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MENTAL HEALTH

⊗ "A state of well-being where a person can realize his or her own abilities to
cope with the normal stresses of life and work productively." (WHO)
⊗ Balance in person’s internal life and adaptation to reality. Criteria for Mental Disorder:
⊗ State of well-being in which a person is able to realize his potentials. ⊗ Dissatisfaction with:
 one’s characteristics, abilities and accomplishments
Criteria for Mental Health:  one’s place in the world
⊗ Self-awareness ⊗ Ineffective:
♦ Ability to:  interpersonal relationship
 recognize one’s thoughts feelings, asset potentials and weakness.  coping or adaptation to the events in one’s life
 experience genuine feelings as anger, happiness, resentment
 leads to self-acceptance, self-understanding in order to understand
MENTAL ILLNESS
others
⊗ A state in which an individual shows deficit in functioning and is unable to
⊗ Autonomy: ability to function independently and function with others
maintain personal relationship.
⊗ Perceptive ability
⊗ State of imbalance characterized by a disturbance in a person’s thoughts,
 Awareness of stimuli, reality orientation.
feelings and behavior
 Orientation to: Time, Place, Person
⊗ Factors that increase the risk are: Crises, Abuses, Poverty
⊗ Integral capacity: Ability to harmonize psychic forces (id, ego, super ego).
⊗ Self-actuation
 Ability to adopt to life changes, happy to work with others Historical View of Mental Illness
 Satisfaction in every endeavor ⊗ In the past, mental illness has been viewed as:
 Genuine cooperation  Demonic possession
⊗ Mastery of one’s environment: Awareness of the changes around him  Influence of ancestral spirits
 Result of violating taboo or neglecting cultural, ritual, and spiritual
condemnation
MENTAL HYGIENE ⊗ Period of Enlightenment (1745-1886)
⊗ a science that deals with: Promotive, Preventive, Curative, Rehabilitative  Lunatics were restrained in iron menacles
aspects of care.  Mentally ill were exhibited as diversion and entertainment for the
public
 Establishment of asylums
MENTAL DISORDER  Opening of state hospitals for mentally ill.
⊗ A medically diagnosable illness which results in significant impairment of ⊗ Period of Scientific Study
one's cognitive, affective or relational abilities and is equivalent to mental  Psychoanalysis by Sigmund Freud
illness.
⊗ Psychotropic Drugs (1950)
 Use of chlorpromazine and imipramine
 Mental illness is caused by chemical imbalance in the brain.

Psychiatric Nursing: Lecture Aid Page 1


⊗ The Decade of the Brain (1990)  Art - therapeutic use of self
 Focused on the connections between mental illness and biological ⊗ Clientele:
malfunction in the brain and the neuroendocrine-immune system.  Individual, family and the community
 Biological views holds that biological defects are responsible for  Both mentally healthy and mentally ill
certain serious mental illness.
Main tool of the nurse: Therapeutic use of Self

Diagnosis of Mental Illness Characteristics of a Good Psychiatric Nurse:


⊗ Use of the Diagnostic and Statistical Manual of Mental Illness (DSM-IV) ⊗ Empathy
⊗ Provides diagnostic criteria for each mental disorder and a system of 5 ⊗ Genuineness
axes to give a comprehensive view of the client’s mental illness. ⊗ Congruence
 Axis I: The clinical disorder that is the focus of treatment ⊗ Unconditional positive regard
 Axis II: Personality disorders and mental retardation
 Axis III: Medical conditions Roles of the Nurse in Psychiatric Setting:
 Axis IV: Psychosocial and environmental problems  Clinician
 Axis V: Global assessment of functioning (GAF)  Collaborator
 Counselor
 Healthy role model
PSYCHIATRIC NURSING  Parent surrogate
 Patient advocate
Importance:  Reality based
 Researcher
 Socializing agent
 Teacher
 Technician
 Therapist
 Ward manager

Levels of Interventions in Psychiatric Nursing

Level Description Examples


Primary Aimed at altering the stressors  Health education
⊗ An interpersonal process through:  Information
⊗ Concerned with all the aspects of care  promotion of mental health dissemination
⊗ Both a Science and an Art  lowering the rate of cases  Counseling
Secondary Interventions that limits the severity of  Crisis intervention
 Science – uses different theories
a disorder thorugh:  Drug administration

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 Case finding  Under 18, parents can confine with confirmation by a neutral fact
 Prompt treatment finder
Tertiary Aimed at reducing the disability after  Alcoholics  Must be released at end of statutory time or put on voluntary
a disorder through: anonymous status or have a hearing
 Prevention of complication  Occupational therapy ‘
 Active program of rehabilitation
Judicial Precedents
Unless incompetent, client maintains all previous rights
THE PSYCHIATRIC SETTING
Admitting a Client in the Psychiatric Setting

Areas to be assessed: Insanity as a Defense


⊗ Health perception ⊗ Insanity : determined in court; legal terminology
⊗ Orientation McNaughten Rule
⊗ Metabolic pattern “At the time of the crime, the individual didn’t know the nature and quality of the
⊗ Elimination pattern act or didn’t know right from wrong.”

⊗ Cognitive pattern: Judgment, Insight, Memory


COMMON BEHAVIORAL SIGNS AND SYMPTOMS
⊗ Activity and exercise pattern
⊗ Thought process Disturbance in Perception
⊗ Sleep-rest pattern ⊗ Illusion - misperception of an actual external stimuli
⊗ Hallucination - false sensory perception in the absence of external
stimuli
LEGAL ASPECTS OF PSYCHIATRIC NURSING
Management:
Types of Admissions: ⊗ Acknowledge the feelings
⊗ Voluntary ⊗ Reorient to reality
 Persons admit themselves ⊗ Provide distractions
 Client consents to all treatment ⊗ Neologism - pathological coining of new words
 Client can refuse treatment, including drugs, unless danger to self or ⊗ Circumstantiality - over inclusion of details
others
⊗ Word salad - incoherent mixture of words and phrases
⊗ Involuntary
 Judicial process ⊗ Flight of ideas - shifting of one topic from one subject to another in a
 Initiated when someone files a petition somewhat related way
 Certification of the likelihood of serious harm to self or others, or ⊗ Looseness of Association - shifting of a topic from one subject to another
unable to care for self in a completely unrelated way

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⊗ Verbigeration - meaningless repetition of word or phrases ⊗ Deja vu - feeling of having been to place which one has not yet visited
⊗ Perseveration - persistence of a response to a previous question ⊗ Jamais vu - feeling of not having been to a place which one has visited
⊗ Echolalia - pathological repetition of words of others ⊗ Dementia
⊗ Clang association - the sound of the word gives direction to the flow of • gradual deterioration of intellectual functioning
thought • results in the decreased of capacity to perform ADL
⊗ Delusion - false belief which is inconsistent with one's knowledge and
culture Other behavioral signs & symptoms
 Grandeur - is an exaggerated belief of identity ⊗ Agitation - severe anxiety associated with motor restlessness.
 Nihilistic - the client denies the existence of self or part of self ⊗ Agnosia - inability to recognize and interpret sensory stimuli.
 Persecution - belief that he or she is the object of environmental ⊗ Akathisia - subjective feeling of muscular tension, restlessness and pacing
attention and being singled out for harassment repeated sitting and standing.
 Self-depreciation - worthlessness or hopelessness ⊗ Ambivalence - presence of two opposing feelings at the same time.
 Somatic - false belief to body function.
⊗ Aphasia - inability or difficulty to speak or recall words
Disturbances of Affect ⊗ Apraxia - inability to carry out specific task or activity.
⊗ Inappropriate affect - disharmony between the stimuli and the emotional ⊗ Delirium
reaction • refers to acute change or disturbance in a person's: LOC, cognition,
⊗ Blunted affect - severe reduction in emotional reaction emotion , perception
⊗ Flat affect - absence or near absence of emotional reaction ⊗ Depression - feeling of sadness
⊗ Apathy - dulled emotional tone ⊗ Derealization - feeling of strangeness towards the environment.
⊗ Dysthymia - persistent state of sadness
Disturbances in Motor Activity ⊗ Elation (euphoria)- a feeling of high degree of confidence, boastfulness
⊗ Echopraxia - the pathological imitation of posture/action of others and joy with increase motor activity.
⊗ Waxy flexibility - maintaining the desired position for long periods of time ⊗ Narcolepsy - sleep disorder characterized by frequent irresistible urge to
without discomfort sleep with episodes of cataplexy (sudden loss of muscle power)
⊗ Akinesia - loss of movement
⊗ Bradykinesia - slowness of all voluntary movement including speech.
⊗ Ataxia - loss of coordinated movement USE OF APPROPRIATE COMMUNICATION TECHNIQUES

Disturbances in Memory Communication: reciprocal exchange of ideas between or among persons


⊗ Confabulation - filling in of memory gaps
⊗ Amnesia - inability to recall past events Modes:
• Anterograde - immediate past ⊗ Verbal - written/spoken
⊗ Non-verbal - posture, tone of voice, facial expression
• Retrograde - distant past

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Types of Non-verbal communication: ⊗ Genuineness
E
⊗ Kinesis ⊗ Respect G R A T
• body movement ⊗ Empathy
• eye contact
⊗ Attentive listening
• gestures
⊗ Trust (rapport)
⊗ Paralanguage
• voice quality
• non-language vocalization (crying, sobbing, moaning) Barriers to a Therapeutic Communication
⊗ Proxemics – law of space relationship ⊗ Belittling
⊗ Touch – physical act ⊗ Interrupting / ignoring
⊗ Cultural artifacts
⊗ Giving advice
⊗ Meta communication
• based on role expectations
⊗ Social response
• hidden meaning of words
⊗ Changing the subject
⊗ Approving / disapproving
⊗ Moralizing

Elements:

FEEDBACK Examples: Therapeutic Technique


Technique Example
Accepting Yes, that must have been difficult for you.

Message Acknowledging or giving


recognition
I noticed that you've fixed your bed.

Asking direct questions How does your wife feel about your
hospitalization?
(Channel)
(Context) Clarifying

Confronting or presenting
I'm not sure that I understand what you are
trying to say.
I see no bats flying in this room.
Therapeutic Communication: a way of interacting in a purposeful manner to reality
promote the client’s ability to express his thoughts and feelings openly. Encouraging comparison Has this ever happened before?
Encouraging description How do you feel when you take your
Essentials for a Therapeutic Communication: medication?

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Encouraging evaluation Does participating in group therapy enable you
to discuss your feelings?
Exploring Tell me more about your job. Would you
describe your responsibilities?
Focusing (assisting a patient to explore specific topic)
Giving broad openings or Is there something you'd like to do?
asking open-ended Hildegard Peplau
questions
Informing (giving needed facts) Phases:
I'll be your nurse for today, from 7:00 until 3:00
this afternoon. Pre-Interaction Phase
Making observations You appear to be angry. / I noticed that you're ⊗ begins when the nurse is assigned/chooses a patient
trembling. ⊗ patient is excluded as an active participant
Offering general leads Go on. / You were saying… ⊗ nurse feels certain degree of anxiety
Restating Client: I can't sleep, I stay awake all night. ⊗ includes all of what the nurse thinks and does before interacting with the
Nurse: You can't sleep at night, (restating) patient
Summarizing During the past hour, we talked about your plans ⊗ develop self-awareness
for the future, they include...
⊗ data gathering, planning for first interaction
Using silence (to induce thought, pacing, acceptance)
Validating (confirming one's observation)
“So you mean . . .”
Voicing doubt I find that hard to believe.
Examples: Non-therapeutic Technique and Ineffective Communication
Agreeing and disagreeing “I think you did the right thing.” Orientation phase
Advice “You should.….” ⊗ when the nurse-patient interacts for the first time
Belittling "Don't be concerned, evervone feels like that".
⊗ establish of contract with the patient
Defending "All doctors here are simply great".
False reassurance "Don't worry, everything will be all right". ⊗ establish of trust and rapport
Focus on caregiver’s “I feel that way too.” ⊗ learn about the patient and his initial concerns and needs
feeling ⊗ encourage the patient to feel comfortable with the meeting
Judging "It's your own mistake". ⊗ conduct initial interview
⊗ manage present emotion of the patient
NURSE – PATIENT RELATIONSHIP ⊗ provide support and empathy of the patient’s feelings
⊗ assure of confidentiality

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Working / Therapeutic Phase:
⊗ it is highly individualized
⊗ identification and resolution of the patient's problems
⊗ more structured than the orientation phase
⊗ the longest and most productive phase
⊗ limit setting must be employed
⊗ planning and implementation

Problems:
⊗ Transference
 the development of an emotional attitude towards the nurse
 positive or negative
⊗ Counter transference – experienced by the nurse / therapist 3 Psychic Energies

Termination Phase
⊗ Evaluate the summary of progress
⊗ Reinforce change and strength of patient
⊗ Give rewards for the cooperation during interaction
⊗ Encourage expression of feelings about termination of the relationship
⊗ Terminate the relationship without giving promises

THEORIES OF HUMAN DYNAMICS ⊗ Libido - are the instinctual drives


⊗ Regression and fixation are common terms in this theory.
Psychosexual Development : Sigmund Freud ⊗ Gave prominence to sexual feelings: defined "sex" as anything that gives
gratification
Levels of Consciousness

Stages:

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Oral Stage (0-2 years) ⊗ Oedipus complex
⊗ The area of gratification is the mouth ⊗ Electra complex
⊗ Pleasures: sucking activities like fingers, toes or nipples ⊗ Concepts
⊗ Dissatisfaction: resurface at a later  Onset of “normal homosexuality”
 overeating, smoking, nail-biting
Nursing implications:
Nursing Implication: ⊗ Accept child's sexual interest
⊗ Provide oral stimulation by giving pacifiers ⊗ Help the parents answer child's questions about birth or sexual differences.
 Breastfeeding may provide more stimulation.
⊗ Do not discourage thumb sucking Latency Stage (6 to 12 years)
⊗ Period of calmness / stable period.
Anal Stage (2-4 years) ⊗ Many of the disturbing behaviors are buried in the subconscious mind.
⊗ Children's attention is focused on the anal region. ⊗ Their energies are absorbed by the concerns in school, peers, sports and
⊗ Pleasure: elimination. other recreational activities
⊗ Covers the ideal age for "toilet training" (2 1/2 years)
⊗ 2 concepts: Nursing Implication: Help the child have positive experiences.
 Holding on
 Letting go Genital Stage (12 years & up)
⊗ Oedipal feelings are reactivated toward opposite sex
Possible problems: ⊗ The person is on his way in establishing a satisfying life of his own
⊗ Compulsive need to be clean and orderly.
⊗ Frugality and stinginess Nursing Implication:
⊗ Greed ⊗ Provide appropriate opportunities for the child to relate with opposite sex.
⊗ Insistence on doing things at one's own rate at the expense of others ⊗ Allow child to verbalize feelings about new relationships.
⊗ Rigid training
⊗ Excessive messiness and disorderly habits. Psychosocial Development Theory: Erik Erikson
Nursing Implication: Help children achieve bowel and bladder control without ⊗ Childhood is very important in personality development.
undue emphasis on its importance.
⊗ Rejected Freud's attempt to describe personality solely on the basis of
sexuality,
 believed that social factors greatly affect
 felt that personality continued to develop beyond five years of age.
Phallic Stage (4-6 years)
⊗ Pleasure: genital region.
 activities associated with stroking and manipulating their sex organs. Identified 8 developmental stages throughout the whole life cycle.
⊗ Stages 1-5 - childhood and adolescent

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⊗ Stages 6-8 - Adulthood Period of Life Preschool, 3 to 6 years (Purpose)
Psychosocial Crisis Initiative vs. Guilt
Stages:
Relationship with Family
Stage 1: Positive Resolution The ability to learn to initiate activities, to enjoy
Period of Life Infant, 0-18 months, (Hope) achievement and competence
Negative Resolution o The inability to control newly developed power
Psychosocial Crisis Trust vs. Mistrust
o Realization of potential failure leads to fear of
Relationship with Maternal person punishment and guilt
Positive Resolution o Reliance on the caregiver
o Development of trust in the environment Stage 4
Negative Resolution o Fear, anxiety and suspicion Period of Life Schooler, 6 to 12 yrs. (Competence)
o Lack of care, both physical & psychological by Psychosocial Crisis Industry vs. Inferiority
caretaker leads to mistrust of environment Relationship with Neighbors/School
Positive Resolution o Learning the value of work
Stage 2: o Acquiring skills and tools of technology
Period of Life Toddler, 18 mos. to 3 years o Competence helps to order life and make things
(Willpower) work
Psychosocial Crisis Autonomy vs. Shame/doubt Negative Resolution Repeated frustrations and failures lead to feelings of
Relationship with Paternal person inadequacy and inferiority that may affect their view of
Positive Resolution o Sense of self-worth life
o Assertion of choice and will
o Environment encourages independence, leading to Stage 5:
sense of pride Period of Life Adolescent, 12 to 18 yrs, (Fidelity)
Negative Resolution o Loss of self-esteem Psychosocial Crisis Identity vs. Role confusion
o Sense of external control may produce self-doubt in Relationship with Peer group
others Positive Resolution Experiments with various roles in developing mature
individuality
Negative Resolution Pressures and demands may lead to confusion about
self

Stage 6:
Period of Life Young Adult, 18 to 54 yrs., (Love)
Stage 3:
Psychosocial Crisis Intimacy vs. Isolation

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Relationship with Partners in friendship ⊗ Words become symbols for objects – symbolic thinking
Positive Resolution o A commitment to others ⊗ Formation of ideas of categorization.
o Close heterosexual relationship and procreation ⊗ Lack of ability to go back and rethink a process or concept.
Negative Resolution Withdrawal from such intimacy, isolation, self- ⊗ Mental image – the symbolic process which are evident in plays
absorption and alienation from others ⊗ Construction of verbal schemas – preconcepts
Stage 7:
Period of Life Middle Adult, 24 to 54 yrs., (Care) Concrete Operations (7 – 11 years)
Psychosocial Crisis Generativity vs. Self-absorption ⊗ Thinking appears to be stabilized
Relationship with Partner o ability to think of the possible consequences of actions
Positive Resolution o The care and concern for the next generation ⊗ Logical implications
o Widening interest in work and ideas
Formal Operations
Negative Resolution Self-indulgence and resulting psychological
(11 years to adulthood)
impoverishment
⊗ Full patterns of thinking
Stage 8:
Period of Life Late Adult, 54 yrs. to death, (Wisdom) ⊗ Ability to use logic and symbolic processes
Psychosocial Crisis Integrity vs. Despair o mathematical and scientific reasoning
⊗ Combinatorial thinking - multidimensional approach
Relationship with Mankind
o hypothetic or hypothetico-deductive reasoning
Positive Resolution o Acceptance of one’s life
o Realization of the inevitability of death
o Feeling of dignity and meaning of existence Moral Development Theory: Laurence Kohlberg
Negative Resolution Disappointment of one’s life and desperate fear of
death Level One Stage 1
(Preconventional Morality) • Behavior is based on the desire to avoid
Cognitive Development Theory: Jean Piaget • Children’s judgments severe physical punishment by a superior
are based on external power.
Stages: criteria. • Right or wrong is based on consequences to
• Standards of right and him.
Sensorimotor (0-2 years)
wrong are absolute and • Punishment = wrong act
⊗ Reflex to complex
laid down by authority.
⊗ Begins to organize visual images and control motor responses. Level Two (Conventional Stage 2
⊗ Coordinates sensory impressions. Morality) • Actions are based largely on satisfying one’s
⊗ Pre-verbal stage • Children’s judgments own personal needs.
are based on the norms Stage 3
Preoperational Stage (2-7 years) and expectations of the • Good behavior is that which pleases others
⊗ Transitional period group. and judgments are based on intentions.
⊗ Egocentric and irreversible thinking • Children conform to rules to win the approval

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of others and to maintain good relationships. ⊗ Hierarchy of needs in order of importance
Stage 4 ⊗ Primary needs (physiologic) need to be met prior to dealing with higher
• What is right is what is accepted.
level needs.
If the social accepts rules as appropriate for all
group members, children will conform to them to
Psychobiologic Model
avoid social disapproval and censure
Level Three Stage 5 ⊗ Focus is in mental illness as a biophysical impairment.
(Post Conventional • Behavior recognizes the laws as arbitrary ⊗ Human behavior is influenced by genetics, biochemical alterations and
Morality) and changeable. function of brain and CNS.
• The individual • For aspects of life not governed by laws, ⊗ The stress response is a neuroendoctine response.
recognizes the right and wrong are personal decisions
arbitrariness of social based on agreement and contracts. Important structure (limbic system):
and legal conventions. Stage 6 ⊗ Thalamus – regulates activity, sensation, emotion
• The individual attempts • Morality is based on respect for others ⊗ Hypothalamus – themoregulation, appetite control, endocrine function,
to define moral values rather than on personal desires. appetite control, impulsive behavior associated with feelings of anger, rage
that are separate from • The individual conforms to both social or excitement.
group norms. standards and to internalized ideals to ⊗ Hippocampus and amygdale – emotional arousal and memory
avoid self-condemnation rather than to ⊗ Neurons – basic functioning unit of the CNS
avoid social censure. ⊗ Neurotransmitters
 Chemical substances manufactured in the neuron
Other Theories  Aid transmission of information throughout the body
⊗ Dopamine
Behavioral Model (Ivan Pavlov, John Watson, B. F. Skinner)  An excitatory neurotransmitter
⊗ Behavior is:  Located primarily at the brain stem
• a response to a stimulus from the environment  Involved in control of complex movements, motivation, cognition and
regulation of emotional responses
• learned and retained by positive reinforcement  Associated with pyschosis and Parkinson’s disease
⊗ Catecholamines (norepinephrine and epinephrine)
Interpersonal Model (Harry Stack Sullivan)
⊗ Norepinephrine
⊗ Focused on the role of the environment and interpersonal relations as  Attention, learning and memory, sleep and wakefulness
the most significant influences on a individual’s development.  Excess of this is associated with anxiety, memory loss, social
⊗ Anxiety is communicated interpersonally. withdrawal and depression.
⊗ Epinephrine – responsible in the fight or flight mechanism
⊗ Serotonin
 An inhibitory neurotransmitter
 Derived from tryptophan
Human Motivational Need Model. (Abraham Maslow)

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 Involved in control of food intake, sleep and wakefulness, pain • Ideal number :8-10
control, sexual behavior and emotions
 Involved in anxiety and mood disorders, schizophrenia and its • Advantages:
symptoms o decreases isolation
⊗ Histamine o decreases dependence
 Primarily involved in immunity and allergic reactions o develops coping skills
 Some psychotropic drugs are block by histamine o develops interpersonal learning
⊗ Acetylcholine o develops opportunities for helping others
 Affects sleep-wake cycle o develops ability to listen to other members
 Associated with Alzheimer’s disease
⊗ Glutamate ⊗ Remotivation Therapy: Promotes expression of feeling through interaction
 An excitatory neurotransmitter facilitated by discussion of neutral topics
 At high levels, it can cause neurotoxicity. ⊗ Family therapy: A method in which family members gain:
 Associated with Alzheimer’s and Huntington’s disease o insight into the problems
⊗ Gama-Aminobutyric Acid o improve communication
 An inhibitory neurotransmitter o improve functioning of individual members as well as the family as a
 Associated to treat anxiety and induce sleep. whole.
o It focuses on the total family as an interactional system
⊗ Milieu Therapy
PSYCHOTHERAPY • A therapeutic environment is organized to:
o encourage and assist the client to control problematic behavior
⊗ Is a process in which a person enters into a contract to interact with a o function within the range of social norms
therapist to relieve symptoms, resolve problems in living, seek personal ⊗ Play therapy
growth
• Effective for children suffering from maladjustment or behavior disorder.
• The child is usually placed in a play room
INDIVIDUAL THERAPY: Is a confidential relationship between client and • Purpose - to discover the causes of the child's conflict through
therapist. observation of his play and to interpret it to the child.
⊗ Hypnotherapy: Involves various methods and techniques to induce a ⊗ Recreational therapy
trance state where the patient becomes submissive to instructions • Uses activities which vitalize the patient's interest and help him or her to
⊗ Humor therapy: Use of humor to facilitate expression of feelings and to relax and feel refreshed.
enhance interaction • Example: Playing baseball may be prescribed for as a means of
⊗ Psychoanalysis: Focuses on the exploration of the unconscious, to expressing hostility in a group.
facilitate identification of the patient's defenses ⊗ Occupational therapy: Uses any mental or physical activity prescribed or
guided to aid an individual's recovery from a disease or injury.
GROUP THERAPY ⊗ Musical therapy
• minimum number : 3

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• Involving the music which allows the child or adolescent to express o Teaches the client to control or change aspects of their internal
herself or himself. environment.
• Also effective with those who have difficulty communicating. • Aversion therapy
⊗ Art therapy: Clients are encouraged to express their feelings or emotions o Uses unpleasant or noxious stimuli to change inappropriate
by painting, drawing or sculpture. behavior.
⊗ Psychodrama therapy: Patients dramatizes their emotional problems in a o Examples
group setting. o Antabuse to treat alcoholics
⊗ Behavior Therapy o Showing films to drivers who are arrested for speeding or driving
• Is a mode of treatment that focuses on modifying observable (overt) and while under the influence of alcohol or drugs.
• Assertiveness Training
quantifiable behavior
• Systematic manipulation of the environment and variables thought to be o Clients are encouraged and taught how to appropriately relate to
functionally related to the behaviors. others
o Teaches the individual to ask for what is beneficial to both mentally
• Limit Setting ill and mentally healthy persons.
o Therapist gives an advanced warning of the limit and the • Token-economy: Utilizes the principle of rewarding desired behavior to
consequences will follow if the client does not adhere to the limit. facilitate change.
o The consequences should occur immediately after the client has
exceeded the limit ELECTROCONVULSIVE THERAPY (ECT)
o Consistency must occur with all personnel. • Exact mechanism is unknown
o Purposes: • Requires a consent
o Minimizes manipulation and splitting of the staff. • Usually given at 70-150 volts for about .5-2 seconds
o Provide a framework for the client to function in and enable a • Effectivity: 6-12 treatments with at least 48 hour interval
client to learn to make requests. • Indicator of effectiveness: tonic-clonic seizure
• Systematic Desensitization Indications of use:
o Clients are exposed slowly to a feared object or a thing that inhibits • Depression
anxious responses and taught ways to relax. • Mania
o Effective in treating phobias. • Catatonic schizophrenia
• Implosive therapy Contraindications (not absolute)
o The clients are exposed abruptly to intense forms of anxiety • Fever • Unhealed fracture
producers, either in imagination or in real life • Increased ICP • Retinal detachment
• Cognitive Behavior therapy • Cardiac conditions • Pregnancy
o Uses confrontation as a means of helping the clients restructure or • TB with history of hemorrhage
rearrange irrational beliefs, maladaptive thinking, perception-, and
behaviors. Before the procedure:
o Used for depression and adjustment difficulties. • Diagnostic procedures
• Biofeedback o X-ray

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o ECG Advise gradual change in position
o EEG Extra Pyramidal Symptoms Report at once
• Drugs given o Pseudoparkinsonism
o Atrophine sulfate (decrease secretions) o pill-rolling tremors
o Anectine (Succinylcholine) – relax muscles mask-like face
o Methohexital Na (Brevital) - anesthetic o cog-wheel rigidity
During the procedure: o propulsive gait
• Observe for tonic-clonic seizure o Akathisia - restless leg syndrome
After the procedure: o Dystonia - defect in muscle tone
• Position
• Check vital signs Adverse effect: report promptly
• Reorient the client • Tardive dyskinesia - lip smacking
• Watch out for complications: • Agranulocytosis
o Memory loss o Assess for:
o Headache  Fever
o Apnea  Sore throat
o Respiratory depression  Lab data: WBC count
o Fracture • Hepatotoxicity
o Assess for ALT & AST
BASIC CONCEPTS ON PSYCHOPHARMACOLOGY
MINOR TRANQUILIZERS/ ANXIOLYTICS
MAJOR TRANQUILIZERS/ ANTIPSYCHOTICS ⊗ Common indication: Anxiety disorders
⊗ Indication: Schizophrenia and Other Psychosis ⊗ Desired Effect: Decreased anxiety, adequate sleep
⊗ Desired effect: control of symptoms
⊗ Best taken after meals Examples:
• Diazepam (Valium) • Chlorazepate Dipotassium
Examples: • Oxazepam (Serax) (Tranxene)
• Haloperidol (Haldol) • Fluphenazine (Prolixin) • Chlordiazepoxide (Librium) • Alprazolam (Xanax)
• Prochlorperazine (Compazine) • Chlorpromazine (Thorazine)
Nursing Implications:
Side effects: Nursing Action • Best taken before meals
Blurred vision Avoid driving • Advise to avoid driving
Dry mouth Give sugarless gum • Avoid alcohol and caffeine-containing foods
Tachycardia, palpitation, constipation, Monitor & report • Administer it separately with any drug
urinary retention
Photosensitivity Don’t expose skin to sunlight
Orthostatic hypotension Monitor BP ANTIDEPRESSANTS

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Desired effects: increased appetite, adequate sleep ⊗ There should be at least a two-week interval when shifting from one anti-
depressant to another

Tricyclic Antidepressants Selective Serotonin Reuptake Inhibitors

Examples: Examples:
• Imipramine (Tofranil) • Amitriptyline (Elavil) • Fluoxetine (Prozac) • Paroxetine (Paxil)
• Celatopram (Celexa) • Fluvoxamine (Luvox)
Nursing Implications: • Sertraline (Zoloft)
⊗ Best given after meals
⊗ Effectivity: after 2-3 weeks
⊗ Check the BP, it causes hypotension
⊗ Check the heart rate, it causes cardiac arrythmias
⊗ Monitor I & O Nursing Implications:
⊗ Monitor for signs of increased IOP ⊗ Avoid the use of:
• diazepam
• Alcohol
MAO INHIBITORS • Tryptophan
Indication: refractory depression • Monitor PTT, PT
⊗ Never give to pregnant / lactating mothers.
Examples:
• Tranylcypromine (Parnate)
• Phenelzine (Nardil)
• Isocarboxazid (Marplan) PaN aM a ANTI-MANIC AGENT

Examples:
Nursing Implications: • Lithium Citrate (Cibalith – S) • Lithium Carbonate (Eskalith,
⊗ Best taken after meals Lithane, Lithobid)
⊗ Report headache; it indicates hypertensive crisis
⊗ Avoid tyramine containing foods like: Nursing implications:
• Avocado ⊗ Best taken after meals
• Banana ⊗ Increase intake of:
• Cheddar and aged cheese • fluids (3 L /day)
• Soysauce • sodium (3 gm/day)
• Preserved foods ⊗ Avoid activities that increase perspiration
⊗ Effectivity: 2-3 weeks ⊗ Never give to pregnant mothers
⊗ Monitor the BP ⊗ Effectivity: 10-14 days

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⊗ Antipsychotic is administered during the first 2 weeks o Acute phase of the syndrome
⊗ Therapeutic level:.5-1.5 meq/L o Characterized as the “flight and fight” reaction
⊗ If ineffective: Tegretol o Defensive by nature but self-limiting
o If stress is intense, it may lead to death.
⊗ Signs of toxicity:
o Vomiting • Resistance
o Anorexia o Characterized as the state of adaptation
o Nausea o Person moves back to homeostasis
o Diarrhea • Exhaustion
o Abdominal cramps o Result of a prolonged exposure to stress and adaptive mechanisms can
no longer persist.
o Lightheadedness (late)
⊗ Antidote: Mannitol Local Adaptation Syndrome
• Refers to inflammatory response and repair processes that occur at the
local site of tissue injury.

STRESS
Eustress - positive stress
• A nonspecific response of the body to any demand made upon it. (Hans
Selye, 1936) Distress
• A state produced by a change in the environment that is perceived as • Negative stress
challenging, threatening or damaging to the person’s dynamic equilibrium.
• Damaging stressors which may result in various physical and emotional
(Smeltzer, 1992)
disorders such as: anxiety, frustration, insecurity, aimlessness
Adaptation
CRISIS AND CRISIS INTERVENTION
• A constant ongoing process that occurs along time continuum, beginning • A situation that occurs when an individual's habitual coping ability becomes
with birth and ending with death. (Smeltzer, 1992)
ineffective to meet the demands of a situation.
• A continuous process of seeking harmony in an environment. • As a serious interruption and disturbance of one's equilibrium or
homeostasis
Types of Adaptation: • Leads to potentially dangerous, self-destructive or socially unacceptable
behavior.
General Adaptation Syndrome (GAS)
• Involves the whole body in response to stress. Characteristics
• Compared to life process as it focuses on the “wear and tear of the body • Highly individualized
tissues. • Self-limiting: 4-6 weeks
• Person affected becomes passive and submissive
Phases:
• Alarm • Affects a person’s support system

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• Nonconsensual sexual penetration of an individual, obtained by force or
Type Description Example threat, or in cases in which the victim is not capable of consent.
Maturational/developmental expected, predictable Puberty, adolescence,
crisis and internally young adulthood, Kinds of Rape
motivated marriage, or the aging • Power – to prove masculinity
process. • Anger – means of retaliation
Situational/accidental Unexpected, Economic difficulty,
• Sadistic – to express erotic feelings
unpredictable and illness, accident, rape,
externally motivated divorce or death
Silent Rape Syndrome
• Is a maladaptive reaction to rape
Social crisis Due to acts of nature Natural calamities
• The victim:
• fails to disclose information about the rape
• is unable to resolve feelings about the sexual assault
• Results to increase anxiety and may develop a sudden phobic reaction.

Phases
• Denial
• Increased Tension Rape Trauma Syndrome (RTS)
• Disorganization • Refers to a group of signs and symptoms experienced by a victim in
• Attempts to reorganize reaction to rape
• Stage for full reorganization
Phases:
• Acute Phase – shock, numbness, disbelief
CRISIS INTERVENTION • Denial – refusal to discuss the event
• Major Goal: • Heightened Anxiety – fear, tension, nightmares
o Restore the maximum level of functioning (pre-crisis state) • Stage of Reorganization
o It is an active but temporary entry into the life situation of an individual
or a family during a period of stress.
o A way of entering into the situation to help them mobilize their resources Battered Wife Syndrome (BWS)
and to decrease the effect of stress. • A form of cyclic domestic violence
• Men: low self-esteem
Domestic Violence Requiring Crisis Intervention: • Women: Dependent personality disorder

RAPE

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• They have negative attitude towards the management of the abused

Warning signs of Child Abuse / Neglect:


• Child’s excessive knowledge on sex and abusive words
• Hair growth in various lengths
• Inconsistent stories from the child and parent/s
• Low self-esteem
• Depression

• Apathy
• Bruised or swollen genitalia; tears or bruising of rectum or vagina
• Unusual injuries for the child’s age and development
Child Abuse • Serious injuries (fractures, burns, lacerations)
• Is an act of omission of responsibility or commission in which intentional • Evidence of old injuries not reported
harm is inflicted on a child.
Republic Act 7610
Components of Omission: (Anti Child Abuse Law)
• Child abandonment – leaving the child physically • Required reporting of suspected cases
• Child neglect - lack of provision of those things which are necessary for the • Report cases to the nearest authorities within 48 hours
child's growth and development

Types of Commission:
Physical Abuse
• Is an intentional physical harm inflicted on a child by a parent or other Assessment, Planning and Nursing Actions for Crisis
person. • Primary concerns:
o Physical injuries
Emotional abuse - insult and undermining one's confidence o Alleviation of psychological trauma
• Nurse should display:
Sexual abuse - abuse in the form of sexual contact o Sensitivity
o Attitude (Nonjudgmental)
Characteristics of Abusive Parents: o Confidentiality
• They come from violent families o Respect
• They were also abused by their parents o Empathy
• They have inadequate parenting skills o Dignity
• They are socially isolated because they don't trust anyone • Evidences are important:
• They are emotionally immature o stained clothing

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o fingernail scrapings • Displacement
o mouth or anal smears containing semen o the redirection of feelings to a less threatening object
• Intervention focuses family as a unit. o An adolescent boy, after an argument with his father, goes to the room
• If the victim is a child: Play and art therapy and kicked his room’s door.

• Fantasy
o Conscious distortion of unconscious feelings or wishes
DEFENSE MECHANISM o A boy who is being bullied by his friends wished he had the power of
Wolverine.
• These are automatic and usually unconscious processes or act by the
individuals to: • Fixation
o reduce or cope anxiety or fear o An unhealthy mechanism which is an arrest of maturation at certain
o resolve emotional or mental conflict stages of development.
o protect one's self-esteem o A boy never overcame being fully reliant from his mother.
o protect one's sense of security
• Becomes pathologic when overused. • Introjection
• Used by both mentally healthy and mentally ill individuals o Symbolic assimilation or taking into oneself a love/hatred object.
Derived from the word "introject" which literally means to take into or
Common Defense Mechanisms Used: ingest.
• Compensation o Common to depressed clients.
o An attempt to overcome a real or imagined short coming, inferiority,
inabilities and weaknesses. • Identification
o A blind woman becomes proficient in playing piano. o An individual integrates certain aspects of someone else's personality
into one's own.
o A young school teacher adopts his former mentor's teaching style when
conducting class sessions.
• Conversion
o Emotional problems are converted to physical symptoms
o A student unprepared for a report suffered headache the day she is • Intellectualization
supposed to deliver her report. o An overuse of intellectual concepts by an individual to avoid expression
of feelings
• Denial o A man who was asked to share a memorable experience about his
o Failure to acknowledge an intolerable thought, feeling, experience or grandmother who died discussed the stages of death and dying by
reality Elizabeth Kubler Ross.
o A middle-aged man after being admitted to the CCU because of an AMI,
insists that he is in the hospital for just a diagnostic work-up. • Projection
o Attributing to others one's unconscious wishes/fear.

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o Literally, this means to "throw off.
o A student who failed a subject blames his failure on poor teaching. • Substitution
o Replacing the desired unattainable goal with one that is attainable
• Reaction – Formation o A woman who failed the nursing board exam 3 times, worked as a
o Expression of feeling that is the direct opposite of one's real feeling. nursing aide just to be in the hospital.
o Also referred to as overcompensation.
o A student who dislikes one of her classmates may act or show concern • Sublimation
toward her. o The redirection of unacceptable instinctual drive with one that is socially
acceptable
• Rationalization o Instead of harming his mother, a man expressed his anger by
o An individual finds a justifiable cause and acceptable reasons just to be composing a song.
saved from an embarrassing and anxiety producing thoughts or
situations. • Symbolization
o A basketball player claims that he missed the shot and lost the game o Less threatening object is used to represent another
because of the distractions made by the audience. o A woman, missing her husband finds comfort in hugging her son who
looks like his father.
• Regression
o Is the turning back to earlier patterns of behavior in solving personal • Undoing
conflicts. o An attempt to erase an act, thought, feeling, guilt or desire
o Commonly seen to schizophrenic patients o A man gives her wife a bunch of roses after their argument last night.
o A person who becomes ill in the face of disappointment has regressed
to a form of childish behavior.

• Repression
o It is the involuntary or unconscious forgetting of an unpleasant ideas or
impulses.
o During the nurse-patient relationships, patients often unconsciously
avoid discussing those experiences producing anxiety which are
emotionally difficult to verbalize.

• Suppression
o Permits the individual to store away or consciously forget the
unpleasant, painful and unacceptable thoughts, desires, experiences
and impulses.
o "I'll think it about tomorrow", "I'd rather go now", "Can we change the
topic?"
o A boy walked out from the group and said "I have to go now", when he
was asked what was happened to their relationship with his girlfriend.

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