St.

Louis Review Center

MENTAL HEALTH
⊗ A state in which an individual shows deficit in functioning and is unable to maintain personal
⊗ "A state of well-being where a person can realize his or her own abilities to cope with the normal relationship.

⊗
stresses of life and work productively." (WHO)
Balance in person’s internal life and adaptation to reality.
⊗ State of imbalance characterized by a disturbance in a person’s thoughts, feelings and behavior
⊗ State of well-being in which a person is able to realize his potentials. ⊗ Factors that increase the risk are: Crises, Abuses, Poverty

Criteria for Mental Health:

⊗ Self-awareness Historical View of Mental Illness
♦ Ability to: ⊗ In the past, mental illness has been viewed as:
 recognize one’s thoughts feelings, asset potentials and weakness.  Demonic possession
 experience genuine feelings as anger, happiness, resentment  Influence of ancestral spirits
 Result of violating taboo or neglecting cultural, ritual, and spiritual condemnation
 leads to self-acceptance, self-understanding in order to understand others
⊗ Period of Enlightenment (1745-1886)
⊗ Autonomy: ability to function independently and function with others  Lunatics were restrained in iron menacles
⊗ Perceptive ability  Mentally ill were exhibited as diversion and entertainment for the public
 Awareness of stimuli, reality orientation.  Establishment of asylums
 Opening of state hospitals for mentally ill.
 Orientation to: Time, Place, Person
⊗ Period of Scientific Study
⊗ Integral capacity: Ability to harmonize psychic forces (id, ego, super ego).  Psychoanalysis by Sigmund Freud
⊗ Self-actuation ⊗ Psychotropic Drugs (1950)
 Ability to adopt to life changes, happy to work with others  Use of chlorpromazine and imipramine
 Satisfaction in every endeavor
 Mental illness is caused by chemical imbalance in the brain.
 Genuine cooperation ⊗ The Decade of the Brain (1990)
⊗ Mastery of one’s environment: Awareness of the changes around him  Focused on the connections between mental illness and biological malfunction in the brain
and the neuroendocrine-immune system.
 Biological views holds that biological defects are responsible for certain serious mental illness.
MENTAL HYGIENE
⊗ a science that deals with: Promotive, Preventive, Curative, Rehabilitative aspects of care.
Diagnosis of Mental Illness
⊗ Use of the Diagnostic and Statistical Manual of Mental Illness (DSM-IV)
⊗ Provides diagnostic criteria for each mental disorder and a system of 5 axes to give a comprehensive
MENTAL DISORDER
view of the client’s mental illness.
⊗ A medically diagnosable illness which results in significant impairment of one's cognitive, affective or
relational abilities and is equivalent to mental illness.  Axis I: The clinical disorder that is the focus of treatment
 Axis II: Personality disorders and mental retardation
 Axis III: Medical conditions
 Axis IV: Psychosocial and environmental problems
Criteria for Mental Disorder:  Axis V: Global assessment of functioning (GAF)
⊗ Dissatisfaction with:
 one’s characteristics, abilities and accomplishments
 one’s place in the world PSYCHIATRIC NURSING
⊗ Ineffective:
 interpersonal relationship Importance:
 coping or adaptation to the events in one’s life
⊗ An interpersonal process
⊗ Concerned with all the aspects of care
MENTAL ILLNESS ⊗ Both a Science and an Art

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 Science – uses different theories ⊗ Health perception
 Art - therapeutic use of self
⊗ Clientele: ⊗ Orientation
Individual, family and the community

 Both mentally healthy and mentally ill
⊗ Metabolic pattern
⊗ Elimination pattern
Main tool of the nurse: Therapeutic use of Self

Characteristics of a Good Psychiatric Nurse: ⊗ Cognitive pattern: Judgment, Insight, Memory

⊗ Empathy
⊗ Activity and exercise pattern
⊗ Genuineness
⊗ Congruence ⊗ Thought process
⊗ Unconditional positive regard
⊗ Sleep-rest pattern
Roles of the Nurse in Psychiatric Setting:
 Clinician
LEGAL ASPECTS OF PSYCHIATRIC NURSING
 Collaborator
 Counselor Types of Admissions:
 Healthy role model ⊗ Voluntary
 Parent surrogate  Persons admit themselves
 Patient advocate
 Reality based  Client consents to all treatment
 Researcher  Client can refuse treatment, including drugs, unless danger to self or others
 Socializing agent ⊗ Involuntary
 Teacher  Judicial process
 Technician  Initiated when someone files a petition
 Therapist  Certification of the likelihood of serious harm to self or others, or unable to care for self
 Ward manager  Under 18, parents can confine with confirmation by a neutral fact finder
 Must be released at end of statutory time or put on voluntary status or have a hearing
Levels of Interventions in Psychiatric Nursing ‘

Level Description Examples Judicial Precedents

Primary Aimed at altering the stressors through:  Health education Unless incompetent, client maintains all previous rights
 promotion of mental health  Information dissemination
 Counseling
 lowering the rate of cases
Secondary Interventions that limits the severity of a disorder  Crisis intervention Insanity as a Defense
thorugh:  Drug administration ⊗ Insanity : determined in court; legal terminology
 Case finding
 Prompt treatment McNaughten Rule
Tertiary Aimed at reducing the disability after a disorder  Alcoholics anonymous “At the time of the crime, the individual didn’t know the nature and quality of the act or didn’t know right from
through:  Occupational therapy wrong.”
 Prevention of complication
 Active program of rehabilitation
COMMON BEHAVIORAL SIGNS AND SYMPTOMS

THE PSYCHIATRIC SETTING Disturbance in Perception

Admitting a Client in the Psychiatric Setting ⊗ Illusion - misperception of an actual external stimuli
Areas to be assessed: ⊗ Hallucination - false sensory perception in the absence of external stimuli

Management:
⊗ Acknowledge the feelings
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⊗ Provide distractions
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• Retrograde - distant past
⊗ Deja vu - feeling of having been to place which one has not yet visited

⊗ Neologism - pathological coining of new words

⊗ Jamais vu - feeling of not having been to a place which one has visited

⊗ Circumstantiality - over inclusion of details

⊗ Dementia
• gradual deterioration of intellectual functioning
⊗ Word salad - incoherent mixture of words and phrases • results in the decreased of capacity to perform ADL
⊗ Flight of ideas - shifting of one topic from one subject to another in a completely unrelated way
Other behavioral signs & symptoms
⊗ Looseness of Association - shifting of a topic from one subject to another in a somewhat related way ⊗ Agitation - severe anxiety associated with motor restlessness.
⊗ Verbigeration - meaningless repetition of word or phrases ⊗ Agnosia - inability to recognize and interpret sensory stimuli.
⊗ Perseveration - persistence of a response to a previous question ⊗ Akathisia - subjective feeling of muscular tension, restlessness and pacing repeated sitting and
⊗ Echolalia - pathological repetition of words of others standing.

⊗ Clang association - the sound of the word gives direction to the flow of thought ⊗ Ambivalence - presence of two opposing feelings at the same time.

⊗ Delusion - false belief which is inconsistent with one's knowledge and culture
 Grandeur - is an exaggerated belief of identity
 Nihilistic - the client denies the existence of self or part of self
 Persecution - belief that he or she is the object of environmental attention and being singled
out for harassment
 Self-depreciation - worthlessness or hopelessness
 Somatic - false belief to body function.
Disturbances of Affect
⊗ Inappropriate affect - disharmony between the stimuli and the emotional reaction
⊗ Blunted affect - severe reduction in emotional reaction
⊗ Flat affect - absence or near absence of emotional reaction
⊗ Apathy - dulled emotional tone
⊗ Aphasia - inability or difficulty to speak or recall words
⊗ Apraxia - inability to carry out specific task or activity.
⊗ Delirium
• refers to acute change or disturbance in a person's: LOC, cognition, emotion , perception
⊗ Depression - feeling of sadness
⊗ Derealization - feeling of strangeness towards the environment.
⊗ Dysthymia - persistent state of sadness
⊗ Elation (euphoria)- a feeling of high degree of confidence, boastfulness and joy with increase motor
activity.
⊗ Narcolepsy - sleep disorder characterized by frequent irresistible urge to sleep with episodes of
cataplexy (sudden loss of muscle power)

Disturbances in Motor Activity

⊗ Echopraxia - the pathological imitation of posture/action of others USE OF APPROPRIATE COMMUNICATION TECHNIQUES

⊗ Waxy flexibility - maintaining the desired position for long periods of time without discomfort Communication: reciprocal exchange of ideas between or among persons
⊗ Akinesia - loss of movement
Modes:
⊗ Bradykinesia - slowness of all voluntary movement including speech. ⊗ Verbal - written/spoken
⊗ Non-verbal - posture, tone of voice, facial expression
⊗ Ataxia - loss of coordinated movement
Types of Non-verbal communication:
Disturbances in Memory ⊗ Kinesis
⊗ Confabulation - filling in of memory gaps • body movement
• eye contact
⊗ Amnesia - inability to recall past events • gestures
• Anterograde - immediate past ⊗ Paralanguage

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• voice quality Acknowledging or giving I noticed that you've fixed your bed.
• non-language vocalization (crying, sobbing, moaning) recognition
⊗ Proxemics – law of space relationship Asking direct questions How does your wife feel about your hospitalization?
⊗ Touch – physical act
Clarifying I'm not sure that I understand what you are trying to say.
⊗ Cultural artifacts
⊗ Meta communication
Confronting or presenting reality I see no bats flying in this room.
• based on role expectations
• hidden meaning of words Encouraging comparison Has this ever happened before?
Encouraging description How do you feel when you take your medication?

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 asking Is there something you'd like to do?
Therapeutic Communication: a way of interacting in a purposeful manner to promote the client’s ability to
open-ended questions
express his thoughts and feelings openly.
Informing (giving needed facts)
I'll be your nurse for today, from 7:00 until 3:00 this afternoon.
Essentials for a Therapeutic Communication:
Making observations You appear to be angry. / I noticed that you're trembling.
⊗ Genuineness Offering general leads Go on. / You were saying…
Restating Client: I can't sleep, I stay awake all night. Nurse: You can't sleep
⊗ Respect
at night, (restating)
⊗ Empathy Summarizing During the past hour, we talked about your plans for the future,
they include...
⊗ Attentive listening Using silence (to induce thought, pacing, acceptance)
⊗ Trust (rapport)
Validating (confirming one's observation)
“So you mean . . .”
Voicing doubt I find that hard to believe.
Examples: Non-therapeutic Technique and Ineffective Communication
Barriers to a Therapeutic Communication
Agreeing and disagreeing “I think you did the right thing.”
⊗ Belittling Advice “You should.….”
Belittling "Don't be concerned, evervone feels like that".
⊗ Interrupting / ignoring
Defending "All doctors here are simply great".
⊗ Giving advice False reassurance "Don't worry, everything will be all right".
Focus on caregiver’s feeling “I feel that way too.”

⊗ Social response Judging "It's your own mistake".

⊗ Changing the subject
⊗ Approving / disapproving NURSE – PATIENT RELATIONSHIP

⊗ Moralizing

Examples: Therapeutic Technique

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

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Hildegard Peplau
⊗ Evaluate the summary of progress
Phases: ⊗ Reinforce change and strength of patient
⊗ Give rewards for the cooperation during interaction
Pre-Interaction Phase
⊗ begins when the nurse is assigned/chooses a patient ⊗ Encourage expression of feelings about termination of the relationship
⊗ patient is excluded as an active participant ⊗ Terminate the relationship without giving promises
⊗ nurse feels certain degree of anxiety
⊗ includes all of what the nurse thinks and does before interacting with the patient
⊗ develop self-awareness
⊗ data gathering, planning for first interaction

THEORIES OF HUMAN DYNAMICS

Psychosexual Development : Sigmund Freud

Orientation phase
⊗ when the nurse-patient interacts for the first time Levels of Consciousness
⊗ establish of contract with the patient
⊗ establish of trust and rapport
3 Psychic Energies
⊗ learn about the patient and his initial concerns and needs
⊗ encourage the patient to feel comfortable with the meeting
⊗ conduct initial interview
⊗ manage present emotion of the patient
⊗ provide support and empathy of the patient’s feelings
⊗ assure of confidentiality

Working / Therapeutic Phase:

⊗ it is highly individualized
⊗ identification and resolution of the patient's problems
⊗ more structured than the orientation phase ⊗ Libido - are the instinctual drives
⊗ the longest and most productive phase
⊗ limit setting must be employed ⊗ Regression and fixation are common terms in this theory.
⊗ planning and implementation ⊗ Gave prominence to sexual feelings: defined "sex" as anything that gives gratification
Problems:
⊗ Transference
 the development of an emotional attitude towards the nurse Stages:

 positive or negative Oral Stage (0-2 years)

⊗ Counter transference – experienced by the nurse / therapist ⊗ The area of gratification is the mouth
⊗ Pleasures: sucking activities like fingers, toes or nipples
Termination Phase ⊗ Dissatisfaction: resurface at a later
 overeating, smoking, nail-biting

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⊗ Oedipal feelings are reactivated toward opposite sex
Nursing Implication: ⊗ The person is on his way in establishing a satisfying life of his own
⊗ Provide oral stimulation by giving pacifiers
 Breastfeeding may provide more stimulation. Nursing Implication:
⊗ Do not discourage thumb sucking ⊗ Provide appropriate opportunities for the child to relate with opposite sex.
⊗ Allow child to verbalize feelings about new relationships.
Anal Stage (2-4 years)
⊗ Children's attention is focused on the anal region.
⊗ Pleasure: elimination.
Psychosocial Development Theory: Erik Erikson

⊗ Covers the ideal age for "toilet training" (2 1/2 years) ⊗ Childhood is very important in personality development.
⊗ 2 concepts: ⊗ Rejected Freud's attempt to describe personality solely on the basis of sexuality,
 Holding on  believed that social factors greatly affect
 Letting go  felt that personality continued to develop beyond five years of age.
Possible problems:
⊗ Compulsive need to be clean and orderly. Identified 8 developmental stages throughout the whole life cycle.
⊗ Frugality and stinginess ⊗ Stages 1-5 - childhood and adolescent
⊗ Greed ⊗ Stages 6-8 - Adulthood
⊗ Insistence on doing things at one's own rate at the expense of others
⊗ Rigid training Stages:
⊗ Excessive messiness and disorderly habits.
Stage 1:
Nursing Implication: Help children achieve bowel and bladder control without undue emphasis on its Period of Life Infant, 0-18 months, (Hope)
importance.
Psychosocial Crisis Trust vs. Mistrust

Relationship with Maternal person

Positive Resolution o Reliance on the caregiver

Phallic Stage (4-6 years)
o Development of trust in the environment
⊗ Pleasure: genital region.
Negative Resolution o Fear, anxiety and suspicion
 activities associated with stroking and manipulating their sex organs.
o Lack of care, both physical & psychological by caretaker leads to
⊗ Oedipus complex mistrust of environment
⊗ Electra complex
⊗ Concepts Stage 2:
 Onset of “normal homosexuality” Period of Life Toddler, 18 mos. to 3 years
(Willpower)
Nursing implications:
⊗ Accept child's sexual interest Psychosocial Crisis Autonomy vs. Shame/doubt
⊗ Help the parents answer child's questions about birth or sexual differences. Relationship with Paternal person

Latency Stage (6 to 12 years) Positive Resolution o Sense of self-worth

⊗ Period of calmness / stable period. o Assertion of choice and will
⊗ Many of the disturbing behaviors are buried in the subconscious mind. o Environment encourages independence, leading to sense of pride

⊗ Their energies are absorbed by the concerns in school, peers, sports and other recreational activities
Negative Resolution o Loss of self-esteem
o Sense of external control may produce self-doubt in others
Nursing Implication: Help the child have positive experiences.

Genital Stage (12 years & up)

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Stage 3:
Period of Life
Psychosocial Crisis
Relationship with
Positive Resolution
Negative Resolution
Stage 4
Period of Life
Psychosocial Crisis
Relationship with
Positive Resolution
Negative Resolution
Stage 5:
Period of Life
Psychosocial Crisis
Relationship with
Positive Resolution
Negative Resolution
Stage 6:
Period of Life
Psychiatric Nursing: Lecture Aid
St. Louis Review Center
Psychosocial Crisis Intimacy vs. Isolation
Relationship with Partners in friendship
Positive Resolution o A commitment to others
o Close heterosexual relationship and procreation
Negative Resolution Withdrawal from such intimacy, isolation, self-absorption and alienation from
others
Stage 7:
Period of Life Middle Adult, 24 to 54 yrs., (Care)
Preschool, 3 to 6 years (Purpose)
Initiative vs. Guilt Psychosocial Crisis Generativity vs. Self-absorption
Family Relationship with Partner
The ability to learn to initiate activities, to enjoy achievement and Positive Resolution o The care and concern for the next generation
competence o Widening interest in work and ideas
Negative Resolution Self-indulgence and resulting psychological impoverishment
o The inability to control newly developed power
o Realization of potential failure leads to fear of punishment and guilt
Stage 8:
Period of Life Late Adult, 54 yrs. to death, (Wisdom)
Psychosocial Crisis Integrity vs. Despair
Relationship with Mankind
Schooler, 6 to 12 yrs. (Competence) Positive Resolution o Acceptance of one’s life
Industry vs. Inferiority o Realization of the inevitability of death
o Feeling of dignity and meaning of existence
Neighbors/School
Negative Resolution Disappointment of one’s life and desperate fear of death
o Learning the value of work
o Acquiring skills and tools of technology
o Competence helps to order life and make things work
Repeated frustrations and failures lead to feelings of inadequacy and Cognitive Development Theory: Jean Piaget
inferiority that may affect their view of life
Stages:
Sensorimotor (0-2 years)
Adolescent, 12 to 18 yrs, (Fidelity) ⊗ Reflex to complex
⊗ Begins to organize visual images and control motor responses.
Identity vs. Role confusion ⊗ Coordinates sensory impressions.
Peer group ⊗ Pre-verbal stage
Experiments with various roles in developing mature individuality
Preoperational Stage (2-7 years)
⊗ Transitional period
Pressures and demands may lead to confusion about self
⊗ Egocentric and irreversible thinking
⊗ Words become symbols for objects – symbolic thinking
⊗ Formation of ideas of categorization.
⊗ Lack of ability to go back and rethink a process or concept.
⊗ Mental image – the symbolic process which are evident in plays
⊗ Construction of verbal schemas – preconcepts
Young Adult, 18 to 54 yrs., (Love) Concrete Operations (7 – 11 years)
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⊗ Thinking appears to be stabilized
o ability to think of the possible consequences of actions
⊗ Logical implications
Formal Operations
(11 years to adulthood)
⊗ Full patterns of thinking
⊗ Ability to use logic and symbolic processes
o mathematical and scientific reasoning
⊗ Combinatorial thinking - multidimensional approach
o hypothetic or hypothetico-deductive reasoning
Moral Development Theory: Laurence Kohlberg
Level One (Preconventional
Morality)
• Children’s judgments are based
on external criteria.
• Standards of right and wrong are
absolute and laid down by
authority.
Level Two (Conventional Morality)
• Children’s judgments are based
on the norms and expectations of
the group.
Level Three
(Post Conventional Morality)
• The individual recognizes the
arbitrariness of social and legal
conventions.
• The individual attempts to define
moral values that are separate
from group norms.
Psychiatric Nursing: Lecture Aid
St. Louis Review Center
Behavioral Model (Ivan Pavlov, John Watson, B. F. Skinner)
⊗ Behavior is:
• a response to a stimulus from the environment
• learned and retained by positive reinforcement
Interpersonal Model (Harry Stack Sullivan)
⊗ Focused on the role of the environment and interpersonal relations as the most significant influences on a
individual’s development.
⊗ Anxiety is communicated interpersonally.
Human Motivational Need Model. (Abraham Maslow)
Stage 1
⊗ Hierarchy of needs in order of importance
• Behavior is based on the desire to avoid severe physical
⊗ Primary needs (physiologic) need to be met prior to dealing with higher level needs.
punishment by a superior power.
• Right or wrong is based on consequences to him.
Psychobiologic Model
• Punishment = wrong act ⊗ Focus is in mental illness as a biophysical impairment.
⊗ Human behavior is influenced by genetics, biochemical alterations and function of brain and CNS.
Stage 2 ⊗ The stress response is a neuroendoctine response.
• Actions are based largely on satisfying one’s own personal
needs. Important structure (limbic system):
Stage 3 ⊗ Thalamus – regulates activity, sensation, emotion
• Good behavior is that which pleases others and judgments ⊗ Hypothalamus – themoregulation, appetite control, endocrine function, appetite control, impulsive
are based on intentions. behavior associated with feelings of anger, rage or excitement.
• Children conform to rules to win the approval of others and to ⊗ Hippocampus and amygdale – emotional arousal and memory
maintain good relationships. ⊗ Neurons – basic functioning unit of the CNS
Stage 4 ⊗ Neurotransmitters
• What is right is what is accepted.  Chemical substances manufactured in the neuron
If the social accepts rules as appropriate for all group members,  Aid transmission of information throughout the body
children will conform to them to avoid social disapproval and ⊗ Dopamine
censure  An excitatory neurotransmitter
Stage 5  Located primarily at the brain stem
• Behavior recognizes the laws as arbitrary and  Involved in control of complex movements, motivation, cognition and regulation of emotional
changeable. responses
• For aspects of life not governed by laws, right and wrong  Associated with pyschosis and Parkinson’s disease
are personal decisions based on agreement and ⊗ Catecholamines (norepinephrine and epinephrine)
contracts. ⊗ Norepinephrine
Stage 6
 Attention, learning and memory, sleep and wakefulness
• Morality is based on respect for others rather than on
 Excess of this is associated with anxiety, memory loss, social withdrawal and depression.
personal desires.
⊗ Epinephrine – responsible in the fight or flight mechanism
• The individual conforms to both social standards and to
⊗ Serotonin
internalized ideals to avoid self-condemnation rather
than to avoid social censure.  An inhibitory neurotransmitter
 Derived from tryptophan
 Involved in control of food intake, sleep and wakefulness, pain control, sexual behavior and
Other Theories emotions
 Involved in anxiety and mood disorders, schizophrenia and its symptoms
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⊗ Histamine o improve functioning of individual members as well as the family as a whole.
 Primarily involved in immunity and allergic reactions o It focuses on the total family as an interactional system
 Some psychotropic drugs are block by histamine ⊗ Milieu Therapy
⊗ Acetylcholine • A therapeutic environment is organized to:
 Affects sleep-wake cycle o encourage and assist the client to control problematic behavior
 Associated with Alzheimer’s disease o function within the range of social norms
⊗ Glutamate ⊗ Play therapy
 An excitatory neurotransmitter • Effective for children suffering from maladjustment or behavior disorder.
 At high levels, it can cause neurotoxicity. • The child is usually placed in a play room
 Associated with Alzheimer’s and Huntington’s disease • Purpose - to discover the causes of the child's conflict through observation of his play and to
⊗ Gama-Aminobutyric Acid interpret it to the child.
 An inhibitory neurotransmitter ⊗ Recreational therapy
 Associated to treat anxiety and induce sleep. • Uses activities which vitalize the patient's interest and help him or her to relax and feel refreshed.
• Example: Playing baseball may be prescribed for as a means of expressing hostility in a group.

PSYCHOTHERAPY
⊗ Is a process in which a person enters into a contract to interact with a therapist to relieve symptoms,
resolve problems in living, seek personal growth
INDIVIDUAL THERAPY: Is a confidential relationship between client and therapist.
⊗ Hypnotherapy: Involves various methods and techniques to induce a trance state where the patient
becomes submissive to instructions
⊗ Humor therapy: Use of humor to facilitate expression of feelings and to enhance interaction
⊗ Psychoanalysis: Focuses on the exploration of the unconscious, to 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.
⊗
Musical therapy
• Involving the music which allows the child or adolescent to express herself or himself.
• Also effective with those who have difficulty communicating.
⊗ Art therapy: Clients are encouraged to express their feelings or emotions by painting, drawing or
sculpture.
⊗ Psychodrama therapy: Patients dramatizes their emotional problems in a group setting.
⊗ Behavior Therapy
• Is a mode of treatment that focuses on modifying observable (overt) and quantifiable behavior
• Systematic manipulation of the environment and variables thought to be functionally related to the
behaviors.

GROUP THERAPY • Limit Setting

• minimum number : 3 o Therapist gives an advanced warning of the limit and the consequences will follow if the client
• Ideal number :8-10 does not adhere to the limit.
o The consequences should occur immediately after the client has exceeded the limit
• Advantages: o Consistency must occur with all personnel.
o decreases isolation o Purposes:
o Minimizes manipulation and splitting of the staff.
o decreases dependence o Provide a framework for the client to function in and enable a client to learn to make
o develops coping skills requests.
o develops interpersonal learning • Systematic Desensitization
o develops opportunities for helping others o Clients are exposed slowly to a feared object or a thing that inhibits anxious responses and
o develops ability to listen to other members taught ways to relax.
o Effective in treating phobias.
• Implosive therapy
⊗ Remotivation Therapy: Promotes expression of feeling through interaction facilitated by discussion of o The clients are exposed abruptly to intense forms of anxiety producers, either in imagination
neutral topics or in real life
⊗ Family therapy: A method in which family members gain: • Cognitive Behavior therapy
o insight into the problems o Uses confrontation as a means of helping the clients restructure or rearrange irrational beliefs,
o improve communication maladaptive thinking, perception-, and behaviors.

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o Used for depression and adjustment difficulties. o Headache
• Biofeedback o Apnea
o Teaches the client to control or change aspects of their internal environment. o Respiratory depression
Fracture
• Aversion therapy
o

o Uses unpleasant or noxious stimuli to change inappropriate behavior. BASIC CONCEPTS ON PSYCHOPHARMACOLOGY
o Examples
o Antabuse to treat alcoholics MAJOR TRANQUILIZERS/ ANTIPSYCHOTICS
o Showing films to drivers who are arrested for speeding or driving while under the ⊗ Indication: Schizophrenia and Other Psychosis
influence of alcohol or drugs. ⊗ Desired effect: control of symptoms
• Assertiveness Training ⊗ Best taken after meals
o Clients are encouraged and taught how to appropriately relate to others
o Teaches the individual to ask for what is beneficial to both mentally ill and mentally healthy Examples:
persons. • Haloperidol (Haldol) • Fluphenazine (Prolixin)
• Token-economy: Utilizes the principle of rewarding desired behavior to facilitate change. • Prochlorperazine (Compazine) • Chlorpromazine (Thorazine)

ELECTROCONVULSIVE THERAPY (ECT) Side effects: Nursing Action

• Exact mechanism is unknown Blurred vision Avoid driving
• Requires a consent Dry mouth Give sugarless gum
• Usually given at 70-150 volts for about .5-2 seconds Tachycardia, palpitation, constipation, urinary Monitor & report
retention
• Effectivity: 6-12 treatments with at least 48 hour interval
Photosensitivity Don’t expose skin to sunlight
• Indicator of effectiveness: tonic-clonic seizure Orthostatic hypotension Monitor BP
Indications of use: Advise gradual change in position
• Depression Extra Pyramidal Symptoms Report at once
• Mania o Pseudoparkinsonism
• Catatonic schizophrenia o pill-rolling tremors
Contraindications (not absolute) mask-like face
• Fever • Unhealed fracture o cog-wheel rigidity
• Increased ICP • Retinal detachment o propulsive gait
• Cardiac conditions • Pregnancy o Akathisia - restless leg syndrome
• TB with history of hemorrhage o Dystonia - defect in muscle tone

Adverse effect: report promptly

Before the procedure:
• Tardive dyskinesia - lip smacking
• Diagnostic procedures
• Agranulocytosis
o X-ray
o Assess for:
o ECG
o EEG  Fever
 Sore throat
• Drugs given
 Lab data: WBC count
o Atrophine sulfate (decrease secretions)
• Hepatotoxicity
o Anectine (Succinylcholine) – relax muscles
o Assess for ALT & AST
o Methohexital Na (Brevital) - anesthetic
During the procedure:
MINOR TRANQUILIZERS/ ANXIOLYTICS
• Observe for tonic-clonic seizure
⊗ Common indication: Anxiety disorders
After the procedure:
⊗ Desired Effect: Decreased anxiety, adequate sleep
• Position
• Check vital signs
Examples:
• Reorient the client • Diazepam (Valium) • Chlorazepate Dipotassium (Tranxene)
• Watch out for complications: • Oxazepam (Serax) • Alprazolam (Xanax)
o Memory loss

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• Chlordiazepoxide (Librium)
Examples:
Nursing Implications: • Fluoxetine (Prozac) • Paroxetine (Paxil)
• Best taken before meals • Celatopram (Celexa) • Fluvoxamine (Luvox)
• Advise to avoid driving • Sertraline (Zoloft)
• Avoid alcohol and caffeine-containing foods
• Administer it separately with any drug

ANTIDEPRESSANTS Nursing Implications:

Desired effects: increased appetite, adequate sleep ⊗ Avoid the use of:
• diazepam
Tricyclic Antidepressants • Alcohol
• Tryptophan
Examples:
• Monitor PTT, PT
• Imipramine (Tofranil) • Amitriptyline (Elavil)
⊗ Never give to pregnant / lactating mothers.
Nursing Implications:
⊗ Best given after meals
ANTI-MANIC AGENT
⊗ Effectivity: after 2-3 weeks
⊗ Check the BP, it causes hypotension Examples:
⊗ Check the heart rate, it causes cardiac arrythmias • Lithium Citrate (Cibalith – S) • Lithium Carbonate (Eskalith, Lithane, Lithobid)
⊗ Monitor I & O
⊗ Monitor for signs of increased IOP Nursing implications:
⊗ Best taken after meals
⊗ Increase intake of:
MAO INHIBITORS • fluids (3 L /day)
Indication: refractory depression • sodium (3 gm/day)
⊗ Avoid activities that increase perspiration
Examples:
⊗ Never give to pregnant mothers
• Tranylcypromine (Parnate)
⊗ Effectivity: 10-14 days
• Phenelzine (Nardil)
• Isocarboxazid (Marplan) ⊗ Antipsychotic is administered during the first 2 weeks

Nursing Implications: ⊗ Therapeutic level:.5-1.5 meq/L

⊗ Best taken after meals ⊗ If ineffective: Tegretol
⊗ Report headache; it indicates hypertensive crisis ⊗ Signs of toxicity:
⊗ Avoid tyramine containing foods like: o Vomiting
• Avocado o Anorexia
• Banana
o Nausea
• Cheddar and aged cheese
o Diarrhea
• Soysauce
• Preserved foods o Abdominal cramps
⊗ Effectivity: 2-3 weeks o Lightheadedness (late)
⊗ Monitor the BP
⊗ There should be at least a two-week interval when shifting from one anti-depressant to another
⊗ Antidote: Mannitol

Selective Serotonin Reuptake Inhibitors

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• Highly individualized
STRESS • Self-limiting: 4-6 weeks
• Person affected becomes passive and submissive
• A nonspecific response of the body to any demand made upon it. (Hans Selye, 1936) • Affects a person’s support system
• A state produced by a change in the environment that is perceived as challenging, threatening or
damaging to the person’s dynamic equilibrium. (Smeltzer, 1992) Type Description Example
Maturational/developmental crisis expected, predictable and Puberty, adolescence, young
Adaptation internally motivated adulthood, marriage, or the
• A constant ongoing process that occurs along time continuum, beginning with birth and ending with aging process.
death. (Smeltzer, 1992) Situational/accidental Unexpected, unpredictable and Economic difficulty, illness,
externally motivated accident, rape, divorce or death
• A continuous process of seeking harmony in an environment.
Social crisis Due to acts of nature Natural calamities
Types of Adaptation:

General Adaptation Syndrome (GAS)

• Involves the whole body in response to stress. Phases
• Denial
• Compared to life process as it focuses on the “wear and tear of the body tissues.
• Increased Tension
Phases: • Disorganization
• Alarm • Attempts to reorganize
o Acute phase of the syndrome • Stage for full reorganization
o Characterized as the “flight and fight” reaction
o Defensive by nature but self-limiting
o If stress is intense, it may lead to death. CRISIS INTERVENTION
• Resistance • Major Goal:
o Characterized as the state of adaptation o Restore the maximum level of functioning (pre-crisis state)
o Person moves back to homeostasis o It is an active but temporary entry into the life situation of an individual or a family during a period of
• Exhaustion stress.
o Result of a prolonged exposure to stress and adaptive mechanisms can no longer persist. o A way of entering into the situation to help them mobilize their resources and to decrease the effect
of stress.
Local Adaptation Syndrome
• Refers to inflammatory response and repair processes that occur at the local site of tissue injury. Domestic Violence Requiring Crisis Intervention:

RAPE
• Nonconsensual sexual penetration of an individual, obtained by force or threat, or in cases in which the
Eustress - positive stress victim is not capable of consent.
Distress Kinds of Rape
• Negative stress • Power – to prove masculinity
• Damaging stressors which may result in various physical and emotional disorders such as: anxiety, • Anger – means of retaliation
frustration, insecurity, aimlessness • Sadistic – to express erotic feelings

CRISIS AND CRISIS INTERVENTION Silent Rape Syndrome

• A situation that occurs when an individual's habitual coping ability becomes ineffective to meet the • Is a maladaptive reaction to rape
demands of a situation. • The victim:
• As a serious interruption and disturbance of one's equilibrium or homeostasis • fails to disclose information about the rape
• Leads to potentially dangerous, self-destructive or socially unacceptable behavior. • is unable to resolve feelings about the sexual assault
• Results to increase anxiety and may develop a sudden phobic reaction.
Characteristics

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• Inconsistent stories from the child and parent/s
• Low self-esteem
• Depression

• Apathy
Rape Trauma Syndrome (RTS)
• Bruised or swollen genitalia; tears or bruising of rectum or vagina
• Refers to a group of signs and symptoms experienced by a victim in reaction to rape
• Unusual injuries for the child’s age and development
Phases: • Serious injuries (fractures, burns, lacerations)
• Acute Phase – shock, numbness, disbelief • Evidence of old injuries not reported
• Denial – refusal to discuss the event
• Heightened Anxiety – fear, tension, nightmares Republic Act 7610
(Anti Child Abuse Law)
• Stage of Reorganization
• Required reporting of suspected cases

Battered Wife Syndrome (BWS) • Report cases to the nearest authorities within 48 hours
• A form of cyclic domestic violence
• Men: low self-esteem
• Women: Dependent personality disorder
Assessment, Planning and Nursing Actions for Crisis
• Primary concerns:
o Physical injuries
Child Abuse o Alleviation of psychological trauma
• Is an act of omission of responsibility or commission in which intentional harm is inflicted on a child. • Nurse should display:

Components of Omission:
o Sensitivity
• Child abandonment – leaving the child physically o Attitude (Nonjudgmental)
• Child neglect - lack of provision of those things which are necessary for the child's growth and o Confidentiality
development
o Respect
Types of Commission: o Empathy
Physical Abuse
o Dignity
• Is an intentional physical harm inflicted on a child by a parent or other person. • Evidences are important:
o stained clothing
Emotional abuse - insult and undermining one's confidence o fingernail scrapings
o mouth or anal smears containing semen
Sexual abuse - abuse in the form of sexual contact
• Intervention focuses family as a unit.
Characteristics of Abusive Parents: • If the victim is a child: Play and art therapy
• They come from violent families
• They were also abused by their parents
• They have inadequate parenting skills DEFENSE MECHANISM
• They are socially isolated because they don't trust anyone
• They are emotionally immature • These are automatic and usually unconscious processes or act by the individuals to:
• They have negative attitude towards the management of the abused o reduce or cope anxiety or fear
o resolve emotional or mental conflict
Warning signs of Child Abuse / Neglect: o protect one's self-esteem
• Child’s excessive knowledge on sex and abusive words o protect one's sense of security
• Hair growth in various lengths • Becomes pathologic when overused.

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• Used by both mentally healthy and mentally ill individuals
• Reaction – Formation
Common Defense Mechanisms Used: o Expression of feeling that is the direct opposite of one's real feeling.
• Compensation o Also referred to as overcompensation.
o An attempt to overcome a real or imagined short coming, inferiority, inabilities and weaknesses. o A student who dislikes one of her classmates may act or show concern toward her.
o A blind woman becomes proficient in playing piano.
• Rationalization
o An individual finds a justifiable cause and acceptable reasons just to be saved from an
embarrassing and anxiety producing thoughts or situations.
• Conversion o A basketball player claims that he missed the shot and lost the game because of the distractions
o Emotional problems are converted to physical symptoms made by the audience.
o A student unprepared for a report suffered headache the day she is supposed to deliver her report.
• Regression
• Denial o Is the turning back to earlier patterns of behavior in solving personal conflicts.
o Failure to acknowledge an intolerable thought, feeling, experience or reality o Commonly seen to schizophrenic patients
o A middle-aged man after being admitted to the CCU because of an AMI, insists that he is in the o A person who becomes ill in the face of disappointment has regressed to a form of childish
hospital for just a diagnostic work-up. behavior.

• Displacement • Repression
o the redirection of feelings to a less threatening object o It is the involuntary or unconscious forgetting of an unpleasant ideas or impulses.
o An adolescent boy, after an argument with his father, goes to the room and kicked his room’s door. o During the nurse-patient relationships, patients often unconsciously avoid discussing those
experiences producing anxiety which are emotionally difficult to verbalize.
• Fantasy
• Suppression
o Conscious distortion of unconscious feelings or wishes
o Permits the individual to store away or consciously forget the unpleasant, painful and unacceptable
o A boy who is being bullied by his friends wished he had the power of Wolverine.
thoughts, desires, experiences and impulses.
o "I'll think it about tomorrow", "I'd rather go now", "Can we change the topic?"
• Fixation
o A boy walked out from the group and said "I have to go now", when he was asked what was
o An unhealthy mechanism which is an arrest of maturation at certain stages of development.
happened to their relationship with his girlfriend.
o A boy never overcame being fully reliant from his mother.
• Substitution
• Introjection
o Replacing the desired unattainable goal with one that is attainable
o Symbolic assimilation or taking into oneself a love/hatred object. Derived from the word "introject"
o A woman who failed the nursing board exam 3 times, worked as a nursing aide just to be in the
which literally means to take into or ingest.
hospital.
o Common to depressed clients.
• Sublimation
• Identification o The redirection of unacceptable instinctual drive with one that is socially acceptable
o An individual integrates certain aspects of someone else's personality into one's own. o Instead of harming his mother, a man expressed his anger by composing a song.
o A young school teacher adopts his former mentor's teaching style when conducting class sessions.
• Symbolization
o Less threatening object is used to represent another
• Intellectualization o A woman, missing her husband finds comfort in hugging her son who looks like his father.
o An overuse of intellectual concepts by an individual to avoid expression of feelings
o A man who was asked to share a memorable experience about his grandmother who died • Undoing
discussed the stages of death and dying by Elizabeth Kubler Ross. o An attempt to erase an act, thought, feeling, guilt or desire
o A man gives her wife a bunch of roses after their argument last night.
• Projection
o Attributing to others one's unconscious wishes/fear.
o Literally, this means to "throw off.
o A student who failed a subject blames his failure on poor teaching.

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