Chapter One- Roles and Functions of

Psychiatric-Mental Health Nurses: Competent Caring

History of Psychiatric Nursing

 Before 1860 attendants hired for custodial care

 Linda Richards (1873)

 “First American psychiatric nurse”

 Developed better nursing care in psychiatric hospitals
 Organized nursing services and educational programs in Illinois state
mental hospitals
Developments in Early 1900s
 In 1913 Johns Hopkins was first school of nursing with fully developed psychiatric
course
 In 1930s nursing education recognized importance of psychiatric knowledge in
nursing care for all illnesses
 In 1930s insulin shock therapy, psychosurgery, and electroconvulsive therapy
(ECT) developed
 In 1947 eight graduate programs in psychiatric nursing had been started

Developments in 1950s
 NLN required accredited schools of nursing to provide experience in psychiatric
nursing
 Hildegard Peplau published Interpersonal Relations in Nursing

 Maxwell Jones published The Therapeutic Community: A New Treatment

Method in Psychiatry
 Major tranquilizers developed

Nurse-Patient Relationship
 Described by Tudor in 1952

 Peplau defined nursing as “significant, therapeutic process”

 Evolved role of psychiatric nursing and was considered “Mother of

Psychiatric Nursing”
  Based clinical competence on interpersonal techniques and use of nursing
process
Developments in Somatic Therapies
 Insulin shock therapy

 Psychosurgery

 ECT

 All required medical-surgical skills of nurses

 Helped control behavior and made patients more open to psychotherapy

 Showed need for improved psychological treatment for nonresponsive
patients
Therapeutic Community
 Social environment provided therapeutic experience

 Patient active participant in care

 Involved in daily problems of the unit

 Helped solve problems, plan activities, develop required unit roles
 Therapeutic communities became preferred psychiatric environments

Psychotropic Drugs
 Developed in early 1950s

 More patients became treatable

 Fewer restraints and locked doors needed

 More personnel needed to provide therapy

 Roles of psychiatric practitioners and nurses expanded

Evolving Nursing Functions

 Dealing with patient problems of attitude, mood, interpretation of reality

 Exploring disturbing or conflicting thoughts

 Using positive feelings from relationships to bring about psychophysiological

homeostasis
 Counseling patients in emergencies
  Strengthening “well part” of patients

Developments in 1960s
 Focus began to shift to primary prevention, care, and consultation in community

 Community Mental Health Centers Act of 1963

 Federal money available to states for planning, construction, staffing

 Treated people in the community and prevented hospitalization if possible
 Formed multidisciplinary treatment teams
Developments in 1970s
 Psychiatric nurses pacesetters in specialty nursing practice:

 Developed first standards and statements on scope of practice

 Established generalist and specialist certification
 Psychiatric concepts valued and blended into nursing education as “psychosocial
nursing”
Developments in 1980s
 Exciting scientific growth with new focus

 Brain-imaging techniques
 Neurotransmitters and neuronal receptors
 Psychobiology of emotions
 Understanding the brain
 Molecular genetics related to microbiology
Challenges Faced in 1980s
 Integrating expanding bases of neurosciences into psychiatric nursing education and
practice

 Understanding that knowledge of the specialty is based on integration of

biological, psychological, spiritual, social, and environmental realms of the
human experience
Psychiatric Nursing Defined
 “A specialized area of nursing practice committed to promoting mental health
through the assessment, diagnosis, and treatment of human responses to mental
health problems and psychiatric disorders.”
  “[It] employs a purposeful use of self as its art and a wide range of nursing,
psychosocial, and neurobiological theories and research evidence as its
science.”

Psychiatric Nursing Activities

 Make culturally sensitive biopsychosocial health assessments

 Design and implement treatment plans for patients and families with complex
health problems and co-morbid conditions
  Organize, access, negotiate, coordinate, and integrate services and benefits for
individuals, families
 Provide “health care map” to guide them to community resources

 Promote and maintain mental health, managing effects of mental illness through
teaching, counseling
 Provide care for patients with both physical and psychological problems

 Manage and coordinate systems of care, integrating needs of patients, families,

staff, regulators
Levels of Performance: Laws
 Nurse practice act in one’s state

 Also addresses advanced practice roles and prescriptive authority

Levels of Performance: Qualifications

 Basic level: psychiatric-mental health registered nurse cares for mental health
patients in various settings and roles
 Advanced level: advanced practice RN- psychiatric-mental health
(APRN-PMH) has master’s degree or higher and experience, knowledge of
theory and practice, competence in advanced skills
Practice Settings
 Psychiatric facilities

 Community mental health centers

 Psychiatric units in general hospitals

 Residential facilities

 Home health care

 Primary care is emerging focus of care

 Clinics, schools, industry, HMOs, prisons, managed care settings, home

health, nursing homes, emergency departments
Personal Initiative
 Support groups

 Networking

 Professional associations
Future Challenges
 Psychiatric nurses to focus energy on:

 Outcome evaluation
 Leadership skills
 Political action
 Proactive strategies for advancing mental health system that is fair, sensitive,
responsive to needs of patients, families, communities

Chapter 2- Therapeutic Nurse-Patient Relationship

Therapeutic Nurse-Patient Relationship
 Mutual learning experience

 Corrective emotional experience

 Based on the humanity of nurse and patient

 Includes mutual respect and acceptance of sociocultural differences

 Nurse uses personal attributes, clinical techniques

 Promotes insight, behavior change

Long-Term Patient Goals

 Self-realization, self-acceptance, self-respect

 Clear sense of personal identity, integration

 Form intimate, interdependent, interpersonal relationships with capacity to give

and receive love
 Improved functioning, able to satisfy needs and achieve realistic personal goals
Qualities of a Competent Psychiatric Nurse
 Awareness of self

 Clarification of values

 Exploration of feelings

 Ability to serve as role model

 Altruism

 Sense of ethics and responsibility

Achieving Therapeutic Goals

 Explore various aspects of patient’s life experiences

 Allow patient to express thoughts, feelings

 Observe and relate behaviors to thoughts

 Clarify areas of conflict, anxiety

 Identify and maximize patient’s ego strengths

 Encourage socialization, family relatedness

Awareness of Self
 Who am I?

 How do I deal with anxiety, anger, sadness, and joy?

 Broad range of experiences

 Recognize health-illness continuum

Listen to self
Listen and learn from others
May self-disclose/reveal aspects of self
Awareness of Self
 Acknowledge differences, uniqueness

 Increase openness, authenticity

 Interact spontaneously and honestly

 Identify, discuss, analyze, and resolve problems constructively

Clarification of Values
 What is important to me?

 Values from experiences with family, friends, culture, education, work, relaxation

 Framework for daily decisions, actions

  Examples: religious beliefs, family ties, sexual preferences, other ethnic groups,
gender role beliefs
Value Clarification Process
 Change may occur when certain contradictions perceived in person’s value
system
 To eliminate distress that follows such a realization, person chooses and realigns
values
 Uses new choices with new view of self

Role Model
 Nurses have obligation to model adaptive and growth-producing behavior

 Effective nurses approach life with sense of growing, hopefulness, adapting

 Chaos, conflict, distress, or denial in nurse’s personal life will decrease

effectiveness of care
Altruism
 Concern for welfare of others

 Love for humanity and helping people

 Nurses need to balance altruism with their needs for satisfaction, compensation,
recognition
 Can be self-destructive if overzealous

Ethics and Responsibility

 Assume responsibility for behavior

 Know limitations, strengths

 Use resources, knowledge, expertise of others

 Responsible ethical choices, accountability

Phases of Nurse-Patient Relationship

 Each phase builds on preceding one

 Characterized by specific tasks

 Preinteraction phase
 Introductory/orientation phase
  Working phase
 Termination phase
Preinteraction Phase
 Initial task: self-exploration, self-analysis

 Challenges of psychiatric setting may cause stress and fear related to:

 Inadequacy related to inexperience

 Saying the wrong thing
 Unpredictable or aggressive behavior
 Questioning own mental health status
 Analyze strengths, limitations

 Gather data about patient

 Plan for first interaction

Introductory/Orientation Phase
 Find out why patient sought help

 Explore patient’s feelings, identify problems

 Establish trust, understanding, acceptance, open communication

 Establish goal consensus, collaboration

 Formulate contract, explaining roles, confidentiality, responsibilities, expectations

of patient and nurse
Working Phase
 Nurse and patient explore stressors

 Promote development of insight by linking perceptions, thoughts, feelings,

actions
 Translate insight into action/behavior change

 Master anxieties, increase self-responsibility, develop constructive coping

mechanisms
 Standoff, impasse, or plateau may develop if patient resists moving forward

Termination Phase
  Learning maximized because of higher levels of trust, intimacy

 Exchange feelings and memories to evaluate patient progress, goal attainment

 Establish reality of separation; explore feelings of rejection, loss, sadness, anger

 Make referrals if needed for continued care or treatment

Communication
 Verbal communication

 Nonverbal communication: includes voice inflection, body movements, facial

expression, gestures, posture, physical energy, eye contact, use of space, touch
 If patient has difficulty speaking English,
 use fewer words, more gestures, expressive facial behaviors, trained interpreter

Use of Touch
 Use touch carefully in psychiatric setting

 Patients may be sensitive to issues of closeness

 Could be misinterpreted as an invasion
 Potential problem if patient interprets touch as sexual invitation to intimacy
 If procedures require physical contact, explain carefully before and during
procedure
Communication Process
 Perception: brain receives visual, auditory, or other stimuli for communication

 Evaluation: cognitive response to information and affective response to

relationship aspect of message
 Transmission: feedback returned to sender after receiver evaluates it
Knowledge of Context
 Context: setting where communication takes place

 Knowledge of context necessary to understand full meaning of message

 Also includes psychosocial setting

 Relationships
 Past experiences with each other
 Experiences with similar situations
 Cultural values, norms
Key Terms
 Congruent communication: sender communicating same message on verbal and
nonverbal levels
 Incongruent communication: messages on verbal and nonverbal levels differ

 Causes dilemma, confusion, frustration for listener, who does not know to
which level to respond
Therapeutic Communication Techniques
 Listening is the foundation

 Use broad openings to encourage patient to communicate what is

important to him/her
 Restate part of patient’s statement
 Clarify vague ideas, thoughts
  Reflect on/validate patient’s behavior, feelings
Communication Techniques
 Use appropriate depth of feeling

 Use focusing to help patient expand on topic of importance

 Share perceptions by asking patient to verify nurse’s perception of patient’s

thoughts
 Identify themes by noting underlying issues or problems

 Use silence appropriately

 Use humor as a constructive coping behavior

 Consistent with social, cultural values

 To promote insight and decrease tension or anxiety
 Don’t use to mask feelings, increase social distance, allow avoidance, or ridicule
others
 Limit repetitive direct questions (especially “why” or yes/no questions)

 Inform: share simple facts or information

 Suggest: can be therapeutic or nontherapeutic

 Communicate understanding before giving suggestions or advice

 Communication must preserve self-respect of both individuals

Motivational Interviewing
• Help people:
 Talk about their ambivalence toward change
 Use their own motivation, energy, and commitment to learn new skills and
make needed changes in their lives
 Guided rather than directive approach
Principles of Motivational Interviewing
 Express empathy through reflective listening

 Understand patient’s motivations

 Identify discrepancies between patient’s goals or values and current behavior

 Avoid trying to make things right

 Support patient’s self-efficacy

Responsive Dimensions of Therapeutic Relationship
 Convey genuineness or “real” caring

 Respect or unconditional positive regard

 Empathic understanding: perceive and convey understanding of patient’s current

feelings and meanings
 Concreteness: use specific terminology rather than abstractions to avoid
vagueness, generalizations, ambiguity

Action Dimensions
 Confrontation: discuss patient’s behavior with empathy and respect

 Immediacy: current nurse-patient interaction

 Nurse self-disclosure: only for therapeutic goal

 Emotional catharsis: encourage patient to talk about troublesome fears, feelings

 Role playing: dialogue to develop insight and practice more adaptive behaviors
Therapeutic Impasses
 Resistance: patient reluctant/avoids verbalizing or exploring troubling aspects of
himself or herself
 Transference: unconscious patient response of feelings toward nurse originally
associated with significant others
 Countertransference: nurse’s specific emotional response to qualities of patient

 Inappropriate to content and context of relationship

 Inappropriate intensity of emotion

 Intense love or caring

 Disgust or hostility

 Intense anxiety, often in response to resistance by patient

 Can be group phenomenon

 Boundary violations of nurse

 Behavior intrusive with patients or families

 Difficulty setting limits

 Relates to patient like friend or family

 Has sexual feelings toward patient

 Feels he/she is only one who understands patient

 Too involved with patient or family

 Feels other staff too critical of patient

  Believes other staff members are jealous of his/her relationship with
patient
Types of Boundary Violations
 Intimacy and sexual boundaries

 Role boundaries

 Time boundaries

 Place and space boundaries

 Money boundaries

 Gifts and services boundaries

 Clothing boundaries

 Language boundaries

 Postdischarge social boundaries

Therapeutic Outcome
 Effectiveness of nurse-patient relationship related to:

 Knowledge base
 Clinical skills
 Capacity for introspection and self-evaluation
 Pattern of reciprocal emotions
Emotional Response of Nurse
 May bring up painful feelings

 Emotionally draining if patient expresses prolonged, intense sadness, despair, or

anger
 Working with suicidal patients can cause feelings of helplessness, intense
anxiety
 Therapeutic use of self is challenging and stressful

 Use available guidance and support

Chapter 3 - The Stuart Stress Adaptation Model of

Psychiatric Nursing Care
Stuart Stress Adaptation Model
 Basis for clinical chapters in Unit 3 of textbook

 Unified framework for practice

 Synthesizes diverse bodies of knowledge from perspective of psychiatric nursing

 Applies integrated knowledge to clinical practice

Assumption 1
 Nature is ordered as a social hierarchy from simplest unit to most complex

 Each level is an organized whole with distinct properties

 Each level is part of a higher level—not isolated
 Most basic level of nursing intervention is the individual
 Dynamic system must incorporate other levels
 Wholeness is the essence of psychiatric nursing

Assumption 2
 Nursing care is provided within biological, psychological, sociocultural, legal,
ethical, policy, and advocacy contexts
  Must understand each to provide competent, holistic care
 Includes theories from nursing science and behavioral, social, biological
sciences
Assumption 3
 Health/illness continuum distinct from adaptation/maladaptation continuum

 Health/illness continuum comes from medical world view

 Adaptation/maladaptation continuum comes from nursing world view
Assumption 4
 Prevention, treatment, and recovery described in four discrete stages

 Crisis
 Acute
 Maintenance
 Health promotion
 Create structure for documenting process and outcome of psychiatric treatment

 Include full continuum of psychiatric care in hospital, community, home settings

Assumption 5
 Model based on use of nursing process and standards of care and professional
performance
 Psychiatric nursing provided through assessment, diagnosis, outcome
identification, planning, implementation, evaluation
 Nurse responsible for all actions implemented
 Maintains professional nursing role
Conformity/Deviance
 Separate continuum from health/illness

 Unusual lifestyles not regarded as sick

 Combines into four patterns:

Criteria of Mental Health
 Positive attitudes toward self

 Growth, self-actualization, and resilience

 Integration

 Autonomy

 Reality perception

 Environmental mastery

Using Criteria of Mental Health

 Each person seen in both group and individual contexts

 Don’t use vague or ideal notions of health

 What is reasonable for a particular person?
 Is there continuity with the past?
 Does the person adapt to changing needs through the life cycle?
Mental Illness Defined
 Behavioral or psychological pattern demonstrated by an individual that causes
significant distress, impaired functioning, and decreased quality of life
 Underlying psychobiological dysfunction
  Is not the result of social deviance or conflicts with society

Dimensions of Mental Illness

 Nearly 50% of all people 18 years and older have had a psychiatric or substance
abuse disorder
 More than half of all lifetime disorders occur in 17% of the population, who have
three or more co-existing disorders
Global Burden of Disease Study
 Disabling outcomes examined in 1996

 5 of the 15 leading causes of disability in developed countries were mental

illnesses
 Unipolar major depressive disorder
 Alcohol use
 Schizophrenia
 Self-inflicted injuries
 Bipolar disorder
Magnitude of Mental Illness
 By 2020 mental disorders projected to increase

 Worldwide, major depression predicted to become second-leading

disease burden
 Mental illness impact previously underestimated

 Highlights public significance and need for mainstreaming mental health issues

Biopsychosocial Components
 Views human behavior holistically

 Includes both individual and environment

 For example:

 Man with myocardial infarction may also become severely depressed

because he fears ability to work and satisfy wife sexually
 Woman seeking treatment for major depression also may develop gastric
ulcers exacerbated by depression
Stuart Stress Adaptation Model

Predisposing Factors: Biological

 Genetic background

 Nutritional status

 Biological sensitivities

 General health

 Exposure to toxins

Predisposing Factors: Psychological

 Intelligence

 Verbal skills
  Morale

 Personality

 Past experiences

 Self-concept

 Motivation

 Psychological defenses

 Locus of control (sense of control over fate)

Predisposing Factors: Sociocultural

 Religious upbringing and beliefs

 Political affiliation

 Socialization experiences

 Level of social integration or relatedness

 Age

 Gender

 Education

 Income

 Occupation

 Social position

 Cultural background

Precipitating Stressors
 Stimuli that are challenging, threatening, or demanding to individual

 Require increased energy

 Produce tension and stress

 May originate in person’s internal or external environment

 Timing, duration, number, frequency of stressors significant

Stressful Life Event Categories

  Social activity: family, work, educational, social life, health, financial, or legal
crises
 Social field: entrance of new person into social field or exit of significant other

 Social desirability

 Favorable social event: promotion, engagement, marriage

 Unfavorable event: death, financial problems, divorce, being fired
Life Strain and Hassles
 Chronic conditions related to family tension, job dissatisfaction, loneliness

 Strife associated with marital relations

 Parental challenges associated with teenage and young adult children
 Strain related to household economics
 Overload or dissatisfaction in work role
 Small, daily hassles or strains may affect moods and health more than major
misfortunes do
Appraisal of Stressors
 Determines meaning of stressful situation’s impact for individual

 Evaluation of event’s significance to person’s well-being

 Cognitive
 Affective
 Physiological
 Behavioral
 Social responses
Cognitive Response Appraisal
 Damage and potential damage evaluated

 Situation’s power to produce harm

 Resources available to neutralize or tolerate harm
Perception of stressful life events in people with hardiness or resilience
 Commitment
  Challenge
 Control
Affective Response Appraisal
 Affective response is arousal of a feeling

 Usually nonspecific or generalized anxiety reaction, expressed as emotions

 May include joy, sadness, fear, anger, acceptance, distrust, anticipation,

or surprise
 Emotion over long period is a mood
 Prolonged mood may be considered an attitude
Physiological Response Appraisal
 Brain responses reflect interaction of several neuroendocrine hormones and
transmitters
 May include growth hormone, prolactin, adrenocorticotropic hormone
(ACTH), luteinizing and follicle-stimulating hormones, thyroid-stimulating
hormones, vasopressin, oxytocin, insulin, epinephrine, norepinephrine
 Fight-or-flight physiological response to stress affects immune system,
decreasing ability to fight disease
 Emotional and physiological responses, with cognitive analysis of stressful
situation
 Phase 1: behavior to change stressful environment or allow escape from it
 Phase 2: behavior to change external circumstances and aftermath
 Phase 3: intrapsychic behavior that defends against unpleasant emotional
arousal
 Phase 4: intrapsychic behavior that comes to terms with event by internal
readjustment
Social Response Appraisal
 Search for meaning

 Seeking information about problem

 Social attribution

 Identifying contributing factors

 Social comparison
  Comparing skills and capacities with others with similar problems
 Evaluating need for support from social network or support system
Appraisal of Stressors Is Key
 Must understand nature and intensity of stress response

 Nurses must not presume to know how certain stressors will affect patient

 Individual appraisal of stressful event is key to understanding coping efforts

 Essential part of psychiatric nurse’s assessment

Coping Resources
 Options or strategies for determining what can be done? What is at stake?

 Economic assets, abilities, skills

 Defensive techniques, social supports, motivation
 Health and energy, spiritual supports, positive beliefs
 Problem-solving and social skills
 Material resources, physical well-being
 Relationships with individual, family, group, society
Coping Mechanisms
 Efforts directed at stress management

 Problem focused (coping with threat itself)

• Negotiation, confrontation, seeking advice
 Cognitively focused (control meaning)
• Positive comparison, selective ignorance, substitution of rewards,
devaluation of desired objects
 Emotion focused (ego defense mechanisms)
• Denial, suppression, projection
Coping Mechanisms
Constructive
 Anxiety treated as warning signal

 Individual accepts it as challenge to resolve problem

  Uses past experiences to meet future threats

Destructive
 Anxiety warded off

 Conflict not resolved

 Uses evasion instead of resolution

Pattern of Response
 Based on specific predisposing factors

 Nature of stressor

 Perception of situation

 Analysis of coping resources, mechanisms

Evaluation of Coping Responses

 Evaluated on continuum of adaptation or maladaptation

 Responses that support integrated functioning are adaptive

 Lead to growth, learning, goal achievement

 Responses that block integrated functioning are maladaptive

 Prevent growth, decrease autonomy, interfere with mastery of

environment
Nursing Diagnosis
 Based on patient’s response to actual or potential stress, including:

 Clinical judgment about individual, family, or community response to

stress
 Statement of problem from nursing perspective
 Adaptive and maladaptive responses
 Contributing stressors
 Use NANDA-I–approved diagnoses

Medical Diagnoses
 Health problems or disease states of patient in medical model of psychiatry

 Mental disorders or mental illnesses

  Important to distinguish between nursing and medical models of care
Psychiatric nurses can promote patients’ adaptive responses regardless of health or
illness state

Neurosis/Neuroses
 Distressing symptom or group of symptoms

 Unacceptable and alien to individual

 Reality testing grossly intact

 Behavior does not violate major social norms

(but functioning may be impaired)
 Enduring or recurrent without treatment

 No organic cause or factor

Psychosis/Psychoses
 Regressive behavior

 Personality disintegration

 Significant reduction in level of awareness

 Great difficulty in functioning adequately

 Gross impairment in reality testing

  Presence of delusions or hallucinations without insight into their pathological
nature
 Psychotic problems most severe level of mental illness

DSM-IV-TR
 Axis I: Clinical syndromes

 Axis II: Personality disorders

 Axis III: General medical conditions

 Axis IV: Psychosocial and environmental problems

 Axis V: Global assessment of functioning

 Planning treatment, measuring its impact, predicting outcomes

 Cultural formulation

Treatment Stages
 Each stage has its own treatment goals, assessments, interventions
Chapter 5 Biological Context of Psychiatric Nursing Care
Field of Neuroscience

Neuroscience Topics
 Structure and function of brain
 Neurotransmissions: neurons communicating with each other in various brain
regions
 Involve electrical impulses, chemical messengers
 Neuroimaging techniques: brain-imaging techniques for direct viewing of
structure, function of intact, living brain
Brain Cell Networks
 Cerebral cortex: decision-making, higher-order thinking/abstract reasoning

 Limbic system: involved in regulating emotional behavior, memory, learning

 Basal ganglia: coordinate involuntary movements, muscle tone

 Hypothalamus: regulates pituitary hormones; temperature; behaviors such as

eating, drinking, sex
  Locus ceruleus: makes norepinephrine, neurotransmitter involved in body’s
response to stress
 Raphe nuclei: serotonin, neurotransmitter; regulates sleep, behavior, mood

 Substantia nigra: makes dopamine, neurotransmitter involved in complex

movements, thinking, emotions
Neuroscience Topics
 Biological rhythms and sleep affect every aspect of health, well-being

 Lifestyle, sleep, mood, eating, drinking, fertility, body temperature, menses

 Circadian rhythm: like internal clock coordinating events in body according
to 24-hour cycle
 Sleep cycles change in rhythm with light and darkness, temperature
changes
 Psychoneuroimmunology: interactions among CNS, endocrine system, immune
system, and impact of behavior/stress
 Genetics of mental illness: familial factors cause most major psychiatric illnesses

 Biological components of mental illness

 Biological assessment of patient: physical or organic disorders can significantly

complicate psychiatric status
Key Terms
 Neural plasticity: brain continues to develop and change throughout life span

 Synaptic pruning: during adolescence efficiency of brain is refined by eliminating

unneeded circuits but strengthening others
 Process allows human brain to accommodate both its genetic potential and
surrounding environmental influences
 Neurons: about 100 billion brain cells form highly specialized groups or structures

 Neurotransmission: communication of neurons through electrical impulses,

chemical messengers
Neurotransmission Review

 Like a key inserted into a lock, chemicals fit precisely into specific receptor cells
(made of protein) in axons, dendrites
  Receptor cells open or close doors (ion channels) into cell; allow interchange of
chemicals, ions, e.g., sodium (Na+),
potassium (K+), calcium (Ca+)
 Depolarization changes cell’s electrical charge

Neurotransmitter Roles
 Absence or excess can play major role in brain disease, behavioral disorders

 Single neurotransmitter can affect other brain chemicals and several different
subtypes of receptor cells in different brain regions
 Neurotransmitters can have different effects in different brain parts

Types of Neurotransmitters
 Amines

 Monoamines (norepinephrine, dopamine, serotonin, melatonin)

 Acetylcholine
 Amino acids (glutamate, GABA [gamma-aminobutyric acid])
 Peptides (endorphins, enkephalins, substance P) may affect pain transmission

Therapeutic Interventions
 Psychotropic medications, electroconvulsive therapy (ECT), alternative therapies,
cognitive behavioral therapy work by:
 Regulating neurotransmission with a chemical, electricity, or thoughts
  Facilitating normal brain communication, thus decreasing “symptoms” of
illness and enhancing “normal” behavior
 Neural tissue changes in response to external and internal stimuli (visual, tactile,
cognitive, chemical)
 Both psychotherapy and medications may improve psychiatric illnesses based on
restructuring of neural pathways
 Repairing brain tissue through both “talk therapy” and medications may provide
powerful synergy to heal brain
Understanding Neurobiological Processes
 Psychiatric nurses can:

 Recognize underlying psychiatric symptoms

 Know actions of interventions (medications, therapies)
 Make correct diagnoses
 Select effective treatments
 Maximize positive effects and minimize unwanted effects
 Predict, measure, refine outcomes
Neuroimaging Techniques
 Positron emission tomography (PET scan)

 Computed tomography (CT)

 Magnetic resonance imaging (MRI)

 Brain electrical activity mapping (BEAM)

 Single-photon emission computed tomography (SPECT)

 Starting to be used to diagnose mental illness

 Body fluids and tissues function according to circadian rhythms

 Physical and mental abilities, moods may vary widely from one time of day to
another
 To run on 24-hour clock, circadian system must have cue from external
environment
 Sunlight resets clock each day and synchronizes complex set of body rhythms

Body’s Daily Rhythms

From the Sun to the Brain

Sleep Cycles
Psychoneuroimmunology
 Research shows suppression of white blood cells and increased susceptibility to
illness after sleep deprivation, marathon running, space flight, death of spouse,
and with depression
 Natural killer (NK) cells seem to decrease in number with increasing levels of
stress; believed to play role in controlling tumors, viral infections
Genetics Key Terms
 Genome: organism’s complete set of DNA instructions

 Genes: specific sequences of bases that encode instructions on how to make

proteins
 Proteomics: explores protein structure and activities, including effects on health,
illness
 Genetic mapping, also called linkage mapping: first step in isolating a gene

Current Genetic Testing

 Several hundred genetic tests in clinical use for illnesses, including:

 Muscular dystrophies
 Cystic fibrosis
 Sickle cell anemia
 Huntington disease
 Breast, ovarian, colon cancers
Pharmacogenetics
 Blends pharmacology with genomic capabilities
  Will eventually allow researchers to match DNA variants with individual
responses to medical treatments
 Will allow for design of custom drugs based on individual genetic profiles

 Targeting drugs to specific patients may avoid unwanted side effects

Gene Therapy
 Experimental field

 Holds potential for treating or even curing genetic and acquired diseases, e.g.,
cancer, AIDS
 Uses normal genes to supplement or replace defective genes or bolster normal
functions, e.g., immunity
Genetics of Mental Illness
 Research confirms genetic transmission of mental illness

 One challenge is chronic nature of many mental illnesses with gradual increase
of symptoms
 Gradual changes in brain function may involve epigenetics, mechanisms that can
modify gene expression long-term without emending genetic code
Role of Psychiatric Nurse
 Objectively share current evidence with patients

 Remind people that information is often preliminary and growing regularly

 Convey genetic information with highest respect for patient’s and family’s
autonomy
 Consider referral to genetic counselor

Biological Assessment
 Symptoms of psychiatric vs. neurological illnesses overlap and mimic each other

 Screening for both undiagnosed physical and psychiatric disorders includes:

 Assessment of presenting symptoms

 Treatment selection
 Possible need for referral to specialist in another discipline
Biological Issues
  Undiagnosed physical illness, particularly organic brain disorders, can be costly
and dangerous if treated incorrectly
 Physical illnesses (brain tumors, endocrine disorders) can cause psychiatric
symptoms, exacerbate psychiatric illness
 Psychiatrically ill patients may be misdiagnosed in nonpsychiatric settings

Co-Morbidity
 Mortality and medical co-morbidity greatly increased among mentally ill patients

 High rates of undiagnosed and untreated physical illnesses; may lack

primary care provider
 Patients have risk factors for preventable disease: smoking, obesity,
sedentary lifestyles, poor nutrition
Role of Psychiatric Nurse
 Address mental and physical health needs when formulating assessments,
treatment plans, patient education
 Perform basic physical examination to assess for gross abnormalities

 Interpret results of more complex physical examinations

Biological Assessment
 Health care history

 General health care

 Treatments
 Brain impairment
 Cancer
 Lung and cardiac problems
 Diabetes or other endocrine disturbances
 Menstrual, sexual, reproductive histories
 Lifestyle

 Diet
 Medications and other remedies
 Substance use
  Toxins
 Occupation
 Injuries, abuse
 Physical examination

 Laboratory values

 Presenting symptoms, coping responses

 With assessment/screening, psychiatric nurses may identify overlooked physical
illnesses and refer patient for thorough diagnostic work-up

Nursing Assessment
 Obtain patient’s permission to access other people and documents to help health
care team gain information, including current medications
 Note inconsistencies in patient’s account, from others, and health care records

 Be alert for history/indications of head trauma: accidents, fevers, surgery,

seizures
 Assess appearance, gait, coordination, bilateral strength, speech, symptoms
(e.g., tremors and tics, headaches, blurred vision, dizziness, vomiting, motor
weakness, disorientation, confusion, memory problems) in detail
 Document baseline symptoms so changes may be recognized as side effects