Learning Objectives
yAt the end of the discussion, you should be able to:

Understand the principles of psychiatric nursing care, including: y - Mental Health and Mental Illness y - Competent Psychiatric Nursing Care y - Therapeutic Nurse-Patient Relationship
1. 2. Apply the principles in nursing practice. This y includes: y - Anxiety Disorders y - Somatoforn Disorders y

y y y y y y y 3.

- Mood Disorders - Suicidal Behavior - Schizophrenia and Psychotic Disorders - Personality Disorders - Substance-Related Disorders - Eating Disorders - Sexual Disorders Identify the nursing roles in psychopharmacology and electroconvulsive therapy, cognitive behavioral therapy, and therapeutic groups.

Mental Illness The loss of ability to respond to the environment in ways that are in accord with oneself or the expectations of society. .Mental Health A lifelong process of successful adaptation to a changing internal and external environment.

Competent Psychiatric Nursing y Three Domains of Contemporary Psychiatric Nursing Care Practice: Direct Care Communication Management .

and an increased genuine self-respect. y y Goals of Therapeutic Relationship: 1.Therapeutic Nurse-Patient Relationship This is a mutual learning experience and y corrective emotional experience for the patient. Self-realization. 2. A clear sense of personal identity and an improved level of personal integration . self-acceptance.

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.3. .

y SELF-AWARENESS .

Introductory or Orientation Phase 3.y Phases of the Nurse-Patient Relationship 1. Working Phase 4. Termination Phase . Pre-interaction Phase 2.

and fears.Gather data about patient when possible.Plan for first meeting with patient. . fantasies.Explore own feelings. y y y y y Pre-interaction Phase . .y Nurse s Tasks in Each Phase 1. .Analyze own professional strengths and limitations. .

y y y y y y y Introductory or Orientation Phase .Define goals with patient. .y Nurse s Tasks in Each Phase 2. . and actions. and open communication.Establish trust.Mutually formulate a contract.Explore patient s thoughts. . feelings. acceptance. .Identify patient s problems. .

.y Nurse s Tasks in Each Phase 3.Promote patient s development of insight and use of constructive coping mechanisms.Explore relevant stressors.Overcome resistance behaviors. . Working Phase y y y y . .

.y Nurse s Tasks in Each Phase 4.Establish reality of separation. . loss. and anger and related behaviors. Termination Phase y y y y y . . sadness.Review progress of therapy and attainment of goals.Mutually explore feelings of rejection.

and you want me to start us off? 3. You¶re not sure what we should be talking about. Could you describe to me how you are feeling? y Patient: (Shifting nervously in his chair. I sense that you are uncomfortable to me. and I can feel those same feelings in me as I sit here with you.Facilitative Communication do you the room and avoiding the nurse) What what want to talk about today? Possible Nurse Responses: 1. eyes scanning 2. . You look very nervous.

or contents .Therapeutic Communication Techniques  Listening  Broad Opening  Restating patient select topic repeating the main thought  Clarification attempting to put into words vague ideas or unclear thoughts  Reflection directing back patient s ideas. questions. feelings.

 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 presentation of alternative ideas  Suggesting .

Anxiety Disorders
y Anxiety is a diffuse apprehension that y is vague in nature and associated with y feelings of uncertainty and helplessness. y Levels of Anxiety:  Mild Anxiety y - tension of day-to-day living y - person is alert and the perceptual field is y increased y - motivates learning and produce growth and y creativity y

 Moderate Anxiety y - person focuses only on immediate concerns y - narrowing perceptual field y - blocks selected areas but can attend to y more if directed to do so  Severe Anxiety y - significant reduction in perceptual field y - person focuses on specific detail and not y think about anything else

 Panic y y y

- 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

y y y

y Patient behaviors related to anxiety include:  Physiological  Behavioral  Cognitive  Affective .

first line of psychic defense. resolve conflicts.thoughtful.  Ego-Oriented Reactions y . and gratify needs. . deliberate attempts to solve problems.y Coping Mechanisms  Task-Oriented Reactions y .

though told her father has metastatic cancer. . continues to plan a family reunion 18 months in advance.Unconscious Ego Defense Mechanisms y Compensation makes up for a perceived deficiency by strongly emphasizing a feature that he/she regards as an asset. Denial avoidance of disagreeable realities by ignoring or refusing to recognize them A woman. A high school student too small to play football becomes the star long-distance runner for the track team.

Introjection intense identification in which a person incorporates qualities or values of another person. A 7-year-old tells his little sister. and the husband becomes so angry he hits a door instead of his wife. A husband and wife are fighting.Displacement shift of emotion from a person or object to another. Identification a person tries to become like someone he or she admires. A new graduate suddenly left in charge emulates her faculty role model. . Don t talk to strangers.

.Intellectualization excessive reasoning or logic is used to avoid experiencing disturbing feelings. He wouldn t have wanted to live with a disability. John fails an examination and complains that the lectures were not clearly presented. The pain over a parent s sudden death is reduced by saying. Reaction Formation development of conscious attitudes that are opposite to what one really feels or would like to do. feelings. Rationalization offering a socially acceptable explanation to justify unacceptable impulses. A married woman who feels attracted to one of her husband s friends treats him rudely. or behaviors.

A young woman who denies she has sexual feelings about a co-worker accuses him without basis of trying to seduce her. . Projection attributing one s thoughts to another person. A person with excessive sexual drives invests psychic energy into a well-defined religious value system.Isolation splitting off of emotional components of a thought A second-year medical student dissects a cadaver without being disturbed by thoughts of death. Sublimation displacement of primitive sexual drives to a more socially acceptable activities.

Mr. R does not recall hitting his wife when she was pregnant. A father spanks his child and the next evening brings home a present for him. . Undoing act or communication that partially negates a previous one.Repression involuntary exclusion of a painful memory.

Anxiety Disorders  Generalized Anxiety Disorder  Obsessive Compulsive Disorder  Panic Disorder with or without agoraphobia  Posttraumatic Disdorder .

about a number of events or activities. Assessment: Restlessness Fatigue Difficulty concentrating y - .y Generalized Anxiety Disorder y .irritability .Excessive anxiety and worry.muscle tension .sleep disturbance . occurring more days than not for at least 6 months.

.  Provide safety!  Establish a written contract.y Obsessive-Compulsive Disorder y .  Do not interrupt the compulsive behaviors.Either obsessions or compulsions are recognized as excessive and interfere with person s normal routine.

Pounding heart .Dizziness .Nausea - blurred vision numbness fear of being trapped fear of dying .y Panic Disorder (with or without agoraphobia) y .Recurrent unexpected panic attacks.Labored breathing . y Assessment: .Choking sensation .

y Posttraumatic Stress Disorder y . Assessment: Sleep disturbances Hypervigilance Guilt about surviving the event Poor concentration y - .A person that has been exposed to a traumatic event. reexpperiences the event via recurrent and intrusive dreams or flashbacks.

 Nurses self-awareness.  Modifying the environment  Encouraging activity.  Anti-anxiety medications.  Protecting the patient.y General Interventions for Anxiety Disorders  Establish a trusting relationship. .

characterized by persistent worry or complaints regarding physical illness without supporting physical findings.  Somatization Disorder  Conversion Disorder  Hypochondriasis .Somatoform Disorders y .

y Somatization Disorder y y 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 y - .

a serious disease based on the person s misinterpretation of bodily symptoms. insomnia. or ideas that one has. anxiety Repeatedly visiting the doctor y - . Assessment: Preoccupation with physical functioning Frequent somatic complaints Complaints of fatigue.y Hypochondriasis y Preoccupation with fears of having.

anxiety or frustration Low self-esteem and feelings of inadequacy Unexpressed anger or conflict .y Conversion Disorder y A physical symptom or a deficit suggesting loss or altered body function related to psychological conflict or a neurological disorder. y - Assessment: La belle indifference Physical limitation or disability Feelings of guilt.

y General Interventions for Somatoform Disorders  Do not reinforce the sick role.  Allow a specific time period to discuss physical complaints. .  Antianxiety medications.  Encourage diversional activities.  Convey understanding that the physical symptoms are real.

Mood Disorders  Major Depressive Disorder  Bipolar Disorder .

impaired concentration y .feelings of worthlessness y .Mood Disorders  Major Depressive Disorder y At least 5 of the following must be present: y .loss of interest or pleasure y .fatigue or loss of energy y .weight loss or gain y .thoughts of death or suicide .insomnia or hypersomnia y .psychomotor agitation or retardation y .depressed mood y .

flight of ideas y .inappropriate affect y .sexually promiscuous Depression .grandiose delusions y .restlessness y .easily fatigued .lack of energy.decreased emotion and phy l activity .withdrawn . Bipolar Disorder y Mania y .becomes angry quickly y . etc .delusional self-confiy dence y .inability to make decisions .decrease in ADLs .

y Interventions for Depression  Counseling  Antidepressants  Electroconvulsive y Therapy .

slow interactions.y Interventions for Bipolar Disorder  Use calm. .  Provide gross motor activities.  Provide physical activities and outlets for tension  Avoid competitive games.  Supervise the administration of medication.  Provide high-calorie finger foods and fluids.

Residual 5. Catatonic 3. and disrupted interpersonal relationships. Paranoid 4. inability to trust others. Undiffirentiated .Schizophrenia y A group of mental disorders characterized by psychotic features. disorganized thought processes. y Types: 1. Disorganized 2.

extreme social withdrawal .1. y y y y y Disorganized Schizophrenia .(+) and (-) symptoms .disorganized speech or behavior .flat or inappropriate affect .inability to perform ADLs .

2. Catatonic Schizophrenia y y y y y - immobility stupor waxy flexibility excessive purposeless motor activity echolalia .

3. Paranoid Schizophrenia y y y y y - suspiciousness and mistrust hostility delusions and hallucinations anxiety and anger violence .

4.exhibits considerable social isolation and withdrawal and impaired role functioning .mixed classification . Residual Schizophrenia y y y .diagnosed as schizophrenic in the past .no more (+) symptoms. Undifferentiated Schizophrenia y . just withdrawn 5.

.  Help the client establish what is real and unreal.  Maintain a safe environment.  Speak in a simple direct and concise manner  Assist the client to use alternative means to express feelings.  Antipsychotic medications.y General Interventions for Schizophrenia  Set limits on the client s behavior.

thought processes y .These include various inflexible maladaptive behavior patterns or traits that may impair functioning and relationships. self-perception.Personality Disorders y . reality testing.impaired judgment. y Assessment: . object relations.abandonment and depression y .poor impulse control y .

y Types of Personality Disorders          Schizoid Avoidant Antisocial Borderline Dependent Histrionic Narcissistic Obsessive-Compulsive Paranoid .

inability to form warm.´ 2. There¶s no enjoyment.1. I¶m afraid of criticisms.Avoidant Personality Disorder . y Schizoid Personality Disorder .characterized by social withdrawal and extreme sensitivity to potential rejection ³I avoid people.´ . close social relationships y ³I avoid people.

Borderline Personality Disorder .characterized by instability in interpersonal relationships. and self-image. ³My life is an empty glass. y Antisocial Personality Disorder . mood.´ 4.´ .3.A pattern of irresponsible and antisocial behavior y ³I break the law.

6.overly dramatic and intensely expressive behavior ³I want to be the center of attention!´ .individual lacks self-confidence and the ability to function independently y ³I can¶t live if living is without you.Histrionic Personality Disorder . y Dependent Personality Disorder .´ 7.

increased sense of self-importance y ³I love myself. y Narcissistic Personality Disorder .´ . and a devotion to work ³I am so organized. stubbornness.´ 9.8. the need to control others.Obsessive-Compulsive Personality Disorder .client has difficulty expressing warm and tender emotions and reflects perfectionism.

10.characterized by suspiciousness and mistrust of others y ³I am suspicious. y Paranoid Personality Disorder .´ .

y General Interventions of Personality Disorders  Maintain safety for self-destructive behaviors. and praise nonmanipulative behavior.  Encourage the client to participate in group activities.  Discuss expectations and responsibilities with client. .  Encourage to discuss feelings rather that act them out.  Set and maintain limits to decrease manipulative behavior.

client indulges in eating binges followed by purging behaviors .Eating Disorders  Anorexia Nervosa y .intensely fears obesity  Bulimia Nervosa y .

.y General Interventions for Eating Disorders  Assess nutritional status. expressing neither approval nor disapproval of the behavior.  Encourage to participate in diversional activities.  Be accepting and nonjudgmental.  Supervise during mealtimes and for a specified period after meals.

Sexual Disorders y          Alterations in Sexual Behavior Transsexualism Exhibitionism Fetishism Pedophilia Masochism Sadism Voyeurism Zoophilia Frotteurism .

 Provide a nonjudgmental attitude. .  Encourage to explore personal beliefs.  Provide supportive psychotherapy.y General Interventions for Sexual Disorders  Assess sexual history and precipitating event for sexual disorder.

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