Learning Objectives

At the end of the discussion, you should be able to:

1.Understand the principles of psychiatric nursing care,

including:
 - Mental Health and Mental Illness
 - Competent Psychiatric Nursing Care
 - Therapeutic Nurse-Patient Relationship

2.Apply the principles in nursing practice. This

 includes:
 - Anxiety Disorders
 - Somatoforn Disorders

 - Mood Disorders
 - Suicidal Behavior
 - Schizophrenia and Psychotic Disorders
 - Personality Disorders
 - Substance-Related Disorders
 - Eating Disorders
 - Sexual Disorders
3. Identify the nursing roles in psychopharmacology and
electroconvulsive therapy, cognitive behavioral therapy,
and therapeutic groups.
Mental Health
A lifelong process of successful
adaptation to a changing internal and external
environment.

Mental Illness
The loss of ability to respond to the
environment in ways that are in accord with
oneself or the expectations of society.
Competent Psychiatric Nursing
Three Domains of Contemporary Psychiatric Nursing
Care
Practice:

Direct Care Communication

Management
Therapeutic Nurse-Patient Relationship
 This is a mutual learning experience and
corrective emotional experience for the patient.

Goals of Therapeutic Relationship:

1. Self-realization, self-acceptance, and an increased

genuine self-respect.

2. A clear sense of personal identity and an improved

level of personal integration
3. An ability to form an intimate, interdependent,
interpersonal relationship with a capacity to give
and receive love.

4. Improved functioning and increased ability to

satisfy needs and achieve realistic personal goals.
SELF-AWARENESS
Phases of the Nurse-Patient Relationship

1. Pre-interaction Phase

2. Introductory or Orientation Phase

3. Working Phase

4. Termination Phase
Nurse’s Tasks in Each Phase

1. Pre-interaction Phase

 - Explore own feelings, fantasies, and fears.

 - Analyze own professional strengths and
 limitations.
 - Gather data about patient when possible.
 - Plan for first meeting with patient.
Nurse’s Tasks in Each Phase

2. Introductory or Orientation Phase

 - Establish trust, acceptance, and open

 communication.
 - Mutually formulate a contract.
 - Explore patient’s thoughts, feelings, and
 actions.
 - Identify patient’s problems.
 - Define goals with patient.
Nurse’s Tasks in Each Phase

3. Working Phase

 - Explore relevant stressors.

 - Promote patient’s development of insight and
 use of constructive coping mechanisms.
 - Overcome resistance behaviors.
Nurse’s Tasks in Each Phase

4. Termination Phase

 - Establish reality of separation.

 - Review progress of therapy and attainment
 of goals.
 - Mutually explore feelings of rejection, loss,
 sadness, and anger and related behaviors.
 Patient: (Shifting nervously in his chair, eyes scanning
Facilitative Communication
the room and avoiding the nurse) What… what do you
want to talk about today?

Possible Nurse Responses:

1.I sense that you are uncomfortable to me. Could you
describe to me how you are feeling?

2. You’re not sure what we should be talking about, and you

want me to start us off?

3. You look very nervous, and I can feel those same feelings
in me as I sit here with you.
Therapeutic Communication
Techniques
 Listening

 Broad Opening – patient select topic

 Restating – repeating the main thought

 Clarification – attempting to put into words vague

ideas or unclear thoughts

 Reflection – directing back patient’s ideas, feelings,

questions, or contents
 Informing

 Focusing – questions that help patient to expand on a

topic

 Sharing Perceptions – asking patient to verify nurse’s

understanding of what he/she feels

 Theme Identification – underlying issues or problems

that emerge repeatedly during the nurse-patient
relationship

 Suggesting – presentation of alternative ideas

Anxiety Disorders
 Anxiety is a diffuse apprehension that
is vague in nature and associated with
feelings of uncertainty and helplessness.

Levels of Anxiety:
 Mild Anxiety
 - tension of day-to-day living
 - person is alert and the perceptual field is
 increased
 - motivates learning and produce growth and
 creativity

 Moderate Anxiety
 - person focuses only on immediate concerns
 - narrowing perceptual field
 - blocks selected areas but can attend to
 more if directed to do so

 Severe Anxiety
 - significant reduction in perceptual field
 - person focuses on specific detail and not
 think about anything else
 Panic
 - associated with awe, dread and terror
 - details are blown out of proportion
 - there is increased motor activity,
decreased
 ability to relate to others, distorted
 perceptions, and loss of rational thought
 - incompatible with life
Patient behaviors related to anxiety include:

 Physiological

 Behavioral

 Cognitive

 Affective
Coping Mechanisms

 Task-Oriented Reactions
 - thoughtful, deliberate attempts to solve
problems, resolve conflicts, and gratify needs.

 Ego-Oriented Reactions
 - first line of psychic defense.
Unconscious Ego Defense Mechanisms
 Compensation – makes up for a perceived deficiency by strongly emphasizing
a feature that he/she regards as an asset.

A high school student too small to play football

becomes the star long-distance runner for the track team.

Denial – avoidance of disagreeable realities by

ignoring or refusing to recognize them
A woman, though told her father has metastatic
cancer, continues to plan a family reunion 18 months in
advance.
Displacement – shift of emotion from a person or
object to another.
A husband and wife are fighting, and the husband
becomes so angry he hits a door instead of his wife.

Identification – a person tries to become like

someone he or she admires.
A new graduate suddenly left in charge emulates
her faculty role model.

Introjection – intense identification in which a

person incorporates qualities or values of another
person.
A 7-year-old tells his little sister, “Don’t talk to
strangers.”
Intellectualization – excessive reasoning or logic
is used to avoid experiencing disturbing feelings.

The pain over a parent’s sudden death is reduced by

saying, “He wouldn’t have wanted to live with a disability.”

Rationalization – offering a socially acceptable

explanation to justify unacceptable impulses,
feelings, or behaviors.
John fails an examination and complains that the
lectures were not clearly presented.
Reaction Formation – development of conscious
attitudes that are opposite to what one really feels
or would like to do.
A married woman who feels attracted to one of her
husband’s friends treats him rudely.
Isolation – splitting off of emotional components
of a thought
A second-year medical student dissects a cadaver
without being disturbed by thoughts of death.

Projection – attributing one’s thoughts to another

person.
A young woman who denies she has sexual feelings
about a co-worker accuses him without basis of trying to
seduce her.

Sublimation – displacement of primitive sexual

drives to a more socially acceptable activities.
A person with excessive sexual drives invests
psychic energy into a well-defined religious value system.
Repression – involuntary exclusion of a painful
memory.
Mr. R does not recall hitting his wife when she was
pregnant.

Undoing – act or communication that partially

negates a previous one.
A father spanks his child and the next evening
brings home a present for him.
Anxiety Disorders
 Generalized Anxiety Disorder

 Obsessive Compulsive Disorder

 Panic Disorder with or without agoraphobia

 Posttraumatic Disdorder
Generalized Anxiety Disorder

 - Excessive anxiety and worry, occurring

more days than not for at least 6 months, about a
number of events or activities.

Assessment:
- Restlessness - irritability
- Fatigue - muscle tension
- Difficulty concentrating - sleep disturbance
Obsessive-Compulsive Disorder

 - Either obsessions or compulsions are

recognized as excessive and interfere with person’s
normal routine.

 Do not interrupt the compulsive behaviors.

 Provide safety!
 Establish a written contract.
Panic Disorder (with or without agoraphobia)

 - Recurrent unexpected panic attacks.

Assessment:
- Choking sensation - blurred vision
- Labored breathing - numbness
- Pounding heart - fear of being trapped
- Dizziness - fear of dying
- Nausea
Posttraumatic Stress Disorder

 - A person that has been exposed to a

traumatic event, reexpperiences the event via recurrent
and intrusive dreams or flashbacks.

Assessment:
- Sleep disturbances
- Hypervigilance
- Guilt about surviving the event
- Poor concentration
General Interventions for Anxiety Disorders

 Establish a trusting relationship.

 Nurses’ self-awareness.
 Protecting the patient.
 Modifying the environment
 Encouraging activity.
 Anti-anxiety medications.
Somatoform Disorders
 - characterized by persistent worry or
complaints regarding physical illness without
supporting physical findings.

 Somatization Disorder

 Conversion Disorder

 Hypochondriasis
Somatization Disorder

 A history of many physical complaints,
resulting in treatment being sought or significant
impairment in social or occupational functioning.

Assessment:
- Physical complaints of pain
- Psychosexual symptoms
- Secondary gain
Hypochondriasis

 Preoccupation with fears of having, or ideas

that one has, a serious disease based on the person’s
misinterpretation of bodily symptoms.

Assessment:
- Preoccupation with physical functioning
- Frequent somatic complaints
- Complaints of fatigue, insomnia, anxiety
- Repeatedly visiting the doctor
Conversion Disorder
 A physical symptom or a deficit suggesting loss
or altered body function related to psychological conflict
or a neurological disorder.

Assessment:
- La belle indifference
- Physical limitation or disability
- Feelings of guilt, anxiety or frustration
- Low self-esteem and feelings of inadequacy
- Unexpressed anger or conflict
General Interventions for Somatoform Disorders

 Do not reinforce the sick role.

 Allow a specific time period to discuss physical
complaints.
 Convey understanding that the physical symptoms
are real.
 Encourage diversional activities.
 Antianxiety medications.
Mood Disorders
 Major Depressive Disorder

 Bipolar Disorder
Mood Disorders
 Major Depressive Disorder
 At least 5 of the following must be present:
 - depressed mood
 - loss of interest or pleasure
 - weight loss or gain
 - insomnia or hypersomnia
 - psychomotor agitation or retardation
 - fatigue or loss of energy
 - feelings of worthlessness
 - impaired concentration
 - thoughts of death or suicide
 Bipolar Disorder
 Mania
 - becomes angry quickly
 - delusional self-confi-
 dence
 - flight of ideas
 - grandiose delusions
 - inappropriate affect
 - restlessness
 - sexually promiscuous
Depression
- decrease in ADLs
- decreased emotion
and phy’l activity
- easily fatigued
- inability to make
decisions
- lack of energy, etc
- withdrawn
Interventions for Depression

 Counseling

 Antidepressants

 Electroconvulsive
 Therapy
Interventions for Bipolar Disorder

 Use calm, slow interactions.

 Provide high-calorie finger foods and fluids.
 Provide physical activities and outlets for tension
 Avoid competitive games.
 Provide gross motor activities.
 Supervise the administration of medication.
Schizophrenia
 A group of mental disorders characterized by
psychotic features, inability to trust others, disorganized
thought processes, and disrupted interpersonal
relationships.

Types:
1. Disorganized
2. Catatonic
3. Paranoid
4. Residual
5. Undiffirentiated
1. Disorganized Schizophrenia

 - extreme social withdrawal

 - disorganized speech or behavior
 - flat or inappropriate affect
 - inability to perform ADLs
 - (+) and (-) symptoms
2. Catatonic Schizophrenia

 - immobility
 - stupor
 - waxy flexibility
 - excessive purposeless motor activity
 - echolalia
3. Paranoid Schizophrenia

 - suspiciousness and mistrust

 - hostility
 - delusions and hallucinations
 - anxiety and anger
 - violence
4. Residual Schizophrenia
 - diagnosed as schizophrenic in the past
 - exhibits considerable social isolation and
withdrawal and impaired role functioning
 - no more (+) symptoms; just withdrawn

5. Undifferentiated Schizophrenia
 - mixed classification
General Interventions for Schizophrenia

 Set limits on the client’s behavior.

 Maintain a safe environment.
 Help the client establish what is real and unreal.
 Speak in a simple direct and concise manner
 Assist the client to use alternative means to express
feelings.
 Antipsychotic medications.
Personality Disorders
 - These include various inflexible
maladaptive behavior patterns or traits that may
impair functioning and relationships.

Assessment:
 - poor impulse control
 - abandonment and depression
 - impaired judgment, reality testing, object
relations, self-perception, thought processes
Types of Personality Disorders

 Schizoid
 Avoidant
 Antisocial
 Borderline
 Dependent
 Histrionic
 Narcissistic
 Obsessive-Compulsive
 Paranoid
1. Schizoid Personality Disorder
 - inability to form warm, close social relationships

“I avoid people. There’s no enjoyment.”

2.Avoidant Personality Disorder

- characterized by social withdrawal and
extreme sensitivity to potential rejection
“I avoid people. I’m afraid of criticisms.”
3. Antisocial Personality Disorder
 - A pattern of irresponsible and antisocial behavior

“I break the law.”

4.Borderline Personality Disorder

- characterized by instability in interpersonal
relationships, mood, and self-image.
“My life is an empty glass.”
6. Dependent Personality Disorder
 - individual lacks self-confidence and the ability to function independently

“I can’t live if living is without you.”

7.Histrionic Personality Disorder

- overly dramatic and intensely expressive
behavior
“I want to be the center of attention!”
8. Narcissistic Personality Disorder
 - increased sense of self-importance

 “I love myself.”

9.Obsessive-Compulsive Personality Disorder

- client has difficulty expressing warm and
tender emotions and reflects perfectionism,
stubbornness, the need to control others, and a
devotion to work

“I am so organized.”
10. Paranoid Personality Disorder
 - characterized by suspiciousness and mistrust of others

“I am suspicious.”
General Interventions of Personality Disorders

 Maintain safety for self-destructive behaviors.

 Encourage to discuss feelings rather that act them out.
 Discuss expectations and responsibilities with client.
 Encourage the client to participate in group activities,
and praise nonmanipulative behavior.
 Set and maintain limits to decrease manipulative
behavior.
Eating Disorders
 Anorexia Nervosa
 - intensely fears obesity

 Bulimia Nervosa
 - client indulges in eating binges followed
by purging behaviors
General Interventions for Eating Disorders

 Assess nutritional status.

 Be accepting and nonjudgmental, expressing neither
approval nor disapproval of the behavior.
 Supervise during mealtimes and for a specified period
after meals.
 Encourage to participate in diversional activities.
Sexual Disorders
Alterations in Sexual Behavior
 Transsexualism
 Exhibitionism
 Fetishism
 Pedophilia
 Masochism
 Sadism
 Voyeurism
 Zoophilia
 Frotteurism
General Interventions for Sexual Disorders

 Assess sexual history and precipitating event for

sexual disorder.
 Encourage to explore personal beliefs.
 Provide a nonjudgmental attitude.
 Provide supportive psychotherapy.