BACHELOR OF SCIENCE IN NURSING

RLE MODULE RLE UNIT WEEK

1 4 4
WEEK 4 Bipolar disorder

❖ Read course and unit objectives

❖ Read study guide prior to class attendance
❖ Read required learning resources; refer to unit terminologies for jargons
❖ Proactively participate in classroom/online discussions
❖ Participate in weekly discussion board (Canvas) Answer and submit course unit tasks

At the end of the course unit (CM), learners will:

Cognitive
● Discuss the steps of the nursing process and how to apply in the care of client with
Bipolar disorder.
Psychomotor.
● Perform thorough assessment of clients with Bipolar disorder
● Analyzes assessment data to determine priorities to establish a plan of care
● Set measurable and achievable short- and long-range goals
● Establish appropriate nursing diagnosis based from the assessment data gathered.
● Provide proper interventions to meet the health needs of the client.
● Evaluate both the patient’s status and the effectiveness of the nursing care provided
● Evaluate continuously the care plan and modify as needed.
● Provide education to clients, families, caregivers, and community members to increase
knowledge and understanding of Bipolar disorder.
Affective
 ● Develop empathy to patients with bipolar and other related disorders through effective
communication
● Evaluate your feelings, beliefs, and attitudes in caring patients with Bipolar disorders.

● Computer device or Smartphone with Internet access

BIPOLAR AFFECTIVE DISORDER

BIPOLAR disorder is a mental health condition that causes extreme shifts in a person’s mood
and energy level. While everyone experiences ups and downs, and depending on the type of
bipolar disorder, there are severe shifts in mood and behavior that can seriously impact on a
person’s life.

A person with bipolar disorder may experience periods of an extremely elevated or irritable
mood (called manic episodes) as well as episodes of depression. Both the manic and
depressive periods can be brief, from just a few hours to a few days. Or the cycles can be
much longer, lasting up to several weeks or even months.

Etiology of mood disorders

A. Biological theories

1. Genetic hypothesis

- Life time risk for the first degree relatives is 25%

- Life time risk for the children of one parent with bipolar disorder is 27%
- And of both parents with bipolar disorder is 74%

2. Biochemical theories
 - An abnormality in norepinephrine, dopamine, serotonin, acetylcholine and gaba are
involved in bipolar disorders.

- The side effects of antidepressants and mood stabilizers also cause bipolar disorders.

3. Neuroendocrine theories
- Endocrine function is often disturbed in depression such as hypothyroidism, crushing’s
disease and Addison’s disease.

4. Sleep studies
- Sleep abnormalities are common in mood disorders in client with decreased need for
sleep in mania; insomnia and frequent awakening in depression
5. Brain imaging
- In mood disorders, in imaging study findings include ventricular dilatation, white matter
hyper-intensities and changes in the blood flow and metabolism in several parts of brain

B. Psychosocial theories
1. Psychoanalytic theories
- In depression
- loss of a libidinal object
- Introjection of the lost object
- Fixation in the oral sadistic phase of development
- Intense craving for narcissism or self-love
- Mania represent a reaction formation to depression

2. Stress
- Increased number of stressful life events before the onset or relapse has a formative
rather than a precipitating effect in depression though they can serve a precipitant in
mania

- Increased stressors in the early period of development are probably more important in
depression

3. Cognitive and behavioral theories

The mechanisms of causation of depression include;

- Depressive negative cognition

- Learned helplessness
 - Anger directed inwards

According to the American Psychiatric Association, there are four major categories of bipolar
disorder: bipolar I disorder, bipolar II disorder, cyclothymic disorder, and bipolar disorder due to
another medical or substance abuse disorder.

Different Classification of Bipolar Disorder

Each disorder type is identified by the pattern of episodes of mania and depression. The
treatment that is best for you may differ depending on the type of bipolar disorder you have.

Bipolar I disorder

This type of bipolar disorder is diagnosed when manic episodes last at least seven days and
are accompanied by psychotic features, or the manic symptoms are severe enough to require
immediate hospitalization to prevent harm to oneself or others. Depressive episodes, typically
lasting at least two weeks, also often occur. A person may have manic episodes with some
depressive features or depressive episodes with some manic features.

Bipolar II disorder

Mania is not involved in bipolar II disorder. Instead, the illness involves recurring episodes of
major depression and hypomania, a milder form of mania. In order to be diagnosed with
bipolar II disorder, you must have experienced at least one hypomanic episode and one major
depressive episode in your lifetime. In bipolar I disorder, a major depressive episode (one or
more) usually occurs, but it is not required. Bipolar II disorder involves one or more major
depressive episodes. Common symptoms that occur in a major depressive episode include:
● Insomnia or hypersomnia
● Unexplained or uncontrollable crying
● Severe fatigue
● Loss of interest in things the person typically enjoys
● Recurring thoughts of death or suicide

Cyclothymic disorder
Cyclothymic is a milder form of bipolar disorder. Like bipolar disorder, cyclothymic consists of
cyclical mood swings. However, the highs and lows are not severe enough to qualify as either
mania or major depression.

The condition usually develops in adolescence. People with the disease often appear to
function normally, although they may seem “moody” or “difficult” to others. People will often not
seek treatment because the mood swings do not seem severe. If left untreated, cyclothymic
can increase your risk of developing bipolar disorder.

Bipolar disorder not otherwise specific (BP-NOS)

Some bipolar disorders don’t have a specific pattern. They also don’t match the other three
disorders. Yet, they still have to meet the criteria for abnormal mood changes.
For example, a person may experience mild depressive or hypomanic symptoms that last less
than the two years specified for cyclothymic. Another example is if a person has depressive
episodes, but their symptoms of mood elevation are too mild or brief to be diagnosed as mania
or hypomania.

With treatment and through their own efforts, people with bipolar disorder can live rich,
rewarding lives. Treatment for bipolar disorder usually includes a variety of strategies to
manage the disease over the long term. Because bipolar disorder is a chronic illness,
treatment must be ongoing.

Medications are typically an important part of treatment. Those medications may include mood
stabilizers, antipsychotic medications, or antidepressants. Such medications usually need to
be taken daily and regularly to be effective. If you have been diagnosed with bipolar disorder,
you and your doctor will work together to find the right drug or combination of drugs for your
needs. Because everyone responds to medication differently, you may have to try several
different medications before you find one that relieves your symptoms.

Clinical features

- DEPRESSIVE EPISODES
- Constantly feeling sad and worthless
- Sleeping too much or too little
- Feeling tired and having little energy
- Appetite and weight changes
- Problems focusing
- Thoughts of suicide
 - MANIC DEPRESSIVE

- INCREASE IN ENERGY LEVEL

- LESS NEED FOR SLEEP
- EASILY DISTRACTED
- NONSTOP TALKING
- INCREASED SELF CONFIDENCE
- FOCUSED ON GETTING THINGS DONE, BUT DOES NOT ACCOMPLISH MUCH
- INVOLVED IN RISKY ACTIVITIES EVEN THOUGH BAD THINGS MAY HAPPEN

Current episode can be;

- Hypomanic
- Manic without psychotic symptoms
- Manic with psychotic symptoms
- Mild or moderate depression
- Severe depression without psychotic symptoms
- Severe depression with psychotic symptoms
- mixed

TREATMENT and MANAGEMENT of BIPOLAR DISORDER

Mood stabilizers

People with bipolar disorder usually try mood stabilizers first. In general, people continue
treatment with mood stabilizers for years. Lithium is a very effective mood stabilizer. It was the
first mood stabilizer approved by the FDA in the 1970's for treating both manic and depressive
episodes.

Anticonvulsant medications also are used as mood stabilizers. They were originally developed
to treat seizures, but they were found to help control moods as well. One anticonvulsant
commonly used as a mood stabilizer is valproic acid, also called divalproex sodium. For some
people, it may work better than lithium. Other anticonvulsants used as mood stabilizers are
carbamazepine, lamotrigine and oxcarbazepine.
Atypical antipsychotics

Atypical antipsychotic medications are sometimes used to treat symptoms of bipolar disorder.
Often, antipsychotics are used along with other medications.
Antipsychotics used to treat people with bipolar disorder include:
● Olanzapine, which helps people with severe or psychotic depression, which often is
accompanied by a break with reality, hallucinations, or delusions
● Aripiprazole, which can be taken as a pill or as a shot
● Risperidone
● Ziprasidone
● Clozapine, which is often used for people who do not respond to lithium or
anticonvulsants.
● Lurasidone, Quetiapine

Antidepressants

Antidepressants are sometimes used to treat symptoms of depression in bipolar disorder.

Fluoxetine, paroxetine, or sertraline are a few that are used. However, people with bipolar
disorder should not take an antidepressant on its own. Doing so can cause the person to
rapidly switch from depression to mania, which can be dangerous. To prevent this problem,
doctors give patients a mood stabilizer or an antipsychotic along with an antidepressant.
What are the side effects?

Treatments for bipolar disorder have improved over the last 10 years. But everyone responds
differently to medications. If you have any side effects, tell your doctor right away. He or she
may change the dose or prescribe a different medication.
Different medications for treating bipolar disorder may cause different side effects. Some
medications used for treating bipolar disorder have been linked to unique and serious
symptoms, which are described below.
Lithium can cause several side effects, and some of them may become serious. They include:
● Loss of coordination
● Excessive thirst
● Frequent urination
● Blackouts
● Seizures
● Slurred speech
● Fast, slow, irregular, or pounding heartbeat
● Hallucinations (seeing things or hearing voices that do not exist)
 ● Changes in vision
● Itching, rash
● Swelling of the eyes, face, lips, tongue

If a person with bipolar disorder is being treated with lithium, he or she should visit the doctor
regularly to check the levels of lithium in the blood, and make sure the kidneys and the thyroid
are working normally.
Some possible side effects linked with valproic acid/divalproex sodium include:
● Changes in weight
● Nausea
● Stomach pain
● Vomiting
● Anorexia
● Loss of appetite.
Valproic acid may cause damage to the liver or pancreas, so people taking it should see their
doctors regularly.

Valproic acid may affect young girls and women in unique ways. Sometimes, valproic acid may
increase testosterone (a male hormone) levels in teenage girls and lead to a condition called
polycystic ovarian syndrome (PCOS) .PCOS is a disease that can affect fertility and make the
menstrual cycle become irregular, but symptoms tend to go away after valproic acid is
stopped. It also may cause birth defects in women who are pregnant.

Lamotrigine can cause a rare but serious skin rash that needs to be treated in a hospital. In
some cases, this rash can cause permanent disability or be life-threatening.
In addition, Valproic acid, Lamotrigine, Carbamazepine, Oxcarbazepine and other
anticonvulsant medications (listed in the chart at the end of this document) have an FDA
warning. The warning states that their use may increase the risk of suicidal thoughts and
behaviors. People taking anticonvulsant medications for bipolar or other illnesses should be
closely monitored for new or worsening symptoms of depression, suicidal thoughts or
behavior, or any unusual changes in mood or behavior. People taking these medications
should not make any changes without talking to their health care professional.
Other medications for bipolar disorder may also be linked with rare but serious side effects.
Always talk with the doctor or pharmacist about any potential side effects before taking the
medication.
How should medications for bipolar disorder be taken?
Medications should be taken as directed by a doctor. Sometimes a person's treatment plan
needs to be changed. When changes in medicine are needed, the doctor will guide the
change. A person should never stop taking a medication without asking a doctor for help.
There is no cure for bipolar disorder, but treatment works for many people. Treatment works
best when it is continuous, rather than on and off. However, mood changes can happen even
when there are no breaks in treatment. Patients should be open with their doctors about
treatment. Talking about how treatment is working can help it be more effective.
It may be helpful for people or their family members to keep a daily chart of mood symptoms,
treatments, sleep patterns, and life events. This chart can help patients and doctors track the
illness. Doctors can use the chart to treat the illness most effectively.
Because medications for bipolar disorder can have serious side effects, it is important for
anyone taking them to see the doctor regularly to check for possibly dangerous changes in the
body.

Benzodiazepines (anti-anxiety medications)

The anti-anxiety medications called benzodiazepines can start working more quickly than
antidepressants. The ones used to treat anxiety disorders include:
● Clonazepam, which is used for social phobia and GAD
● Lorazepam, which is used for panic disorder
● Alprazolam, which is used for panic disorder and GAD.
People can build a tolerance to benzodiazepines if they are taken over a long period of time
and may need higher and higher doses to get the same effect. Some people may become
dependent on them. To avoid these problems, doctors usually prescribe the medication for
short periods, a practice that is especially helpful for people who have substance abuse
problems or who become dependent on medication easily. If people suddenly stop taking
benzodiazepines, they may get withdrawal symptoms, or their anxiety may return. Therefore,
they should be tapered off slowly.
Buspirone is an anti-anxiety medication used to treat GAD. Unlike benzodiazepines, however,
it takes at least two weeks for Buspirone to begin working.
Beta-blockers
Beta-blockers control some of the physical symptoms of anxiety, such as trembling and
sweating. Propranolol is a beta-blocker usually used to treat heart conditions and high blood
pressure. The medicine also helps people who have physical problems related to anxiety. For
example, when a person with social phobia must face a stressful situation, such as giving a
speech, or attending an important meeting, a doctor may prescribe a beta-blocker. Taking the
medicine for a short period of time can help the person keep physical symptoms under control.
What are the side effects?
See the section on antidepressants for a discussion on side effects. The most common side
effects for benzodiazepines are drowsiness and dizziness. Other possible side effects include:
● Upset stomach
● Blurred vision
● Headache
● Confusion
● Grogginess
● Nightmares.
As noted above, long-term use of benzodiazepines can lead to tolerance (needing more of the
medication to get the same effect) and dependence. To avoid these problems, doctors usually
prescribe the medication for short periods. Recent research has found that benzodiazepines
are prescribed especially frequently for older people. See the section on older adults for
information on medication use in this age group.

Possible side effects from Buspirone include:

● Dizziness
● Headaches
● Nausea
● Nervousness
● Lightheadedness
● Excitement
● Trouble sleeping.
Common side effects from beta-blockers include:
● Fatigue
● Cold hands
● Dizziness
● Weakness.
In addition, beta-blockers generally are not recommended for people with asthma or diabetes
because they may worsen symptoms.
Like benzodiazepines, Buspirone and beta-blockers are usually taken on a short-term basis for
anxiety. Both should be tapered off slowly. Talk to the doctor before stopping any anti-anxiety
medication.

Psychotherapy

Cognitive behavioral therapy

- Which helps people with bipolar disorder learn to change harmful or negative thought
pattern and behaviors
Family-focused therapy
- Which involves family members
- It helps enhance family coping strategies
- This therapy also improves communication among family members as well as problem
solving

Interpersonal and social rhythm therapy

- help people with bipolar disorder improve their relationship with others
- manage their daily routines
- regular daily routines and sleep schedules may help protect against manic episodes

Psychoeducation
- Teaches people with bipolar disorder about the illness ant it’s treatment
- Can help to recognize signs of impending mood swing so they can seek treatment early
before full-blown episodes occurs

Electroconvulsive therapy (ECT)

- Is a medical treatment most commonly used in client with severe major depression or
bipolar disorder.
- useful for patient with severe bipolar disorder who not been be able to recover with
other treatments
- Involves a brief electrical stimulation of the brain while the patient is under anesthesia

- two major types of ECT: unilateral and bilateral

Side effects of ECT

- slight memory loss
- adverse reactions to anesthesia
- hypertension and hypotension
- Tachycardia
- Not recommended to client with unstable heart problem
 Good candidates for ECT

- people who are catatonic

- suffering from a form of depression known as psychotic depression
(depression associated with delusions and hallucinations).

Electroconvulsive therapy (ECT) is the most effective treatment for mood disorders, but some
sort of maintenance treatment is usually necessary to prevent relapse.

PREPARING FOR ECT PROCEDURE

- Avoid wearing jewelry or contact lenses

- The client received an intravenous line (IV)

- Dress comfortably.

- During the ECT treatment, the client will receive medication through the IV that will put
you to sleep for the duration of the treatment.

- Advice the client not drink alcohol for at least 48 hours before your treatment. Alcohol
may affect your body's response to the anesthetic. Arrange for someone to drive you
home.

COMMUNICATION AND THERAPEUTIC RELATIONSHIP

COMMUNICATION – is the means by which people make their needs known. It is the way they obtain
understanding, reinforcement, and assistance from others. Without communication, effective
functioning in society is impossible.
Communication is divided into two categories:
a. social – it is superficial and meets the needs of both parties; the goal is enjoyment
b. therapeutic – the goal is to develop or maintain a healthy personality and this is done by
relieving stress and assisting the patient in developing better coping mechanisms. It is
effective and purposeful.

GOALS OF THERAPEUTIC COMMUNICATIONS

to obtain useful information
to show caring
to help patient understand himself
to relieve stress
to provide information
to teach problem solving skills
to encourage acceptance of responsibility
to encourage activities of daily living

PART 1: THERAPEUTIC COMMUNICATION The nurse ability to establish effective

communication in nursing is imperative to providing the best care and patient outcomes
possible. Therefore, communication is an integral part in nursing and in developing a helping
relationship

Communication is the exchange of information, ideas, thoughts or feelings between two or

more people. It is a basic component of human relationships, including nursing.
Modes of communication:
1. Verbal Communication uses methods such as talking and listening. But it could also be in
the form of writing, reading, storytelling and other forms of communication using words.
2. Non Verbal Communication uses other forms, such as gestures, facial expressions and
touch. It also include physical appearance, eye contact, posture, gait and others
3. Written Communication uses any forms of written materials such as books, journals,
messages and others. Communication is a process. Meaning it consist of certain steps where
each step constitutes the essentials of an effective communication.

Goals of communication process is to influence others and facilitate behavioral change. It is a

two-way process involving the sending and the receiving of a message.
1. Sender is a person or group who wishes to communicate a message to another. It can be
considered the source-encoder. Encoding involves the selection of specific mode of
communication to transmit the message such as the language and words to use, tone of voice and
gestures to use.

2. Message is what actually is said or written, the body language that accompanies the words, and
how the message is transmitted. Example of which is talking face to face, through telephone or writing
a message in your FB, Twitter, SMS, etc.
3. Receiver is a person who must perceive what the sender is intended to relate. All the
senses are being use to receive the verbal and nonverbal messages.

4. Feedback is the message that the receiver returns to the sender. It is also called the response.
Communication can be described as helpful or unhelpful. It becomes helpful when it encourages
sharing of information, thoughts, or feelings between two or more people. It becomes unhelpful
when it hinders or blocks the transfer of information, thoughts or feelings to others

Nurses need to consider the following when communicating in a face to face manner:

Therapeutic relationships. A helping relationship that's based on mutual trust and

respect, the nurturing of faith and hope, being sensitive to self and others, and assisting
with the gratification of patient’s physical, emotional, and spiritual needs through
adequate knowledge and skill

Timing. The ability to choose the best moment for some action, movement, etc.
Transference. Occur when the client transfers feelings to nurse of a significant person in her life
1. Pace and intonation is the manner of speech, as in the rate or rhythm and tone
2. Simplicity is the use of commonly understood words, brevity, and completeness
3. Clarity is saying precisely what is meant, and brevity is using the fewest words possible.
4. Timing and relevance involves sensitivity to the client’s needs and concerns.
5. Adaptability is altering spoken messages in accordance with behavioral cues from the Client.
6. Credibility means worthiness of belief, trustworthiness, and reliability. Credibility may be is the
most important criterion of effective communication. You can foster credibility by being consistent,
dependable, and honest.
7. Humor can be a positive and powerful tool in the nurse–client relationship, but it must be used
with care. Humor can be used to help clients adjust to difficult and painful situations.

Factors that influences the communication process:

1. Personal space is the distance people prefer in interactions with others. Communication alters
in accordance with four distances, each with a close and a far phase.
 1.1. Intimate: space takes 0 to 11⁄2 feet and communication is characterized by body contact
such as cuddling a baby, assisting a client who is blind or with difficulty walking, positioning clients
and others
1.2. Personal takes 11/2 to 4 feet. This is the distance commonly use between nurses and clients
during interaction and providing nursing care such giving medication, health teaching, sitting with
a patient and others
1.3. Social takes 4 to 12 feet. Communication in this space is formal and is limited to
seeing and hearing.
1.4. Public takes 12 feet and beyond. People at this distance are seen at public
distance where communication requires loud, clear voice.

2. Boundary is the defining limit of an individual. To keep clear boundaries, the nurse must
maintain the professional boundary between the nurses – patient relationships. Professional
boundaries are crucial in the context of the nurse–client relationship. Keeps the focus on the client
and avoids sharing personal information. Avoid gift-giving or receiving, spending more time than
necessary with a client, or the nurse believing only he or she understands the client (Boyd, 2012).
Observe the use of touch. Touching a client can be comforting and supportive when it is welcome
and permitted. The nurse should observe the client for cues that show whether touch is desired or
indicated.

3. Gender. Man and woman communicate differently and that they may interpret the same
communication different manner.

4. Values are the standards that influence behavior, and perceptions are the personal view of an
event. Because each person has unique personality traits, values, and life experiences, each will
perceive and interpret messages and experiences different way.

5. Interpersonal attitudes convey beliefs, thoughts, and feelings about people and events.
Attitudes are communicated convincingly and rapidly to others. Attitudes such as caring, warmth,
respect, and acceptance facilitate communication, whereas lack of interest, and coldness inhibit
communication.
 6. Attentive listening is listening actively and with mindfulness and using all the senses,
and paying attention to what the client says, does, and feels

7. Congruence. Communication is congruent where the verbal and nonverbal aspects of the
message harmonize with each other

Therapeutic communication techniques facilitate communication and focus on the client’s

concerns. There are different techniques you could utilize in working with the client such as the
following.
- Accepting - Conveying that nurse hears or is interested in what the client is saying
Ex: “yes” or simply nodding head - Acknowledge client’s
non-verbal communication - Clarify and validate client’s
statement
Ex: P - “I’m crazy”
N- “What do you mean you are crazy?”
P – “I can’t sleep. I stay awake all night”
N – “You have difficulty sleeping - Encourage
expression of feelings
P – “I want to kill myself”
N – “Tell me of you’re feeling of wanting to kill yourself” -
Encourage hope but not false reassurance - Exploring - Delving further
into a subject or idea
Ex: ‘Tell me more about that ...’ ‘Would you
describe it more fully?’ ‘What kind of work?’ -
Focusing to concentrate on a single point
Ex: N – “This topic seems worth looking at more closely” - Giving
information - Making available facts that client need
Ex: My name is ...... My purpose in being here is .....
- Giving recognition - Acknowledging behavioral changes or indicating awareness
Ex: You’ve combed your hair today –
 Inform and present reality
Ex: P - “Eggs are flying saucer”
N – “Eggs are food to be eaten
- Making observation - Verbalizing what the nurse perceives
Ex: “You appear tense”
“I’ve notice that you’re biting your lips” –
Offering self - Making oneself available
Ex: I’ll sit with you for a while –
Offering general lead - Giving encouragement to continue
Ex: “Yes, o on” “And then?” “Tell me about it”
- Restate or Feedback on what the client has said
Ex: P – “Do you think I should tell my husband what happened?”
N – Do you think you should tell your husband?”
- Reflects on the feelings expressed
P – “No one wants me.”
N - “You mean you feel rejected?”
- Silence but expresses being there
- Nurse says nothing but continues to maintain eye contact and convey interest - Summarizing -
Reviewing main points and conclusions
Ex: Let’s see, so far you have said ......
- Use open ended questions
Ex: P – “What are you feeling right now”
- Using broad opening - Allowing the client to take initiative in introducing the topic
Ex: Where would you like to begin?

Nurses need to recognize barriers or nontherapeutic responses to effective communication.

Failing to listen, improperly decoding the client’s intended message, and placing the nurse’s
needs above the client’s needs are major barriers to communication. Non-therapeutic
Communication Techniques
- Agreeing /Disaggreing
Ex: “That’s right...” / “I don’t believe that” -
Approving/Disapproving
Ex: “I like the way you comb your hair”
“It’s not nice to look the way you comb your hair -

Advising Ex: “I think you should...? -

Asking why questions– asking client to provide reasons for thoughts, feelings, behaviors and
events and patient may become defensive
Ex: “Why do you think that you are crazy?”
“Why do you feel that way?

” - Belittling feeling expressed

– misjudging the degree of the client’s discomfort

Ex: P - “I have nothing to live for... I wish I was dead”

N – “I’ve felt that way before”
- Challenging – demanding proof for the client
Ex: N- “But how can you be president of the United States?”
- Changing topic

Ex: P – “I really want to die”

N – “Your mother did not visit you this week?”
- Defending – attempting to protect someone or something

Ex: P – “My doctor is mean and uncaring

N – “I’m sure your doctor has your best interest in mind”
- False reassurance – indicating there is no reason to worry or other feelings of
discomfort

Ex: N – “Everything will be alright”

 - Giving Personal opinion or value judgment - Testing –
appraising the client’s degree of insight

Ex: “Do you know what kind of hospital this is?”

- Using denial – refusing to admit that a problem exists

Ex: P – “I’m nothing”

N – “Of course you’re something – everybody’s something”

Effective communication is essential for the establishment of a nurse–client relationship. Nurse

patient relationship is a helping relationship that support a patient’s well-being. Key components
needed to develop a therapeutic relationship includes the following:
1. Trust is a key factor in establishing a therapeutic relationship towards recovery process
2. Genuine interest. When the nurse is comfortable with himself or herself, aware of his or her
strengths and limitations, and clearly focused, the client perceives a genuine person showing
genuine interest. The nurse should be open, honest and display congruent behavior
3. Empathy is the ability to perceive the meaning and feelings of the client and to communicate
that understanding to the client. Empathy is one of the essential skills a nurse must develop
4. Acceptance is not just being nice to people. It is a principle of action in which a nurse perceive
and work with the patient as what he really is. She accepts congenial and uncongenial qualities,
his constructive and destructive attitude and his positive and negative feeling while maintaining a
sense of patient’s innate worth. Accepting behaviors are caring action of nurses on the client’s
well-being such as, sensitivity, comforting, attentive listening , honesty and non-judgmental
acceptance

5. Positive regard. The nurse appreciates the client as a unique worthwhile human being who can
respect the client regardless of his or her behavior, background or lifestyle. Measures to convey
respect and positive regard to your client.
5.1. Calling client by name or whatever your client wishes to call him or her
r5.2. Spending time with your client
5.3. Listening and responding openly and
5.4. Considering your client’s ideas and .preferences when planning care

6. Therapeutic use of self is forming a trusting relationship that provide s comfort, safety and non-
judgmental acceptance of clients to help them improve their health status. Therapeutic use of self
requires self-awareness and the use of effective communication techniques Self-awareness is
conscious knowledge of one's own character, feelings, motives, and desires. The process can be
painful but it leads to greater self-understanding

PART 2: THERAPEUTIC RELATIONSHIP The ability to establish a therapeutic relationships with

clients is one of the most important skills a nurse can develop. Although important in all nursing
specialties, the therapeutic relationship is especially crucial to the success of interventions with
clients requiring psychiatric care because the therapeutic relationship and the communication
within it serve as the underpinning for treatment and success.

Therapeutic relationship is defined as a helping relationship that's based on mutual trust and
respect, the nurturing of faith and hope, being sensitive to self and others, and assisting with the
gratification of patient’s physical, emotional, and spiritual needs through adequate knowledge and
skill. This caring relationship develops when the nurse and the patient come together in the
moment, which results in harmony and healing. Effective verbal and nonverbal communication is
an important part of the nurse-patient relationship, as well as providing care in a manner that
enables the patient to be an equal partner in achieving wellness. A helping relationship is:
>Patient centered >Goal directed >Professional relationship >Time bounded >Structured –
planned and follows a sequence (establishing, maintaining, terminating)

Types of Relationships
Area of Differentiation Therapeutic Relationship Social/Intimate Relationship Characteristics
Personal but not intimate Personal or intimate Goal Meet client’s need
Doing favor for mutual benefit Termination With limitation, defined in
the beginning
Not defined Identification of needs Present May not occur
Resources used Specialized professional
skills for intervention
Variety during interaction

Therapeutic Relationships In a helping relationship there are 4 phases to follow.

1. Pre interaction Phase

- It begins before the client first contact with the patient. The nurse gathers information. Such
information may include the client’s name, address, and age, medical and social history. - The
nurse should consider his or her personal strength and limitation when working with
the client and in any area that might signal difficulty because of past experiences

2. Introductory Phase.
- It begin when the nurse and the client first meet - The nurse establishes a relationship ,
develop trust and respect , setting goals, and
security within the nurse–client relationship
1. Establish boundaries and acceptance
2. Establish trust – consistent, congruent, honest, keeping prom genuine interest and respect
3. Establish contract
3.1. Time, place and length of session
3.2. Who will be involved in the treatment plan
3.3. Client responsibilities and nurse responsibilities
3.4. Duration
3.5. Purpose of the meeting -
Nurse’s responsibility during NPI
3.1. Arrive on time
3.2. Maintain confidentiality
3.3. Assess client level of anxiety
3.4. Prepare client for termination and separation of the relationship
3.5. End on time
3.6. Document sessions

4. Establishing relationships
4.1. Gaining the client’s trust
4.2. Establishing the boundary and expectations of the relationship.
4.3. Identifying problem.

3. Working Phase.
- The nurse works with the client on the resolution of the patient’s identified problem. - Perform
evaluation and redefine his or her goals as appropriate

4.Termination Phase
- The nurse summarizes with the clients his progress of the relationship and assessing the
client’s ability to handle situations independently - Nurse-client talks about the progress of the
relationship - Identify and deal with separation issues - Assess client emotional stability - Do
not promise the client that the relationship will be continued - Refer and transfer client to other
support system

Barriers to Therapeutic Relationships ( TRIES)

C – Countertransference
- Nurse transfers feelings to client of a significant person in her life T Transference
- Client transfers feelings to nurse of a significant person in her life R – Resistance
and Avoidance
- Development of ambivalent feelings for self-exploration or self-disclosure I –Inappropriate
boundaries

- Nurse-patient relationship should be maintained within the professional boundary E –

Encouraging dependency
- Nurse should help the client to function independently S – Sympathy
- The nurse should develop empathy

STUDY GUIDE
PSYCHOSOCIAL SKILLS IN THE PSYCHIATRIC-MENTAL HEALTH NURSING PRACTICE
I. Nursing Process
II. Process Recording
II. Psychosocial Assessment
II. Mental Status Examination

I. Nursing Process is a series of organized steps designed for nurses to provide excellent care.
Learn the five phases, including assessing, diagnosing, planning, implementing, and
evaluating.
It functions as a systematic guide to client-centered care with 5 sequential steps. These are:
1. Assessment,
2. Diagnosis,
3. Planning,
4. Implementation
5. Evaluation.

1. Assessment
Assessment is the first step and involves critical thinking skills and data collection; subjective
and objective.

1.1. Subjective data involves verbal statements from the patient or caregiver.
1.2. Objective data is measurable, tangible data such as vital signs, intake and
output, and height and weight.

Data may come from the patient directly or from primary caregivers who may or may not
be direct relation family members. Friends can play a role in data collection. Charts and
other patient’s records may populate data in and assist in assessment.
2. Diagnosis. The formulation of a nursing diagnosis by employing clinical judgment assists in
the planning and implementation of patient care. The North American Nursing Diagnosis
Association (NANDA) provides nurses with an up to date list of nursing diagnoses. A nursing
diagnosis, according to NANDA, is defined as a clinical judgment about responses to actual
or potential health problems on the part of the patient, family or community.
A nursing diagnosis encompasses Maslow's Hierarchy of Needs and helps to prioritize
and plan care based on patient-centered outcomes.
Maslow's Hierarchy of Needs
2.1. Basic Physiological needs: Nutrition (water and food), elimination
(Toileting), airway (suction)-breathing (oxygen)-circulation (pulse, cardiac
monitor, blood pressure) (ABC's), sleep, sex, shelter, and exercise.
2.2. Safety and Security: Injury prevention (side rails, call lights, hand hygiene,
isolation, suicide precautions, fall precautions, car seats, helmets, seat
belts), fostering a climate of trust and safety (therapeutic relationship),
patient education (modifiable risk factors for stroke, heart disease).
2.3. Love and Belonging: Foster supportive relationships, methods to avoid
social isolation (bullying), employ active listening techniques, therapeutic
communication, and sexual intimacy.
2.4. Self-Esteem: Acceptance in the community, workforce, personal
achievement, sense of control or empowerment, accepting one's physical
appearance or body habitus.
2.5. Self-Actualization: Empowering environment, spiritual growth, ability to
recognize the point of view of others, reaching one's maximum potential.

3. Planning.
The planning stage is where goals and outcomes are formulated that directly impact patient
care based on EDP guidelines. These patient-specific goals and the attainment of such assist
in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting.
Care plans provide a course of direction for personalized care tailored to an individual's
unique needs. Overall condition and comorbid conditions play a role in the construction of a

care plan. Care plans enhance communication, documentation, reimbursement, and

continuity of care across the healthcare continuum.

Goals should be:

3.1. Specific
3.2. Measurable or Meaningful
3.3. Attainable or Action-Oriented
3.4. Realistic or Results-Oriented
1.5. Timely or Time-Oriented

4. Implementation.
Implementation is the step which involves action or doing and the actual carrying out of
nursing interventions outlined in the plan of care. This phase requires nursing
interventions such as applying a cardiac monitor or oxygen, direct or indirect care,
medication administration, standard treatment protocols and EDP standards.
5. Evaluation.
This final step of the nursing process is vital to a positive patient outcome. Whenever a
healthcare provider intervenes or implements care, they must reassess or evaluate to
ensure the desired outcome has been met. Reassessment may frequently be needed
depending upon overall patient condition. The plan of care may be adapted based on new
assessment data.
II. Process Recording
Process Recording is a method in which a nurse and student nurses record all the
communication, both verbal and non-verbal, spoken and observed during his or her an
interview with the patient.
Purposes of a Process recording
1. To improve the quality of therapeutic nurse patient relationship
2. Asses the nurse to plan, structure and evaluate the interaction on a conscious rather than
intuitive level
3. To provide means for self-evaluation of verbal and non-verbal communication pattern and
its effect
4. To help the nurse identify the thoughts and feelings in relation to self and others
5. To help to increase the ability to identify problems and gain skills in solving them

PROCESS RECORDING SAMPLE FORM

Name of Student: ____________Group No.: _____Agency____ Area of Assignment________
Name of Client (Initial Only): _____________Age: _____Sex: _________Race: __________
Phase of Interaction: _________Date of NPI: _______Medical Diagnosis:_________________
Objectives of the Interaction:
___________________________________________________________________________
___________________________________________________________________________
______________
General Description of the Client: (Guided by MSE Checklist)
___________________________________________________________________________
___________________________________________________________________________

___________________________________________________________________________
_____________________
Description of the Setting:
___________________________________________________________________________
______________________________________________________________________

Nurse Communication
techniques
used and
Rationale
Patient

Verbal Outcome
Communication

Non-Verbal
Communication

Verbal
Communication

Non-Verbal
Communication

Evaluation of the outcome of the goals:

___________________________________________________________________________
___________________________________________________________________________
III. History Taking and Psychosocial Assessment
Psychosocial assessment is an evaluation of mental, physical, and emotional health. It
considers the client's perception of self and his or her ability to function in the community.
Components:
1. Client initial information - patient’s name, address, and age, gender, etc.
2. Presenting problems
3. Present and Past Health History

- Existing and past medical & mental illness

- Hospitalizations
- Medications & other treatment
- Physiologic and self-care problem

4. Relevant Family History

- Family physical and mental health problems

- Use and abused of drugs by the family

5. Response to mental health problems

- Relationship change
- Role change
- Lifestyle change
- Self-concept change

6. Risk assessment on suicidal or homicide

- Ideation: “Are you thinking about killing yourself?”

- Plan: “Do you have a plan of killing yourself?”
- Method: “How do you plan to kill yourself?”
- Access: “How would you carry out this plan?”
- Where: “Where would you kill yourself?”

- When: “When do you plan to kill yourself?”

- Timing: “What day or time of day do you plan to kill yourself?”

7. Psychosocial development of the patient

- Childhood - describe nurturing
- Adolescence - describe peer group
- Use and abused of drugs by the family

8. Manifestations seen in patients with mental disorders includes the following:

8.1. Disturbances in affect
- Euthymic – normal
- Inappropriate affect – disharmony between thought and emotional response
- Flat affect – no emotion attached to the content of speech
- Blunt affect – decrease emotional response
- Elated affect – extreme and inappropriate joyfulness associated with increased
motor activity and speech
- Depressed affect / dysphoric affect – pathologic feeling of sadness
- Anger/Aggression – pathologic feeling of hostility
- Anxious – grieve feeling of apprehension
- Labile affect – change of emotion from happiness to tearfulness in a very short
span of time

8.2. Disturbance in thoughts

- Delusion – false belief that cannot be corrected by reasons

1. Persecutory delusions – false belief that others are against him or will
harm him
2. Nihilistic delusion – false belief that one denies existence of self or part
of self
3. Thought Broadcasting – false belief that one’s thought can be read by
others
4. Thought Withdrawal – false belief that one’s thought is taken by others
5. Thought Insertion – false belief that others inserted thoughts or ideas into
his mind
6. Ideas of Reference – false belief that situations or event in the
environment are directly projected into the client
7. Grandiosity – false belief that one is superior and powerful
8. Self-depreciation – false belief that one feels unworthy, ugly or sinful
9. Somatic delusion – false belief pertaining to body image or function
- Obsession – a persistent and irresistible thought that a person is driven to think
again and again
- Hypochondria – a morbid belief that one is sick
- Perseverance – a tendency to emit the same verbal or motor response again and
again
- Circumstantiality – patient provide a lot of details before finally answering the
question
- Tangentially - verbal production is not at all related to the question
- Thought blocking – sudden stoppage of thought without apparent reasons
- Neologism – coining new words

Ex; “His BAGELGELS is in the river”

- Loose association – patient verbal production is impossible to follow due to lack of

organization
- Word salad – extreme form of loose association, wherein there is no two words
that connect together to form any logical association
- Clang association – patient speaks in rhymes
- Flight of ideas – over productivity of talk and verbal skipping from one idea to
another
Ex: “I like the color blue. Do you ever feel blue? Feelings can change day to
day. The days are getting longer”
- Poverty of ideas – patient has few ideas and focus only on negative aspects
8.3. Disturbances in perception
- Illusion – false interpretation of the external stimulus. Person falsely interprets or
perceives a real environmental stimulus. It may involve any senses
- Hallucination – false sensory perceptions that occur in the absence of an actual
external stimuli and it may involve any of the senses
G – Gustatory Hallucination > taste
O – Olfactory Hallucination > smell
V – Visual Hallucination > sight
A – Auditory hallucination > hearing
T – Tactile Hallucination > touch

- Depersonalization – a feeling of detachment from the environment and self

- Derealization – a feeling of altered reality
8.4. Disturbance motor behavior
- Catatonic stupor

1. Stupor – client is unresponsive to the surroundings but is conscious

2. Rigidity – client assumes position and will not move when effort is made
to change his/her position

- Waxy flexibility – client maintains his position which he has been originally placed
- Catatonic excitement

- Hyperactivity – presence of motor restlessness and extreme over activity

1. Impulsiveness – unpredictable and sudden outburst of activity
2. Compulsion – unwanted urge to perform repetitive action
- Automatism – unconscious uncontrollable undirected activity
1. Echopraxia – client imitates actions of others
2. Echolalia – client repeats words/statements of others
- Stereotype – repetitive persistent motor activity or speech
1. Verbigeration – constant repetition of same words
2. Mannerism – persistent motor behavior

- Tics and spasm – unconscious twitching or jerking of muscles usually above the
shoulder which are involuntary
8.5. Disturbance in memory
- Amnesia – complete absence of memory

1. Anterograde amnesia – forgetting recent events

2. Retrograde amnesia – forgetting further events

- Paraamnesia – incomplete absence of memory

1. Confabulation – fabricating stories to fill up lapses of memory cause by

2. Blackout – amnesia experienced by alcoholics about behavior during
drinking bouts

- Deja Vu – familiarity of events, situations or places that are unfamiliar

- Jamais vu – unfamiliarity of events situations or places that are familiar
- Deja intendu – familiarity of sounds that are unfamiliar
- Jamais intendu – unfamiliarity of sounds that are familiar
- False memory – recollection of and belief in an event that did not actually occur
- Lethologica is a psychological disorder that inhibits an individual’s ability to
articulate their thoughts by temporary forgetting key words, phrases or names in
conversation. It is temporary inability to remember a name or proper noun

III. Mental Status Examination (ATOMIC)

Mental Status Exam is analogous to the physical exam. It is a series of observations and
examinations on the patient’s behavior, thinking, emotion and cognitive functions at one point
in
time. Focused questions and observations can reveal "normal" or pathological findings.
The data from the Mental Status Exam, combined with personal and family histories and
Psychiatric Review of Systems, forms the data base from which psychiatric diagnoses are
formed.
Components:
A. Appearance and behavior
1. Appearance
- Describe the general physical appearance of the client
- Appropriateness of clothing
- Personal hygiene, grooming, and cleanliness
- Apparent age, body built, height, weight
- Any abnormalities in physical appearance
2. Behavior
- Cooperative? Resistant? Suspicious? Aggressive? Restless? Agitated?
Hyperactive? Hypoactive?
- Social skills: friendly, shy, withdrawn
- Amount and type of motor activity: psychomotor agitation or retardation,
- Tremors, or restlessness
Presence of disturbances in motor behavior
- Presence of disturbances in motor behavior

T – Thinking
1. Thought Content- what the client is saying
- delusions, hallucinations,
- helplessness, hopelessness, worthlessness
- suicidal or homicidal thoughts
- Suspiciousness, obsessions, denial, phobia
2. Thought process – how the client is thinking
- Bizarre, impaired, logical, magical
- Ambivalence, circumstantiality, tangentially,

- thought blocking, loose association, flight of ideas, perseveration, neologism and

- Presence of other thought disturbances
3. Thought clarity: - coherence, confusion or vagueness
4. Speech pattern: - amount, rate, volume, tone, pressure, mutism, stuttering, slurring

O – Orientation to the three spheres

- recognize person, place and time
- Level of consciousness

M – Memory

- Ability of the client to recall distant and recent events or short and long term
memory
- Presence of any disturbance in memory

I – Intellectual functioning

- Educational level: cognitive functions

- Attention: ability to concentrate
- Retention: ability to retain information
- Abstract reasoning: ability to interpret or associate situation, proverbs or
comments

C – Cognitive functioning
1. Comprehension
2. Interpreting information
3. Learning new information
4. Judgment
5. Perception
6. Problem solving
7. Making decision
8. Reasoning

INDIVIDUAL TASK:(100 points)

1. Get a partner from your classmate (thru video call)
2. Perform a mental status examination using the mnemonic
A – Appearance and behavior
T - Thinking
O - Orientation
M - Memory
I – Intellectual function
C – Cognitive function
3. Make at least 4 Drug study use in client with Bipolar disorder.

Boyd (2017), Essentials of Psychiatric Nursing, Wolters/Kluwer

Holland (2018), The Nurses Guide to Mental Health Medicines Elsevier/Mosby
Keltner (2019), Psychiatric Nursing 8th edition, St. Louis, Mo.: Elsevier/Mosby.
Kozier, Barbara, (2017) Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and
Practice 10th edition Upper Saddle River, N.J.:Pearson Prentice Hall
Pullen, Richard (2010) Nursing Made Incredibly Easy. Varcarolis (2015), Manual of Psychiatric
Nursing Care Planning 5th edition, Elsevier/Mosby
Videbeck, Sheila L. (2017) Psychiatric-Mental Health Nursing 7th edition. Wolters
Kluwer/Lippincott Williams and Wilkins
Therapeutic-nurse Patient Relationship (2019)
https://www.journals.lww.com/nursingincrediblyeasy/fulltext/2010/05000/fostering_therapeutic_
nurse_patient_relationships.1.aspx

American Nurses Association Journals https://www.nursingworld.org/practice-

policy/workforce/what-is-nursing/the-nursing-process/
.https://www.webmd.com/bipolar-disorder/guide/bipolar-1-disorder?
fbclid=IwAR2MB6aPSiNYoQ0nEzQVAiHqk-iBFr-4cJ-q8bQO1eCkGQgGmBeH4gtKD9

https://www.nimh.nih.gov/health/topics/mental-health-medications/index.shtml?
fbclid=IwAR0sLEP9cucPYW5P_hSBfrjO2kmZJ_ZEL7e6rDDal-M1_EXU4YoM2J46cVA