lecture Series # 6 (Prepared By: Prince Rener V. Pera, RN)

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

Heavy rains reminds us of CHALLENGES in our lives

We should not ask for a LIGHTER RAIN
Instead, we should PRAY for a BETTER and STRONGER umbrella.

Advance Merry Christmas & a Bountiful New Year!