‘

Psychiatric Nursing
Interventions
Case:
“Joan is a 30-year-old mom to a 1 month old
child, has an accident that leaves her with
reduced movement in her right arm.”
Nursing Interventions
 are nursing activities that promote and foster
health, assess dysfunction, assist patients to
regain or improve their coping abilities, or
prevent further disabilities (ANA et al., 2000).
 In psychiatric nursing, the Scope and Standards
of Psychiatric-Mental Health Nursing Practice
describes the scope of practice , delineates
nursing roles, and guides the selection of
interventions for implementation in the plan of
care (ANA et al., 2000).
 Psychiatric-mental health nurses deliver care
in various roles.
 Insome settings, such as an acute care
hospital or the home, the nurse provides
direct nursing care.
 Inother settings, the nurse may assume the
role of case manager, who coordinates care
for all disciplines as well as nursing.
 The nurse may also be the leader or manager
of a nursing unit and thus responsible for
delegating the care to paraprofessional and
nonprofessional providers.
Nursing Interventions: Biologic Domain
I. Promotion of Self-Care Activities
 Self-care is the ability to perform activities
of daily living successfully.
 Dorothea Orem’s general nursing model is
based on the concept of self-care deficit.
 This model promotes the ideas that self-
care is learned and that these behaviors
regulate human integrity, functioning, and
development.
 In
the inpatient setting, the psychiatric
nurse structures the patient’s activities so
that basic self-care activities are
completed.
 Ina psychiatric facility, patients are
encouraged and expected to develop
independence in completing these basic
self-care activities.
 In
the community, monitoring these basic
self-care activities is always a part of the
nursing visit.
II. Activity & Exercise Interventions
 The nurse must attend to the patient’s level of
activity.
 Exercise can keep patients active and engaged in
life.
 When assuming the responsibility of direct care
provider, the nurse can help patients identify
realistic activities and exercise goals.
 Asleader or manager of a psychiatric unit, the nurse
can influence ward routine.
 As a case manager, the nurse should consider the
activity needs of individuals when coordinating care.
III. Sleep Interventions
 Many psychiatric disorders and medications are
associated with sleep disturbances.
 Sleep is also disrupted in patients with dementia;
such patients may have difficulty falling asleep or
may frequently awaken during the night.
 Nonpharmacologic interventions:
i. Go to bed only when tired or sleepy.
ii. Establish a consistent bedtime routine.
iii. Avoid stimulating foods, beverages, or
medications.
iv. Avoid naps in the late afternoon or evening.
v. Eat lightly before retiring and limit fluid
intake.
vi. Use bed only for sleep or intimacy.
vii. Avoid emotional stimulation before
bedtime.
viii. Use behavioral and relaxation
techniques.
ix. Limit distractions.
IV. Nutrition Interventions
 Psychiatric disorders and medication side effects can
affect eating behaviors.
 Nutrition interventions should be specific and relevant
to the individual’s mental health.
 Recommended daily allowances are important in the
promotion of physical and mental health, and nurses
should consider them when planning care.
 If
a patient believes that food is poisonous, he or she
may eat sparingly or not at all.
 Obesity is common in people with mental disorders.
 Nurses should encourage patients, however, to avoid
quick weight loss programs.
 If weight gain is a problem, careful
monitoring of current intake and helping
the patient develop realistic strategies for
changing eating patterns is the best
approach.
V. Relaxation Interventions
 Relaxation promotes comfort, reduces
anxiety, alleviates stress, eases pain, and
prevents aggression.
 Itcan diminish the effects of hallucinations
and delusions.
 The many different relaxation techniques
used as mental health interventions range
from simple deep breathing to biofeedback
to hypnosis.
 Even though some techniques such as
biofeedback require additional training
and, in some instances, certification,
nurses can easily apply simple relaxation,
distraction, and imagery techniques.
 Relaxation techniques that involve physical
touch (e.g., back rubs) are usually not used
for people with mental disorders.
VI. Hydration Interventions
 Assessingfluid status and monitoring fluid I&O are
often important interventions.
 Some patients with psychotic disorders experience
chronic fluid imbalance.
 The nurse functions as the direct care provider
(teaching patient), unit leader (delegating weighing
of the patient to staff), or coordinator of the protocol.
 Many psychiatric medications affect fluid and
electrolyte balance.
 Interventions that help patients understand the
relationship of medications to fluid and electrolyte
balance are important in their overall care.
VII. Thermoregulation Interventions
 Interventions include:
i. educating patients about the problem of
thermoregulation
ii. identifying potential extremes in
temperatures, and
iii. developing strategies to protect the
patient from the adverse effects of
temperature changes.
VIII. Pain Management
 Emotional reactions are often manifested as pain.
 Insomatization disorder, chronic, unexplained pain
is one of the main symptoms.
 Psychiatric
nurses are more likely to provide care to
patients experiencing chronic pain than acute pain.
 Chronicpain is particularly problematic because no
cause for it is found.
 Pain
is managed by medication; in other instances,
nonpharmacologic techniques are used, such as
simple relaxation techniques, distraction, or
imagery.
 Relaxationis one of the most widely used
cognitive and behavior approaches to pain.
 Physical agents include heat and cold
therapy, exercise and transcutaneous
nerve stimulation.
 The key in managing pain is identifying
how the pain is disrupting the patient’s
personal, social, professional, and family
life.
IX. Medication Management
 The psychiatric-mental health nurse uses many
medication management interventions to help
patients maintain therapeutic regimens.
 Nurses must always assess a medication’s
effectiveness and side effects.
 Nurses also need to consider drug-drug interactions.
 Treatment with psychopharmacologic agents can be
lengthy because of the chronic nature of many
disorders; many patients remain on medication for
years, never becoming medication free.
 Medicationfollow-up may include home visits as well
as telephone calls.
Interventions:
Psychological
Domain
I. Counseling Interventions
 Counseling interventions are specific, time-limited
interactions between a nurse and a patient, family,
or group experiencing immediate or ongoing
difficulties related to their health or well being.
 Usually short-term and focuses on improving
coping abilities, reinforcing healthy behaviors,
fostering positive interactions, or preventing
illness and disability.
 Psychotherapy, which differs from counseling, is
generally a long-term approach aimed at
improving or helping patients regain previous
health status and functional abilities.
II. Conflict Resolution
 Conflict resolution is a specific type of
intervention by which the nurse helps patients
resolve disagreements or disputes with family,
friends, or other patients.
 The nurse may be in the position of actually
resolving a family conflict or teaching family
members how to resolve their own conflicts
positively.
 Nursesare in the positions of leadership, they
often need conflict resolution skills to settle
employee conflicts.
a. Conflict Resolution Process
 The desired outcome of successful conflict
resolution is “win-win” situation- that is, each
party feels good about the outcome.
 Conflict resolution include the following steps:
(1) helping those involved identify the problem;
(2) developing expectations for a win-win
situation;
(3) identifying interests;
(4) fostering creative brainstorming;
(5) combining options into a win-win situation.
b. Cultural Brokering in Patient-System Conflicts
 Thenurse can help to resolve conflicts through cultural
brokering, the act of bridging, linking, or mediating
messages, instructions, and belief systems between
groups or people of differing cultural systems to
reduce conflict or produce change.
 Forthe nurse as broker to be effective, he or she
attempts to establish and maintain a sense of
connectedness or relationship with the patient.
 The nurse establishes and cultivates networks with
other health care facilities and resources.
 Cultural sensitivity enables the nurse to be aware of
and sensitive to the needs of culturally diverse
patients.
III. Bibliotherapy
 Bibliotherapy, sometimes referred to as
bibliocounseling, is the reading of selected
written materials to express feelings or gain
insight under the guidance of a health care
provider.
 The provider assigns and discusses with the
patient a book, story, or article.
 The provider needs to consider the patient’s
reading level before making an assignment.
 If a patient has limited reading ability, the
provider should not use bibliotherapy.
 Literature can help patients identify with
characters and vicariously experience their
reality.
 It can expose patients to situations that
they have not personally experienced, but
the vicarious experience allows growth in
self- knowledge and compassion.
 Through reading, patients can enrich their
lives in the following ways:
(1) Catharsis: expression of feelings
stimulated by parallel experiences.
(2) Problem solving: development of
solutions to problems in the literature from
practical ideas about the problem.
(3) Insight: increased self-awareness and
understanding as the reader explores
personal meaning from what it read.
IV. Reminiscence
 Reminiscence, thinking about or relating past
experiences, is used as a nursing intervention
to enhance life review in older patients.
 The use of reminiscence encourages patients,
either in individual or group settings, to
discuss their past and review their lives.
 Patients can use reminiscence to maintain
self-esteem, stimulate thinking, and support
the natural healing process of life review.
 Activities that facilitate reminiscence
include writing an account of past events,
making a tape recording and playing it
back, explaining pictures in old family
albums, drawing a family tree, and writing
to old friends.
V. Behavior Therapy
 Behavior therapy interventions focus on reinforcing or
promoting desirable behaviors or altering undesirable
ones.
 The basic premise is that, because most behaviors are
learned, new functional behaviors can also be learned.
a. Behavior Modification
• It is a specific, systematized behavior therapy
technique that can be applied to individuals, groups,
or systems.
• The aim of behavior modification is to reinforce
desired behavior responses extinguish undesired ones.
• Desired behavior is rewarded to increase
the likelihood that patients will repeat it,
and over time, replace the problematic
behavior with it.
• Behavior modification is used for various
problematic behaviors, such as
dysfunctional eating and addictions, and
often with children and adolescents.
b. Token Economy
• It is the application of behavior modification
to multiple behaviors and is used in inpatient
settings.
• In less restrictive environments, patients use
tokens to purchase additional privileges such
as attending social events.
• Token economy system has been especially
effective in reinforcing positive behaviors in
people who are developmentally disabled or
have severe and persistent mental illnesses.
VI. Cognitive Interventions
 Cognitive interventions are verbally
structured interventions that reinforce and
promote desirable or alter undesirable
cognitive functioning.
 Cognitive interventions do not solve
problems for the patient but help the patient
develop new ways of viewing situations so
that they solve their problems themselves.
 Nurses may use several models as the basis
for cognitive interventions.
 To
engage in cognitive treatment, the
patient must be capable of introspection
and reflection on thoughts and fantasies.
 Cognitiveinterventions also include
thought stopping, contracting, and
cognitive restructuring.
VI. Psychoeducation
 Psychoeducation uses educational strategies to
teach patients the skill they lack because of a
psychiatric disorder.
 Nurses use psychoeducation to meet the
educational needs of patients through adapting
teaching strategies to their disorder-related deficits.
 This techniques are based on adult learning
principles, such as beginning at the point the
learner is currently at and building on his or her
current experiences.
 Thenurse assesses the patient’s readiness to learn
and current skills.
 Psychoeducation is a continuous process of
assessing, setting goals, developing
learning activities, and evaluating for
changes in knowledge and behavior.
 Nurses use it with individuals, groups,
families, and communities.
 It serves as a basis for psychosocial
rehabilitation (PSR), a service-delivery
approach for those with severe and
persistent mental illness.
VII. Health Teaching
 “The psychiatric-mental health nurse,
through health teaching, assists patients in
achieving satisfying, productive, and healthy
patterns of living” (ANA et al., 2000).
 Health teaching is based on principles of
learning and involves transmitting new
information and providing constructive
feedback and positive rewards, practice
sessions, homework, and experimental
learning.
 Inhealth teaching, psychiatric nurse is
challenged to attend to potential health
care problems other than mental disorders
and emotional problems.
VIII. Spiritual Interventions
 Spiritualcare is based on an assessment of the
patient’s spiritual needs.
 The development of nonjudgmental relationship
and just being with the patient are key to providing
spiritual intervention.
 Toassist people in spiritual distress, the nurse
should know and understand the beliefs and
practices of various spiritual groups.
 Spiritual
support, assisting patients to feel balance
and connection within their relationships, listening
to expressions of loneliness, using empathy, and
providing patients with desired spiritual articles.
Interventions: Social
Domain
 Interventions encompassing the social
domain are geared toward couples, families,
friends, and large and small groups with
special attention to ethnicity and
community interactions.
 The nurse design interventions that affect a
patient’s environment, such as helping a
family member make the decision to place a
loved one in long-term care.
 The nurse actually modifies the
environment to promote positive behaviors.
I. Social Behavior and Privilege Systems in Inpatients
Units
 Unit Rules: The purpose is to facilitate a
comfortable and safe living environment and has
little to do with the patient’s reasons for admission.
 Getting up at certain times, showering before
breakfast, making the bed, and not visiting in
other’s room are typical expectations.
 Most psychiatric facilities use a privilege system to
reinforce appropriate behavior.
A privilege system is also effective in shaping
appropriate social activity and can be used instead
of a token economy.
II. Milieu Therapy
 Milieutherapy provides a stable and coherent
social organization to facilitate an individual’s
treatment.
 The design of the physical surroundings, structure
of patient activities, and promotion of a stable
social structure and cultural setting enhance the
setting’s therapeutic potential.
A therapeutic milieu facilitates patient interactions
and promotes personal growth.
 Milieutherapy is the responsibility of the nurse in
collaboration with the patient and other health
care providers.
 The key concepts of milieu therapy
include:
(a) Containment
(b) Validation
(c) Structured Interaction
(d) Open Communication
Containment
 The process of providing safety and security and
involves the patient’s access to food and shelter.
 Thephysical surroundings are important in this
process and should be clean and comfortable,
with special attention paid to promoting a
noninstitutionalized environment.
 Therapeutic milieus emphasize patient
involvement in treatment decisions and operation
of the unit; nurses should encourage freedom of
movement within the contained environment.
 Patients participate in maintaining the
quality of the physical surroundings,
assuming responsibility for making their
own beds, attending to their own
belongings, and keeping an acceptable
living area.
 Family involvement for admission for
treatment, and the involvement may
include regular family attendance at
therapy sessions.
Validation
 Anyinteraction a staff member initiates
with a patient should reflect his or her
underlying respect for that patient.
 Thestaff should encourage group and
social interaction among patients.
 Patientsshould be actively participate in
the decision made about the treatment
process.
Structured Interaction
 The daily community meeting provides the
structure to explain unit rules and
consequences of violations.
 Insome instances, the treatment team assigns
structured interactions to specific patients as
a part of their treatment.
 Nurses should consistently assume
indulgence, flexibility, passive or active
friendliness, matter-of-fact attitude,
casualness, watchfulness, or kind firmness
when interacting with specific patients.
Open Communication
 In open communication, staff and patient
willingly share information.
 Staff members invite patient self-disclosure
within the support of a nurse-patient
relationship.
 They provide a model of effective
communication when interacting with one
another as well as with patients.
 Support, attention, praise, and reassurance
that staff gives the patients improves self-
esteem and increases confidence.
Milieu therapy in Different Settings
 In
long-term care settings, the therapeutic
milieu becomes essential.
 Structurein daily living is important to the
successful functioning of the individuals
and the overall group but must be applied
within the context of individual needs.
 Recentlyconcepts of milieu therapy have
also been applied to short-term impatient
and community settings.
II. Promotion of Patient Safety on Psychiatric
Units
 One of the most critical aspects of
psychiatric-mental health nursing is the
promotion of patient safety, especially on
the inpatient units.
a. Observation
 It is an ongoing assessment of the patient’s mental
status to identify and subvert any potential problem.
 In psychiatric settings, patients are ambulatory and
thus more susceptible to environmental hazards.
 Judgment and cognition impairment are symptoms
of many psychiatric disorders.
 The intensity of the observation depends on their
risk to themselves and others.
 Mental health facilities and units all have policies
that specify levels of observation for patients of
varying degrees of risks.
b. De-escalation
 It is an interactive process of calming and
redirecting a patient who has an immediate
potential for violence, directed toward either self or
others.
 This intervention involves assessing the situation
and preventing it from escalating to one in which
injury occurs to the patient, staff, or other patients.
 The nurse must avoid rushing toward the patient or
giving orders.
 Nurses can use various interventions in this
situation, including distraction, conflict resolution,
and cognitive intervention.
c. Seclusion
 Itis the involuntary confinement of a person in a
room or in an area where the person is physically
prevented from leaving.
A patient is placed in a seclusion for the purpose
of safety or behavioral management.
 The seclusion room has no furniture except a
mattress and a blanket.
 Once a patient is placed in seclusion, he or she
is observed at all times.
 The use of seclusion must follow the same
guidelines as the use of restraints.
 Seclusion is extremely negative patient
experience; consequently, its use is
seriously questioned and many facilities
have completely abandoned its practice.
d. Restraints
 The most restrictive safety interventions are
restraints, which are used only in the most
extreme circumstances.
 Chemical restraint is the use of medication
to control patients or manage their behavior.
A physical restraint is any manual method
or physical or mechanical device attached or
adjacent to the patient’s body that restricts
freedom or normal access to one’s body,
material, or equipment, and cannot be easily
removed.
 The use of seclusion and restraints must follow
the Quality Standards regulation contained in the
Patient’s Rights Condition of Participation (CoP)
(HCFA, 1999).
 Theapplication of physical restraints should follow
nursing standards and hospital policies.
 Nurses should document all the previously tried
de-escalation interventions before the application
of restraints.
 Theyshould limit use of restraints to times when
an individual is judged to self or others; they
should apply restraints only until the patient has
gained control over behavior.
 Different types of restraints:
(1) Wrist restraints restrict arm movement.
(2) Walkingrestraints, or ankle restraints, are
often used if a patient cannot resist the
impulse to run from a facility but is safe to
go outside and to activities.
(3) Three-pointand four-point restraints are
applied to the wrist and ankles in bed.
(4) Five-point restraints are used, all
extremities are secured, and another
restraint is placed across the chest.
Guidelines for Restraints & Seclusion
1. The patient has the right to be free from restraints of
any form that are not medically necessary or that
staff use as a means of coercion, discipline,
convenience, or retaliation.
2. A restraint can be used only if needed to improve the
patient’s well-being and if less restrictive
interventions have been determined ineffective.
3. The use of a restraint must be (1) selected only when
less restrictive measures have been found
ineffective to protect the patient or others from
harm, (2) in accordance with the order of a physician
or other licensed independent practitioner (LIP)
permitted by the state and hospital.
4. The order must (1) never be written as a
standing or on an as needed basis, and (2) must
be followed by consultation with the patient’s
treating physician in accordance with the patient’s
plan of care.
5. The LIP orders the use of restraint or seclusion.
The LIP must see and evaluate the need for
restraint or seclusion within 1 hour after the
initiation of this intervention.
6. Each written order for a physical restraint or
seclusion is limited to 4 hours for adults, 2 hours
for children and adolescents aged 9 to 17 years, or
1 hour for patients younger than 9 years.
7. Written or verbal orders for initial and
continuing use of restraint are time limited.
8. Patients in restraint or seclusion
continually must be assessed, monitored,
and re-evaluated.
9. Restraint and seclusion may not be used
simultaneously unless the patient is
monitored face to face by an assigned staff
member.
IV. Home Visits
 Delivery of psychiatric nursing has moved
from the hospital into the community.
 The goal of home care is to maximize the
patient’s functional ability within the nurse-
patient relationship and with the family or
significant other as appropriate.
 The psychiatric nurse needs to be able to work
independently, is skilled in teaching patients
and families, can administer and monitor
medications, and uses community resources
for the patient’s needs.
 Home visits are useful in helping individuals become
compliant in taking medication.
 Home visits also help providers develop cultural
sensitivity to families from diverse backgrounds.
 The home visits process consists of three steps:
(1) Previsit Phase
• The nurse sets goals for the home visit based on data
received from other health care providers or the
patient.
• The nurse and patient agree on the time of the visit.
• As the nurse travels to the home, he or she should
assess the neighborhood for access to services,
socioeconomic factors, and safety.
(2) Actual Visit can be divided into four
parts:
i. Greeting phase
ii. Establishment of the focus of the visit –
typically last 30 to 90 minutes
iii. Implementation of the service
iv. Closure of the visit
(3) Postvisit Phase – includes
documentation, reporting, and follow-up
planning.
V. Community Action
 Nurses have a unique opportunity to be
involved in the promotion of mental health
awareness and to support humane treatment
for people with mental disorders.
 Activities
range from being an advisor to
support groups to participating in the political
process through lobbying efforts and serving
on the community mental health boards.
 Animportant role of professionals, however, is
to provide community service in addition to
service through income-generating positions.
Thank you!!!
Activity II: Critical Thinking Challenges
1. Joan, a 35-year-old married woman, is
admitted to an acute psychiatric unit for
stabilization of her mood disorder. She is
extremely depressed but refuses to
consider a recommended medication
change. She asks the nurse what to do.
Using a conflict resolution intervention,
explain how would you approach Joan’s
problem.
2. A nurse reports to work for evening shift.
The unit is chaotic. The television in the day
room is loud; two patients are arguing over
the program. Visitors are mingling in
patients’ rooms. The temperature of the
units is hot. One patient is running up and
down the hall yelling, “Help me, help me”.
Using a milieu therapy approach, what
would you do to calm the unit?
3. A patient is admitted to the unit and
becomes extremely agitated, endangering
himself and others. After trying to de-
escalate the patient, the nurse decides that
the best approach is to put the patient into
restraints. Outline a procedure that the
nurse must follow to meet the Health Care
Finance Administration guidelines regarding
restraints and seclusion contained in the
Patients’ Rights Condition of participants.