Psychiatric Nursing - Foundations

Psychiatric
Nursing
The Heart of the Nursing
Profession
Outline of Psychiatric
Nursing
 Fundamental Concepts of
Psychiatric nursing
 The Definition of Psychiatric Nursing
 The Scope of Psychiatric Nursing
Practice
 Self-Awareness
 Theoretical Framework
 Freud
 Erikson
 Piaget
 Sullivan

Nursing
 The Therapeutic Nursing
Relationship
 The Therapeutic Communication
 Modalities of Psychiatric Care
 Psychiatric Settings- Therapeutic
Environment
 Overview of Psychotherapy-
therapeutic modalities
 Psychopharmacology
 Psychiatric Diagnostic Tests

Nursing
 The Psychiatric Nursing Process
 Psychiatric Assessment: History and
PE
 Diagnostic Examination
 Psychiatric Nursing Diagnosis
 Nursing Planning
 Nursing Implementation
 Nursing Evaluation
Nursing
 Client Responses to illness
 Anxiety and Crisis
 Anger
 Hostility
 Depression
 Abuse
 Violence
 Suicide
 Grief and Loss

Nursing
Psychiatric Disorders: Adult
2. Anxiety and Anxiety Disorders
3. Schizophrenia
4. Mood disorders
5. Personality Disorders
6. Eating Disorders
7. Substance abuse
8. Somatoform disorders
Nursing
Psychiatric Disorders: Children and
adolescents
2. Autism
3. ADHD
4. Mental Retardation
5. Other disorders
Nursing
Psychiatric Disorders: Others
2. Dementia
3. Delirium
Ready
Colleagues?
BY: Prof Joan A. Ocampo
Nature of Psychiatric
Nursing
Let us first review
terms related to
Psychiatric
Nursing
Nursing
Mental Health
A state of emotional, psychological
and social wellness evidenced by
satisfying interpersonal
relationships, effective behavior
and coping, positive self-concept
and emotional stability (Videbeck)
 lifelong process of successful
adaptation to a changing internal
and external environments
Nursing
Mental Disorder
 A clinically significant behavioral or
psychological syndrome or pattern
that occurs in an individual and that
is associated with present distress,
increased risk of suffering, death,
disability and loss of freedom
(Videbeck)
 Loss of ability to respond to
environment in ways that are in
accord with oneself and society
Mentally Healthy Person
 Accepts himself
 Perceives reality
 Mastery of self and environment
 Autonomy
 Unifying, integrated outlook in life
Nursing
The DSM-TR IV
 A taxonomy that describes all
mental disorders, outlining specific
diagnostic criteria for each based
on clinical experience and research
 Clinicians utilize this to diagnose
psychiatric disorders
 Purpose of DSM-TR:
1. Standard nomenclature
2. Defining characteristics
3. Underlying cause of disorders
Nursing
The DSM-TR IV : Multi Axis
Classification
AXIS I- Major Psychiatric Disorders
AXIS II- Mental Retardation and
Personality Disorders
AXIS III- Current Medical Condition
AXIS IV- Psychosocial and
Environmental Problems
AXIS V- Global Assessment of
Nursing
Historical People Worth Mentioning
2. Aristotle- the Humors
3. Freud- -Psychosexual theory
4. Kraeplin- symptomatic
classification of mental disorders
5. Bleuler- coined “schizophrenia”
Nursing
Psychiatric Nursing in the
Philippines
 GO and NGOs
 Mental health programs

Nursing
Psychiatric Nursing in the Philippines
Mental Health= State of well being,
where a person can realize his
potential
Mental Ill Health= disturbance of
thought, feelings and behavior
Mental Disorder= medically
diagnosable illness
Mental Hygiene= Science which deals
with measures employed to promote
mental health
Nursing
Scope of Nursing Practice
 Individual, family and
community
 Healthy and ill person
Nursing
Self Awareness
 The process by which the nurse
gains recognition of his/her own
feelings, beliefs and attitudes
(Videbeck)
 Initial nursing activity to do
before practicing psychiatric
nursing
Nursing
Self Awareness
 This is accomplish through
reflection, spending time
deliberately focusing on how one
feels and what one values or
believes
Theoretical Foundations
 Mental health-Psychiatric
treatment integrates concepts
and strategies from theories.
 Theoretical Models are used as
guides for treatments
 These theories attempt to
explain human behavior, health
and mental illness
 Theoretical frameworks
 allow the systematic organization
of knowledge
 guide data collection
 provide explanations for assessed
behaviors
 guide care plan development
 provides rationales for
interventions and
 determine evaluation criteria
 Guide research by providing
assumptions to be tested.
Psychosexual- Sigmund FREUD
Psychoanalytical
Theory
Psychosocial Erik ERIKSON
Theory
Cognitive Theory Jean PIAGET
Interpersonal Harry Stack

Theory Sullivan
Moral Theory KOHLBERG
Spiritual Theory FOWLER

Behavioral Pavlov and Skinner
Theories
Humanistic Maslow and Carl
Theories Rogers
Psychobiology Neuroanatomy and
theory physiology
Theories of Personality
development
 Freud’s Psychoanalytic theory
 Erikson’s Psychosocial theory
 Sullivan’s interpersonal theory
 Piaget’s Cognitive theory
 Fowler’s Spiritual theory
 Kohlberg’s Moral theory
Psychosexual/Psychoanal
ytical
 This theory supports the notion
that EVERY human behavior is
caused and can be explained
 Freud believes that “repressed”

sexual urges, desires, impulses
or drives motivated much human
behavior
ytical
Components of Personality
2. ID- part of a person that
reflects BASIC or innate
DESIRES, INSTINCT and
SURVIVAL impulses
3. EGO- represents the REALITY
aspect
4. SUPER-EGO- part that reflects
MORALITY and ethical concepts,
and values
ytical
Personality Stages and Functional
Awareness
2. Conscious – perceptions,
thoughts and emotion that
exist in the person’s awareness
3. Pre-conscious/Subconscious-
Thoughts and emotions not
currently in awareness but can
be recalled with effort
4. Unconscious- thoughts, drives
and emotions totally a person is
ytical
According to this theory,

much of our behavior is
motivated by our
SUBCONSCIOUS thoughts
or
feelings
ytical
Five Stages of psychosexual
development
2. Oral
3. Anal
4. Phallic or Oedipal
5. Latency
6. Genital
ytical
Phase Age Focus
Oral 0-18 Site of gratification: Mouth

months
Anal 1½-3 Site of gratification: Anus
years
Phalli 3- 5 Site of gratification: Genitals
c years
Laten 6- 12 Site of gratification: (School
cy years Activities)
Genit 12 & Site of gratification: Genitals
al above
ytical
Phase Age Focus
Oral 0-18 Major task: Weaning

months
Anal 1½-3 Major task: Toilet training
years
Phalli 3- 5 Major task: Oedipal & Electra
c years complex
Laten 6- 12 Major task : School activities
cy years
Genit 12 & Major task: Sexual intimacy
al above
Psychosexual model
(Freud)
1. Oral
a. 0-18 months
b. Pleasure and gratification
through mouth
c. Behaviors: dependency, eating,
crying, biting
d. Distinguishes between self and
mother
e. Develops body image, aggressive
drives
Psychosexual model
(Freud)
2. Anal
a. 18 months - 3 years
b. Pleasure through elimination or
retention of feces
c. Behaviors: control of holding on
or letting go
d. Develops concept of power,
punishment, ambivalence,
concern with cleanliness or being
dirty
Psychosexual model
(Freud)
3. Phallic/Oedipal
a. 3 - 6 years
b. Pleasure through genitals
c. Behaviors: touching of genitals,
erotic attachment to parent of
opposite sex
d. Develops fear of punishment by
parent of same sex, guilt, sexual
identity
Psychosexual model
(Freud)
4. Latency
a. 6 - 12 years
b. Energy used to gain new skills in
social relationships and
knowledge
c. Behaviors: sense of industry and
mastery
d. Learns control over aggressive,
destructive impulses
Psychosexual model
(Freud)
5. Genital
a. 12 - 20 years
b. Sexual pleasure through genitals
c. Behaviors: becomes independent
of parents, responsible for self
d. Develops sexual identity, ability
to love and work
ytical
Ego Defense Mechanisms
Unconscious Ego defense
mechanism
 These are PSYCHOLOGIC adaptive
mechanisms
 Mental mechanisms that develop as
the personality attempts to DEFEND
itself, establishes compromises
among conflicting impulses and
allays inner tensions
Unconscious Ego defense
mechanism
 The unconscious mind working to
protect the person from anxiety
 Releases tension
 Compensation  Covering up
weaknesses by
emphasizing a
more desirable
trait
 Denial
 Attempt to
ignore
unacceptable
realities by
refusing to
 Displacement  Discharging
emotional
reactions from
one object to a
LESS threatening
object/person
 Identification
 Imitation of
someone feared
or respected
 Intellectualizatio  Use of rational
n explanations
that remove
from the event
any personal
significance and
feelings
 Introjection  Acceptance of
other’s norms as
oneself
 Minimization  Not
acknowledging
the significance
of one’s behavior
 Projection
 Blame is
attached to
others or to
environment for
unacceptable
thoughts,
mistakes, etc
 Rationalization  JUSTIFICATION of
certain
BEHAVIORS by
faulty
logic/reasons
 Reaction
Formation
 Acting
OPPOSITELY to
the way they feel
 Regression  Resorting to an
earlier, more
comfortable level
of functioning
that is less
 Repression demanding
 Unconscious
mechanism of
keeping
threatening
desires or
thoughts from
 Sublimation  Re-channeling of
aggressive
energies into
socially
acceptable
activities
 Substitution
 Replacement of a
highly valued
object by a LESS
valuable or
acceptable and
 Undoing  Actions or words
designed to
cancel some
disapproved
thoughts,
impulses , or
acts in which the
person relieves
GUILT by making
reparation
ytical
Transference and Counter-
transference
 TRANSFERENCE is the clients
feeling toward nurse arising
from unconscious experiences
with early significant others
 COUNTER TRANSFERENCE is the
nurse’s feelings toward the
patient arising also form
previous experiences
ytical
The Freudian View of Mental
Illness
 All behavior has meaning
 Mental illness and

manifestations are caused by
unconscious INTERNAL conflict
arising from unresolved issues in
early childhood
 Ego defenses are utilized to
relieve inner tension
Psychosocial Theory
 Theory that focuses on
developmental task, focuses on
EGO as this develops from social
interaction
 The developmental tasks are
sequential and depend on prior
successful mastery
 An individual who fails to
“master” the task at appropriate
age may return to work on
Psychosocial Theory
Use of the theory in Nursing
 Assessment can be done
focusing on the psychosocial
development at specific age
 Appropriate interventions can be
selected based on task
 Nurses can promote healthy
behaviors and encourages hope
that re-learning is possible
Erikson’s Psychosocial
theory
 Trust versus mistrust
 Autonomy versus shame and doubt
 Initiative versus guilt
 Industry versus inferiority
 Identity versus role confusion
 Intimacy versus isolation
 Generativity versus stagnation
 Ego integrity versus despair
Psychosocial Model
(Erikson)
1. Trust vs mistrust
a. 0 - 18 months
b. Learn to trust others and self vs
withdrawal, estrangement
2. Autonomy vs shame and
doubt
b. Learn self-control and the degree to
which one has control over the
environment vs compulsive
Psychosocial Model
(Erikson)
3. Initiative vs guilt
a. 3 - 5 years
b. Learn to influence environment,
evaluate own behavior vs fear of
doing wrong, lack of self-
confidence, over restricting actions
4. Industry vs inferiority
a. 6 - 12 years
b. Creative; develop sense of
competency vs sense of inadequacy
Psychosocial Model
(Erikson)
5. Identity vs role confusion
a. 12 - 20 years
b. Develop sense of self; preparation,
planning for adult roles vs doubts
relating to sexual identity,
occupational career
6. Intimacy vs isolation
a. 18 - 25 years
b. Develop intimate relationship with
another; commitment to career vs
Psychosocial Model
(Erikson)
7. Generativity vs stagnation
a. 21 - 45 years
b. Productive; use of energies to guide
next generation vs lack of interests,
concern with own needs
8. Integrity vs despair
a. 45 years to end of life
b. Relationships extended, belief that
own life has been worthwhile vs
lack of meaning of one’s life, fear of
Interpersonal theory
 This concept focuses on
interaction between an
individual and his environment
 Personality is shaped through
“interaction” with significant
others
 We internalize approval or
disapproval form our parents
Personality has three SELF-
SYSTEM
1. “Good Me” develops in
response to behaviors receiving
approval by parents/SO
2. “Bad Me” develops in response
to behaviors receiving
disapproval by parents/SO
3. “Not Me” develops in response
to behaviors generating extreme
Mental Health is Viewed as:
2. Related to conflict or
problematic interpersonal
relationships
3. Past relationships,
inappropriate communication
and current relationship crisis
are etiologic factors of mental
illness
Treatment of Mental illness:
 Focuses on anxiety and its
causes
 Therapeutic relationship with
client that is active and
participative
 Feelings and emotions are
verbalized by the clients to
modify problematic
relationships
Usefulness in Nursing
 Nurse and client can participate
in and contribute to the
relationship that is therapeutic
 This relationship can be used as
a corrective interpersonal
experience
 Anxiety management
Interpersonal Model
(Sullivan)
1. Infancy
a. 0 - 18 months
b. Others will satisfy needs
2. Childhood
b. Learn to delay need gratification
3. Juvenile
a. 6 - 9 years
b. Learn to relate to peers
Interpersonal Model
(Sullivan)
4. Preadolescence
a. 9—12 years
b. Learn to relate to friends of same
sex
5. Early adolescence
a. 12—14 years
b. Learn independence and how to
relate to opposite sex
6. Late adolescence
a. 14—21 years
b. Develop intimate relationship with
Cognitive Theory
 This theory focuses on the
inborn development of thinking
ability from infancy to adulthood
 A person is born with a tendency
to organize and to adapt to their
environment
 Mental illness is not directly
discussed
Cognitive Theory
Usefulness of Cognitive theory in
Nursing
2. This provides an understanding
how an individual think and
communicate. Nurse can
provide intervention
accordingly
3. Nursing interventions should
be congruent to the age-
specific cognitive level
4. Teaching strategies are
Piaget
 Sensori-motor (birth to 2 )
 Pre-operational (2-7)
 Preoperational preconceptual (2-4)
 Preoperational intuitive (4-7)
 Concrete operational (7-12)

 Formal operational (12 to adulthood)
Cognitive Theory
(Piaget)
A. 0 - 2 years: sensorimotor
-reflexes, repetition of acts
B. 2 - 4 years:
preoperational/preconceptual
-no cause and effect reasoning;
egocentrism; use of symbols;
magical thinking
C. 4 - 7 years:
intuitive/preoperational
Cognitive Theory
(Piaget)
D. 7 - 11 years: concrete
operations
- uses memory to learn
- aware of reversibility
E. 11 - 15 years: formal operations
-reality, abstract thought
-can deal with the past, present
and future
Behavioral Theory
 This concept describes a
person’s function in terms of
identified BEHAVIORS
 People learn to be who they are
 Behavior can be observed,
described and recorded
 Behavior is subject to reward or
punishment
 Behavior can be modified by
changing environment
Behavioral Theory
 The Classical Conditioning by
Pavlov
 Learning can occur when a stimulus
is paired with an unconditioned
response
 Conditioned responses happens
when stimulus is present
 Acquisition – gain of learned
response
 Extinction – loss of learned
response
Behavioral Theory
 The Operant Conditioning by
Skinner
 Rewards and punishments are
utilized
 Positive reinforcement- rewards
 Negative reinforcement-
 Positive punishment
 Negative punishment- withdrawing

reward
Behavioral Theory
Mental Illness is viewed as:
 Mal-adaptive BEHAVIORS are
learned through classical and
operant conditioning
 Mal-adaptive behaviors can be
changed by altering environment
Behavioral Theory
Application to Nursing
2. The nurse assess both adaptive
and ,al-adaptive behaviors
3. The nurse and client
collaborate in identifying
behaviors that need to change
4. Behavioral modification
techniques are utilized by the
nurse in the treatment of
mental illness
Humanistic theory
 Human nature is positive and
growth centered and existence
involves search for meaning and
truth
 Maslow’s theory of Needs are
organized in a hierarchy
Humanistic theory
Mental illness in this framework
2. The failure to develop one’s
FULL potential leads to poor
coping
3. Lack of self awareness and
unmet needs interfere with
feelings of security
4. Fundamental human anxiety is
fear of death which leads to
existential anxiety
Humanistic theory
Application of the theory to
Nursing
2. NCR is based on positive
regard, respect and empathy
3. Nurses assess the spiritual
aspects of the client including
religion, love and relationships
4. Through reflective listening and
emphatic responses, the nurse
helps the client gain self-
understanding
KOHLBERG’S
STAGES OF
MORAL
DEVELOPMENT
PRECONVENTIONAL
LEVEL
 Stage 1 Age 2-
3
 Description:
 Punishment or obedience
(heteronomous morality)
 A child does the right things
because a parent tells him or
her to avoid punishment
PRECONVENTIONAL
LEVEL
 Stage 2 Age :
4-7
 Description:
 Individualism
 Child carries out actions to

satisfy own needs rather than
society’s. The child does
something for another if that
person does something for him
in return
CONVENTIONAL LEVEL level
2
 Stage 3 Age :
7-10
 Description:
 Orientation to interpersonal
relations of mutuality
 A child follows rules because of
a need to be a good person in
own eyes and in the eyes of
others
CONVENTIONAL LEVEL level
2
 Stage 4 Age :
10-12
 Description:
 Maintenance of social order,
fixed rules and authority
 Child follows rules of authority
figures as well as parents to
keep the system working
POSTCONVENTIONAL LEVEL level
3
 Stage 5 Age :older
than 12
 Description:
 social contract, utilitarian law
making perspective
 child follows standards of
society for the good of all
people
POSTCONVENTIONAL LEVEL level 3
 Stage 6 Age :older

than 12
 Descriptions:
 universal ethical principle
orientation
 child follows internalized
standards of conduct
Therapeutic
Relationships
 This is a nurse-client interaction
that is directed toward
enhancing the client’s well-being
(Isaacs)
 A relationship established
between a health care
professional and a client for the
purpose of assisting the client to
solve his problems
Therapeutic
Relationships
 The nurse- patient relationship is
characterized by a helping
process
 The nurse and client work together
for his benefit
 The nurse uses herself
therapeutically and this is achieved
by self-awareness
Therapeutic
Relationships
 The nurse- patient relationship
 Respect the client and vale as
individual
 Holistic care
 Maintain appropriate limits
 Covey empathy not sympathy
 Maintain honest and therapeutic

communication
 Encourage expression of feelings
Therapeutic
Relationships
ELEMENTS OF THE THERAPEUTIC
RELATIONSHIP
 Contract
 Boundaries
 Confidentiality
 Therapeutic Behaviors
Therapeutic
Relationships
ELEMENTS OF THE THERAPEUTIC
RELATIONSHIP
Therapeutic Behaviors
3. Genuineness = sincerity and
honesty
4. Concreteness= ability to
identify client’s feelings
5. Respect= shown through
consideration of patient as
unique being
Therapeutic
Relationships
PHASES OF THE THERAPEUTIC
RELATIONSHIP
2. Pre-Interaction- Pre-orientation
3. Orientation- Interaction
4. Working
5. Termination
Therapeutic
Relationships
Phase Nursing Activities
Pre-interaction Nurse obtains data
from secondary
sources
Interaction- Nurse establishes
Orientation trust, assess client,
establishes mutual
Working agreement
Nurse assists the
client to meet goals
and resolve problems
Termination Nurse and client
express feelings about
termination, observes
regressive behaviors
Orientation
 Establishment of goals, rules,
boundaries etc..
 Rapport is built
 Identify expectations
 Trust is gained
 Assessment is done
 Goals are defined
 Contract is made
Working/Exploration/Identif
ication
 Problems are identified
 Solutions are explored, applied
and evaluated
 Nurse assists the client to
develop coping skills, positive
self concept and independence
 Promote insight and the use of
adaptive coping mechanisms
Termination/Resolution
 Nurse terminates the
relationship based on mutually
agreed goals when these are
already achieved
 Focus of this stage is growth
that has occurred
 Client may become anxious and
reacts
 Nurses must help patient resolve
the anxiety and ends the
Therapeutic
Communication
 Therapeutic communication
 Dynamic process of exchanging
information
 Composed of verbal and non-verbal
techniques that the nurse uses to
focus on the client’s needs
Therapeutic
Relationships
Therapeutic communication :
ELEMENTS
2. Sender- the source of message
3. Message- the information

transmitted
4. Receiver- recipient of message
5. Feedback- receiver’s response

to the message
Therapeutic
Relationships
NON VERBAL COMMUNICATION
2. Proxemics- the physical space
between the sender and
receiver
3. Kinetics- the body movements
such as gestures, facial
expressions and mannerisms
4. Touch- intimate physical
contact
Therapeutic
Relationships
NON VERBAL COMMUNICATION
4. Silence
5. Paralanguage- voice quality
(tone, inflection) or how a
message is delivered
Therapeutic
Relationships
VERBAL COMMUNICATION
 Use of therapeutic
communication techniques
 Effective communication should
be therapeutic, appropriate,
simple, adaptive, concise and
credible
Therapeutic
Communication
Open ended questions
Focus on FEEELINGS
State behaviors observed
Reflect, restate, rephrase
Neutral responses
Therapeutic
Communication
Offering self I am here to help
you
Active listening Eye to eye contact
Exploring Tell me more

about…,.
Broad Openings What do you want
to talk about
Making You seemed
observation depressed
Therapeutic
Communication
Summarizing A few minutes ago, we
were talking about..
Then…
Voicing doubt I find it hard to
believe
Encouraging What are these voices
description of telling you
perception
Presenting reality The sound is produced
by the car
No one is in the room
Seeking clarification I am not sure of what
you mean
Therapeutic
Communication
Verbalizing the Are you saying you
implied want to kill yourself?
Reflecting Do you think you
should?
Restating P: I cant sleep at night
N: You cant sleep at
General leads night
GO on… ? then….
Hmm….you were
saying….
Focusing Lets talk more about
what you think of your
problems
Non-therapeutic
communication
 These are blocks to
communication
 Usually, these are the common
pitfalls of communicating non-
therapeutically:
 Giving advise
 Talking about self
 Telling client is wrong
 False reassurance
 Cliché’
 Asking ‘Why’
Non-therapeutic
communication
Making judgment You are wrong
False reassurance It’s going to be alright
Invalidation I cannot talk now, I’m

busy
Focusing on self I am the best nurse to
care for you
Changing the subject P: I’m afraid of the
surgery
N: Ho many children
Giving advice do
If Iyou have
were you, I will
Non-therapeutic
communication
Agreeing Yes I think you are
right
Disapproving I don’t want you to do
that
Defending This hospital is the
best
Requesting “why”
explanation
Cliché There is the sun after
the rain
Belittling feelings P: I’m so depressed
today
N: everyone feels sad
Proxemics
Distances
INTIMATE= Touching to 1 ½ ft
PERSONAL= 1 ½ to 4 ft
SOCIAL= 4 to 12 ft
PUBLIC= 12 to 15 ft
Psychiatric Nursing
Process
 Applies to all clients
 Utilizes unique process for
psychological assessment
 Similar to other types of nursing
process approaches
Psychiatric Nursing
Process
Nursing ASSESSMENT
Nursing History
Physical Examination including the
Neurological examination
Laboratory Examination
Psychiatric Nursing
Process
 Nursing ASSESSMENT
 Refers to the scientific process of
identifying a patient’s psychosocial
problems, strengths an concerns
 Interview is done to acquires broad
information about a client
Psychiatric Nursing
Process
 MENTAL STATUS ASSESSMENT
 Level of consciousness
 General appearance
 Behavior
 Speech
 Mood and affect
 Judgment
 Memory
 insight
Psychiatric Nursing
Process
 Observation of mood and affect
 Assessment of thought, sensorium
and intelligence
 Speech and content
 Assess developmental status and

family-cultural-spiritual background
Psychiatric Nursing
Process
 Emotional status
 Cognitive assessment
 Socio-cultural assessment
Psychiatric Nursing
Process
 Physical Examination
 Observation for key signs
 Diagnostic Tests
 CT, MRI, PET, EEG
 Laboratory tests= CBC,
Electrolytes, Drug levels
Psychiatric Nursing
Process
 Other diagnostic tests
 Beck depression inventory
 Minnesota multiphasic personality
inventory
 Draw-a person test
 Sentence completion test
 Thematic aperception test

Psychiatric Nursing
Process
 Nursing Diagnoses
 Anxiety
 Ineffective coping- individual,
family
 Fatigue
 Fear
 Sleep pattern disturbance
 Altered thought process
 Etcetera
Psychiatric Nursing
Process
 Nursing Objectives
 Short term goals are set for
immediate problems, feasible
and within client's capabilities
 Long term goals are related to
discharge planning and
prevention of recurrence of
symptoms
Psychiatric Nursing
Process
 Nursing Objectives: The client
will:
 Participate in treatment program
 Becomes oriented to three spheres
and exhibit reality-based behaviors
 Recognize reasons for behavior
 Maintain self-care activities

Psychiatric Nursing
Process
 Nursing Interventions
 Use of therapeutic communication
 Therapeutic Groups
 Psychotherapy: Family, Milieu,

Behavioral modification, Crisis
intervention, Psychopharmacology
 Electroconvulsive therapy
Psychiatric Nursing
Process
 Nursing Evaluation
 Determine if goals are met by
collecting data and comparing them
to baseline
 Clients’ behavior should
demonstrate optimal orientation to
reality and interaction with others
appropriately
Treatment Modalities
1. Therapeutic Environment- Milieu
2. Therapeutic Groups
3. Crisis intervention
4. Family therapy
5. Behavioral modification
6. Cognitive therapy
7. Psychotherapy
Therapeutic environment
 Research has documented that
the environment in which the
mentally ill person is treated is a
major factor in enhancing or
impeding the therapeutic effects
of other treatment modalities
Characteristics of a Therapeutic
environment
2. The clients’ physical needs are
met
3. The client is respected
4. Decision making authority is

clearly defined
5. Client is protected from injury
(self and others)
Characteristics of a Therapeutic
environment
5. Clients are allowed freedom of
choice commensurate to his
ability to decide
6. Nursing Personnel remain
constant and assignments are
stable
7. Emphasis is placed on social
interaction between clients and
Therapeutic Modalities
Milieu therapy
 Total environment has an effect on
the person’s behavior- physical,
emotional, relationships
Purposes of therapy
3. Improve client’s behavior
4. Involve client in decision
making
5. Increase autonomy and
communication
6. Set structure of unit and
Milieu therapy
 The surrounding is made
positive to effect behavioral
changes in the prescribed
directions
 Goals of milieu therapy: to help
patient develop sense of self-
esteem, personal growth,
improve ability to relate to
others and return to the
community better prepared
Therapeutic modalities
Milieu therapy
 The nurse involves the client in
decision making
 The nurse promotes the
involvement of staff in care
 Social skills are developed and
sense of community is fostered
Therapeutic Groups
 A treatment approach in which the
entire milieu is used as treatment
 This includes the physical
environment and the others clients
Therapeutic Groups
Group Therapy
 Involves meaningful interaction
between members of a group as
they relate their personal
experiences to each other
 The main objective is for each
group member to examine his own
behavior and relationship. The
group can influence to change his
behavior and relationships
Therapeutic Groups
 Groups of clients meet with one
or more therapists to work
together to solve client problems
Therapeutic Groups
 Purposes
 To increase self-awareness
 To improve interpersonal
relationships
 To make changes in behavior
 To enhancing group teaching and

learning
Therapeutic Groups
 Structure of the Therapeutic
Group
 One leader chosen by the group
 Members
 Size is usually 10
 Physical arrangement
 Time and place of meeting

Therapeutic Groups
Phases of group development
2. Beginning phase
 Info given, anxiety heightened
3. Middle phase
 Confrontation, cohesiveness, trust
and self-reliance
4. Termination phase
 Goals of the group are achieved
 Individuals leave the group when
work is done
CRISIS
 A disturbance caused by a
precipitating event such as
perceived loss, a threat of loss
or a challenge that is perceived
as a threat to self.
CRISIS
Can be classified as to
maturational crisis, situational
crisis or adventitious crisis
 Maturational= role changes
 Situational= loss of job, death
 Adventitious= fires, earthquakes

and floods
 In a crisis, the person’s usual
methods of coping are
 Characteristics of Crisis:
 It is sudden
 It is short term may last for 4-6
weeks
 Individualized
 The person becomes dependent and

overwhelmed
Factors that can produce crisis
 1. Hazardous EVENTS
 2. Threat to the individual’s

equilibrium
 3. Inadequate coping skills
 There are four PHASES of Crisis

(DIDA)
 Denial
 Increased Tension- when the person
knows the existence of crisis and
still continues ADL
 Disorganization= pre-occupied and
unable to perform function
 Attempts to Reorganize= by
CRISIS INTERVENTION
 A technique of helping the person
go through the crisis
 To mobilize his resources
 To help him deal with the here and

now
 A five step problem solving
technique designed to promote a
more adaptive outcome including
improved abilities to cope with
future crises
Goal of Crisis intervention: help the patient
go back to his state of optimum level of
functioning
 IDENTIFY the problem- A solution is not
possible unless the problem be identified.
 LIST alternatives- all possible solutions to
the problem need to be listed.
 CHOOSE from among the alternatives-
each options is carefully considered, and
the alternative chosen is usually highly
individualized, based on priorities and
values of the person
 IMPLEMENT the plan- the alternative is
put into action. The nurse may need to
support and encourage patient to take
action
 EVALUATE the outcome- the effectiveness
Family therapy
 An approach in which the
therapist focuses on the
behavior of the entire family as
a system instead of focusing on
the pathology of one member
Family therapy
 Focuses on the client as a ‘family”
 Involvement of family members
Purposes of family therapy
3. Improve relationships among family
members
4. Promote family functions
5. Resolve family problems
6. Help family find ways to cope with

problems
Family therapy
 Problems are identified by each
family members and each
discusses his/her involvement
in the problem
 Members discuss how problems
affect them and they explore
how to solve them
Family therapy
 The nurse functions to assess
the family interactions, makes
observations and encourages
expression of feelings
 Helping the family resolve the
problem is the goal
Behavioral Modification
 Therapy to change the
unacceptable behavior to
acceptable
 The nurse determines the
unacceptable behaviors and she
identifies adaptive behaviors
 Punishment is given to
unacceptable behavior
 Reward is given to acceptable
behavior
Behavioral Modification
 Other Behavioral therapies
1. Self-control therapy
2. Aversion therapy
3. Desensitization
4. Modeling
5. Operant conditioning
Cognitive therapy
 An active, directive, time-
limited approach
 Therapeutic techniques are
used to identify reality testing
 The nurse helps the patient
think and act more realistically
and adaptively about his
problems
Play therapy
 Therapy with children in which
they are helped to express
themselves or their behavior
through play
Therapeutic Modality:
Psychotherapy
 A method of treating mental
illness in which verbal and
expressive techniques are used
to help the person resolve inner
conflict and modify behaviors
Psychotherapy
1. Psychoanalysis
2. Client centered therapy
3. Rational emotive therapy
4. Gestalt therapy
5. Reality therapy
6. Transactional analysis
Psychotherapy
1. Psychoanalysis
 THE therapist obtains information
about the past and present
experiences that have repressed
in the person’s subconscious mind
 By learning the source of the
problem, the problems can be
brought to the conscious where
the therapist helps the individual
dealt with them
Psychotherapy
2. Client Centered therapy
 The therapist work with one client
 Accepting, non-judgmental
environment aimed at reducing
the anxiety and reducing negative
defenses
 The patient is encouraged to
express his feelings and increase
self-awareness
 When the person is aware of what
he feels, he can work on improving
Psychotherapy
3. Rational-Emotive therapy
 This is based in the assumption
that a person’s behavior is due to
his own thinking
 Problems arise as the person
believes about eh events
 The therapy aims to change the
person’s belief system
Psychotherapy
4. Gestalt Therapy
 The mind receives experiences as
a whole
 When the experience is complete,
the problem will arise
 The goal of the therapy is to help
patients complete the experience
through awareness
Psychotherapy
5. Transactional Analysis
 A group therapy method
 Helps people “analyze” their
transaction or interaction with
others and guides them to the
conclusion: I’m OK you are OK
Responses to Illness
 Stress
 Anxiety
 Crisis
 Anger and hostility
Importance of studying
stress
 It provides a way of
understanding the person as
a holistic being
 Nurses must also learn to

cope with stress in their work
and life as they are subjected
to the demands of their
career.
Stress and Adaptation
 STRESS
 A condition in which the person
responds to changes in the
normal balanced state
 Selye: non specific response of
the body to any kind of
demand made upon it
 Any event – environmental /
internal demands or both tax or
exceed the adaptive resources of an
 STRESSOR
 Any event or stimulus that causes
an individual to experience stress
 They may neither positive or
negative, but they have positive
or negative effects
 Internal Stressor (illness,
hormonal change, fear)
 External Stressor (loud noise,
cold temperature)
 Developmental Stressor
 Situational Stressor
 COPING- a problem
solving process that the
person uses to manage
the stresses or events
with which he/she is
presented.
 ADAPTATION- the process

by which human system
modifies itself to conform
to the environment. It is a
change that results from
response to stress.
SOURCES OF STRESS
2. Internal
3. External
4. Developmental
5. Situational
Stress Characteristics
 It is a universal phenomenon.
 It is an individual experience.
 It provides stimulus for

growth and change.
 It affects all dimension of
life.
 It is not a nervous energy.
Effects of Stress on the
Body
 Physical- affects physiologic
homeostasis
 Emotional- affects feeling towards
self
 Intellectual- influences perception
and problem solving abilities
 Social – can alter relationships with
others
 Spiritual- affects one’s beliefs and
values
Effects of Stress on the
Body
 Metabolic Disorders  CVD
 Coronary artery
 Hyper/hypothyroi
dism disease
 Essential
 Diabetes hypertension
 Cancer  CHF
 Accident proneness  GIT disorders
 Skin disorders  Constipation
 Eczema  Diarrhea
 Pruritus  Duodenal ulcer
 Anorexia nervosa
 Urticaria
 Obesity
 Psoriasis
 Ulcerative colitis
 Respiratory
disorders  Menstrual irregularities
 Asthma
 Musculoskeletal
disorders
 Hay fever  RA
 Tuberculosis 
GENERAL THEORETICAL
FRAMEWORKS FOR
UNDERSTANDING STRESS
Stress can be defined differently
by the three models
 STIMULUS
 RESPONSE
 TRANSACTION
Models of Stress
2. STIMULUS based models
4. RESPONSE based models
6. TRANSACTION based
models
Stress as a Stimulus
 When viewed as a
stimulus, stress is
defined as an event or
set of events causing
a disrupted response
(Lyon and Werner,
1987)
 Life events or
circumstances causing
Stress as a Stimulus
 Holmes and Rahe 1967: They
studied the relationship
between specific life changes
such as divorce or death, and
the subsequent onset of illness.
 Focus: disturbing events within
the environment
 Advantage: the scale identifies
events stressful for most
people
 Disadvantage: does not provide
individual differences in
perception and response to
Stress as a Transaction
 Views the person and

environment in a dynamic,
reciprocal and interactive
relationships (Lazarus,
1966 )
 Mental and physiologic
(adaptive and affective)
responses to stress
 The transactional stress theory
includes cognitive, affective, and
adaptive responses from person
and environment interaction. The
person responds to perceived
environmental changes by coping
mechanisms.
 Transactional theory of stress

emphasizes that people & groups
differ in their sensitivity &
vulnerability to certain types of
 Includes mental & psychologic
components or responses as part of
his concept of stress
 takes into account cognitive
processes that intervene between the
encounter & the reaction
 encompasses a set of cognitive,
affective & adaptive (coping)
responses that arise out of person-
environment transactions.
 Cognitive appraisal: evaluative
process determines why & to what
Stress As a Response
 Disruptions caused by harmful
stimulus or stressors
 Specifies particular response or
pattern of responses that may
indicate a stressor
 Selye (1976): developed models
of stress, that defines stress as
a non-specific response of the
body to any demand made on it
 Focus: reactions of the BODY
 Selye used the term “stressor’
as the stimulus or agents that
evokes a stress response in the
person .
 A stressor may be anything that
places a demand on the person for
change or adaptation.
 Hans Selye (1976) “ non-specific
response of the body to any kind
of demand made upon it
He called it “non-specific” because
the body goes through a number
of biochemical changes and re-
adjustments without regard to
the nature of the stress
producing agents.
 Any type of stressor may
produce the same responses in
 Advantage : response to
stress is purely physiologic;
determines physiological
response to stress
 Disadvantage: does not

consider individual
differences in response
pattern
Stress as a response
SELYE proposed two Stress
adaptation responses
2. General Adaptation
Syndrome
3. Local Adaptation
Syndrome
General Adaptation
Syndrome
 Physiologic responses of the whole
body to stressors
 Involves the Autonomic Nervous
System, and Endocrine System
 Occurs with the release of adaptive
hormones and subsequent changes
in the WHOLE body
General Adaptation
Syndrome
Three stages adaptation to stress for both GAS/LAS:
Stressor
Alarm reaction
Counter-
Shock phase shock
Phase
Epinephrine Cortisone
Normal
Stages of resistance state
Stages of exhaustion
Rest Death
General Adaptation
Syndrome
I. ALARM REACTION
 Initial reaction of the body; “ fight OR
flight” responses
 Mobilizing of the defense mechanisms
of the body and mind to cope with
stressors.
 SHOCK PHASE- the autonomic nervous
system reacts; release of Epinephrine
and Cortisol
 COUNTERSHOCK PHASE- reversal of
the changes produced in the shock
General Adaptation
Syndrome
II. STAGE OF RESISTANCE:
 The BODY stabilizes, hormonal levels
return to normal, heart rate, blood
pressure and cardiac output return to
normal
2 things may occur:
 Either the person successfully adapts
to the stressors and returns to
normal, thus resolving and repairing
body damage; or
 The stressor remains present, and
adaptation fails (ex. Long-term
terminal illness, mental illness, and
General Adaptation
Syndrome
III. STAGE OF EXHAUSTION:
 Occurs when the body can no
longer resist stress and body
energy is depleted.
 The body’s energy level is
compromised and adaptation
diminishes.
 Body may not be able to defend
self that may end to death.
General Adaptation
Syndrome
Stage 1 ALARM REACTION
Enlargement of adrenal cortex
Enlargement of lymphatic system
Increase in hormone levels
Stage 2 RESISTANCE PHASE

Shrinkage of adrenal gland to normal size
Lymph nodes closer to normal size
Hormone levels sustained
Stage 3 EXHAUSTION PHASE

Rest or death
Increase in hormone levels
Depletion of adaptive hormones
A-R-E
ALARM: sympathetic system is
mobilized!
RESISTANCE: adaptation takes
place
EXHAUSTION: adaptation cannot
be maintained
GAS
Hypothalamus
Anterior Pituitary Gland
Adrenal Gland
Adrenal Cortex
Adrenal medulla
Adrenal gland
Adrenal Gland
Adrenal Gland
Hormonal Changes
Adrenal Adrenal
Cortex Medulla
 MINERALOCORTICOIDS  NOREPINEPHRINE
 Aldosterone  Peripheral
 Na+ retention vasoconstriction
 WATER retention  Decreased blood to
 Protein anabolism kidney
 Increased renin
 GLUCOCORTICOIDS
 Cortisol
(angiotensin)
 EPINEPHRINE
 (Anti-inflammatory)  Tachycardia
 Protein catabolism  Increased myocardial
 Gluconeogenesis activity
 Increased Bronchial
dilatation
 Increased Blood
Local Adaptation
Syndrome
 Localized responses to stress
Ex. Wound healing, blood
clotting, vision, response to
pressure
 Adaptive: a stressor is necessary to
stimulate it
 Short- term
 Restorative: assist in homeostasis
Local Adaptation
Syndrome
Reflex Pain response:
 Localized response of the CNS to pain
 Adaptive response and protects
tissue from further damage
 Involves a sensory receptor, a
sensory serve to the spinal cord, a
connector neuron, motor nerve,
effector’s muscles. Example:
unconscious removal of hand from a
hot surface, sneezing, etc.
Inflammatory Response:
 Stimulated by trauma or infection,
thus preventing it to spread; also
promotes healing
FACTORS INFLUENCING RESPONSE
TO STRESS
 Age, Sex
 Nature of Stressors
 Physiological functioning
 Personality
 Behavioral Characteristics
 Level of personal control
 Availability of support system
 Feelings of competence
 Cognitive appraisal, Economic

Status
The MANIFESTATIONS OF
STRESS
INDICATORS OF STRESS
 Physiologic
 Psychological
 Cognitive
 Verbal-Motor
Physiological Indicators
 Dilated pupils
 Diaphoresis
 Tachycardia, tachypnea,
HYPERTENSION, increased blood flow to
the muscles
 Increased blood clotting
 Bronchodilation
 Skin pallor
 Water retention, Sodium retention
 Oliguria
 Dry mouth, decrease peristalsis
 Hyperglycemia
Remember these Physiologic
Manifestations of Stress
 Pupils dilate to increase visual

perception when serious threats
to the body arise
 Sweat production (diaphoresis)

increases to control elevated
body heat due to increased
metabolism
 Heart rate or pulse rate increases

to transport nutrients &
byproducts of metabolism more
effectively
 Skin becomes pale (Pallor)

because of constriction of
peripheral blood vessels to shunt
blood to the vital organs.
 BP increases due to
vasoconstriction of vessels in
blood reservoir (skin, kidneys,
lungs), due to secretion of renin,
Angiotensin I and II
 Increased rate/depth of
respiration with dilation of
bronchioles, promoting
hyperventilation and increased
oxygen uptake
 Mouth may become dry, urine

output may decrease. The
peristalsis of the intestines
decreases leading to
constipation
 For serious threats, there is

improved mental alertness
 Increased muscle tension to

prepare for rapid motor
activity/defense
 Increased blood sugar

(glucocorticoids &
gluconeogenesis) to supply
energy source to the body.
Psychological indicators
 Thisincludes anxiety,
fear, anger, depression
and unconscious ego
defense mechanisms
Anxiety
A state of mental
uneasiness, apprehension,
or helplessness, related to
anticipated unidentified
stress
 Occurs
in the Conscious,
subconscious, or
unconscious levels
Levels of Anxiety
4 Levels of Anxiety:
 Mild
 Moderate
 Severe
 Panic
Levels of Anxiety
 Mild- increased alertness, motivation
and attentiveness
 Moderate- perception narrowed,

selective inattention and physical
discomfort
Levels of Anxiety
 Severe- behaviors become
automatic, details are not seen,
senses are drastically reduced, very
narrow focus on specific details,
impaired learning ability.
 Panic- overwhelmed, unable to

function or to communicate, with
possible bodily harm to self and
others, loss of strong displeasure
Anxiety
ANXIETY
CATEGOR MILD MODERAT SEVER PANIC
Y E
E
Percepti Increas Narrowe Inability Distorted
on and ed d focus to focus perceptio
attention arousal n
Communication Increase Voice Difficult Trembling
d tremors to unpredicta
questioni Focus on understa ble
ng particular nd response
object Easily
VS NONE Slight distracte
Tachycar Palpitation
changes Increase d
dia, , choking,
Hyperven chest pain
tilation
Fear
 It is a mild to severe feeling of

apprehension about some
perceived threat.
 The Object of fear may or may not
be based on reality.
Anxiety versus fear
ANXIETY FEAR
State of mental Emotion of apprehension
uneasiness
Source may not be Source is identifiable
identifiable
Related to the future Related to the present
Vague Definite
Result of Result of discrete physical
psychological or or psychological entity,
emotional conflict definite and concrete
events
Anger
 Subjective feeling of strong
displeasure
 It is an emotional state
consisting of subjective
feeling of animosity or
strong displeasure
Other terms related
Anger
 Hostility = marked by overt
antagonism & harmful or
destructive behavior
 Aggression = unprovoked
attack or a hostile, injurious,
or destructive action or
outlook
 Violence = exertion of
physical force to injure or
Depression
 Anextreme feeling of
sadness, despair,
dejection, lack of worth
or emptiness
Depression
Emotional Behavioral signs:
Symptoms:  irritability
 Tiredness  inability to
 emptiness concentrate
 numbness  difficulty making
Physical signs decision
 loss of appetite  loss of sexual
 weight loss desire
 constipation  crying
 headache
 dizziness
 sleep disturbance
 social withdrawal
COGNITIVE
MANIFESTATIONS
 Thinking responses that include
problem solving, prayer,
structuring, self control,
suppression and fantasy
 Thinking responses of the

individual toward stress
COGNITIVE
MANIFESTATIONS
 PROBLEM SOLVING: Use of specific
steps to arrive at a solution
 STRUCTURING: manipulation of a
situation so that threatening events
do not occur
COGNITIVE
MANIFESTATIONS
 SELF CONTROL / DISCIPLINE:
assuming a sense of being in control
or in charge of whatever situation
 SUPPRESSION: willfully putting a

thought / feeling out of one’s mind
COGNITIVE
MANIFESTATIONS
 FANTASY / DAYDREAMING: “
make believe” or imagination of
unfulfilled wishes as fulfilled
 PRAYER: identification, description

of the problem, suggestion of
solution, then reaching out for help
or support to the supreme being
VERBAL / MOTOR
MANIFESTATIONS
 First hand responses to stress

VERBAL / MOTOR
MANIFESTATIONS
 CRYING: feelings of pain, joy,

sadness are released
 VERBAL ABUSE: release

mechanism toward non living
objects, and stress producing events
 LAUGHING: anxiety reducing

response that leads to constructive
problem solving
VERBAL / MOTOR
MANIFESTATIONS
 SCREAMING: response to fear or

intense frustration and anger
 HITTING AND KICKING:

spontaneous response to physical
threats or frustrations
 HOLDING AND TOUCHING:

responses to joyful, painful or sad
events
FACTORS INFLUENCING
STRESS
DEPEND ON THE
 Nature of the stressor
 Perception of the stressor
 Number of simultaneous stressor
 Duration of exposure to the
stressor
 Experiences with a comparable
stressor
 Age of the individual
 Support people
Personality Types
TYPE A
 impatient, competitive,
aggressive, and insecure,
always in a hurry,
inability to relax
 Prone to cardiovascular
illness.
Personality Types
TYPE B
 more relaxed, unhurried,
able to enjoy both work and
play without guilt
Personality Types
TYPE C:
 “coping personality” experiences
considerable stress but learns to
cope with it (challenge,
commitment,& control) , uses
personality characteristics to cope
with stress
Coping Characteristics of Type C:
 Challenge
 Commitment

COPING
 A problem solving process or

strategy that the person uses to
manage the out-of-ordinary
events or situations with which
he/she is presented.
 Successfully dealing with
problems
 A cognitive and behavioral effort
to manage specific external and
internal demands that are
Coping related terms
 Coping strategy- is a coping
mechanism, way of responding to
problems
 Problem focused coping- efforts to
improve a situation by making
changes
 Emotion focused coping- includes
thoughts and actions that relieve
emotional stress
Coping related terms
 Long term coping- involves
constructive and realistic changes
 Short term coping- involves stress
reduction to tolerable levels
temporarily
 Adaptive coping- helps person deal
effectively with stress
 Maladaptive coping- results in
unnecessary distress for the person
and stressful events
MODES OF ADAPTATION
1. Physiologic mode (biologic
adaptation)
 Occurs in response to increased or
altered demands placed on the body
& results in compensatory physical
changes.
2. Psychological Mode
 Involves a change in attitude &
behavior toward emotionally stressful
situations. (Ex. Stopping smoking)
3. Socio-cultural Mode
 Changing persons behavior in
CHARACTERISTICS OF ADAPTIVE
RESPONSES
 All attempts to maintain homeostasis

 Whole body or total organism
response
 Have limits (Physiologic,
Psychologic/Social)
 Requires time
 Varies from person to person
 Maybe inadequate or excessive
(infection/allergy
MANIFESTATIONS OF
ALTERED COPING
 Addictive behaviors
 Physical illness
 Anxiety and depression
 Violent behaviors
Applying the Nursing
Process
 A
 D
 P
 I
 E
Assessment
It is important that the nurse have an
understanding of the methods or
strategies used by the patient so
that nursing care can be
appropriately individualized.
1. Utilize the Nursing History
 Subjective data- such as the
functional pattern, risk pattern and
dysfunctional pattern.
2. Physical Examination – centered on
the changes in the ANS and NES.
Objective data- Physical assessment,
Diagnostic tests and procedures
Diagnoses
Utilize those accepted by NANDA
2. Anxiety 7. Fear
3. Caregiver role strain 8. Impaired
adjustment
4. Compromised family coping 9.
Ineffective coping
5. Decisional conflict 10. Ineffective
Denial
6. Defensive coping 11. Post-trauma
Syn
7. Disabled Family coping 12. Relocation
Planning
The goals for the patient with ineffective
individual coping need to be
individualized, taking into
consideration the patient’s history,
areas of risk, evidence of dysfunction
and related objective data.
 There are four important guidelines to be
followed in choosing nursing goals. The
nurse must choose goals geared :
 To eliminate as many stressors as possible
 To teach about the effects of stress to the
body

Planning
Overall client goals are the following:
 To decrease or resolve anxiety
 To increase ability to manage or cope
with stress
 To improve role performance
Examples of Patient Goals are: After

___hours/days:
1. The patient will identify sources of
stress in his/her life
2. The patient will identify usual
personal coping strategies for
stressful situations
3. The patient will define the effect of
Implementation
 Once the diagnosis is made, the nurse
can intervene independently and
collaboratively to help restore function
 The nurse can assist the patient in
recognizing signs and symptoms of
stress, identifying the sources of
distress, and choosing an appropriate
course of action.
 The nurses can assist the patient in
finding techniques that are most
effective.
 The nurse also has significant role in
identifying people at risk for
Implementation
There are essentially three
ways to manage Stress:
 Eliminate the causes/sources
of stress
 Produce a relaxation
response in the body
 Suggest a change in lifestyle,
if possible
Implementation
Stress reduction techniques:
 Proper nutrition
 Regular exercise, physical activity &
recreation
 Meditation, Breathing exercises,
creative imagery, YOGA
 Communication, time management,
expression of feeling, talking it out,
organizing time
 Biofeedback
 Therapeutic touch
Implementation
1. Minimize anxiety
2. Mediate anger
3. Massage
4. Progressive relaxation
5. Guided imagery
6. Biofeedback
7. Therapeutic touch
8. CRISIS INTERVENTION
Implementation
Minimize anxiety
 Support the client and the family
 Orient the client to the hospital or
agency.
 Give the client in a hospital some way
of maintaining identity.
 Provide information when the client
has insufficient information.
 Repeat information when the client has
difficulty remembering.
 Encourage the client to participate in
the plan of care.
 Give the client the time to express
feelings and thoughts.
Implementation
Mediating Anger
 Responses that reduce the client’s anger
& stress
 offering help
 asking relevant questions
 conveying understanding
 Guidelines: to provide understanding
responses
 focus on the feeling words of the
client
 note the general content of the
message
 restate the feeling & content of what
the client has communicated

Implementation
Massage
 These include effleurage (stroking),
friction, pressure, petrissage
(kneading or large, quick pinches of
the skin, subcutaneous tissue and
muscle), vibration and percussion.
 Purposes
 -enhances or induces relaxation
before sleep
 -stimulates skin circulation
Implementation
Progressive Relaxation
 Jacobson (1930), the originator of
the Progressive relaxation technique
Implementation
Guided Imagery
 Imagery is "the formation of a mental
representation of an object that is
usually only perceived through the
senses" (Sodergren 1985). Example:
Visual -A valley scene with its
many greens
Auditory -Ocean waves breaking
rhythmically
Olfactory -Freshly baked bread
Gustatory -A Juicy hamburger
Implementation
 Biofeedback is a technique that brings
under conscious control bodily
processes normally thought to be
beyond voluntary command. muscle
tension, heartbeat, blood flow,
peristalsis, & skin temperature – can
be voluntarily controlled
feedback provided through:
 a. temperature meters (that indicate
temp. changes)
 b. EMG (electromyogram) that shows
Implementation
Therapeutic Touch
 “a healing meditation, because the
primary act of the nurse (healer) is to
"center" the self and to maintain that
center (mental concentration and
focusing) throughout the process.
The process consists of the following
four steps:
 Centering (sense of detachment,
sensitivity & balance)
 Assessing (head to toe scanning
process)
 Unruffling (to enhance the transfer of
energy from nurse to client)
Implementation
Therapeutic Touch
The form of energy has different
effects and is related to colors:
 Blue energy is sedating
 Yellow energy is stimulating and

energizing
 Green energy is harmonizing.
Evaluation
 The evaluation of the plan of care is
based on the mutually established
expected outcomes.
 It is important to observe BOTH
verbal and non-verbal cues when
evaluating the usefulness of the plan.
Evaluation
The nurse must be able to determine the
success of her action by:
 Observing the client for absence or
reduction of manifestations of fear and / or
anxiety.
 Measuring BP and Pulse Rate
 Asking the client’s personal strengths or
coping resources identified
 Determining Effective and ineffective
coping responses and consequences.
 Identifying Situations that use specific
adaptive coping method’s and the client’s
perception of their effectiveness
 Observing Support persons involved
Stress Management for
Nurses
 Plan daily relaxation program
Plan daily relaxation program
 Establish a regular pattern of
exercise
 Study assertive techniques.
Learn to say “no”
 Learn to accept failures
 Accept what cannot be changed
 Develop collegial support
 Participate in professional
Anxiety
 This is the most universal of all
emotions that cannot be observed
directly BUT must be inferred from
behavior
 This is defined as a “Sense of
impending doom” , an apprehension
of dread that seemingly has no basis
in reality
Characteristics of
Anxiety
 Always perceived as a negative
feeling
 Extremely communicable
 Cannot be distinguished from fear
easily
 Occurs in degrees: mild, moderate,
severe, panic
Origin of anxiety
 The PSYCHOSEXUAL theory believes
that anxiety is a response to the
emergence of the ID impulses that
are NOT acceptable to SUPEREGO
 The EGO detects a real or potential
conflict between the ID and the
SUPEREGO resulting to the
development of ANXIETY
Origin of anxiety
 BIRTH is the prototypical separation
anxiety- the threat to life and the
separation from the mother.
 In subsequent developmental
changes, unconscious conflicts are
perceived as life threatening
associated with separation
Origin of anxiety
 SULLIVAN views anxiety as
always occurring in an
interpersonal context
 ANXIETY is generated when the
individual anticipates or actually
receives cues that signal
disapproval from others
 Human being experiences
anxiety during infancy when
either his need for satisfaction
or his need for security is NOT
Adaptation to anxiety
 Use of unconscious ego defense
mechanisms
 Utilized when the person
experiences conflict between the id
and superego
 Use of security operations
 Identified by Sullivan
 Apathy, Somnolent detachment,
selective inattention and
preoccupation
 Use of coping mechanisms
 This is adaptation to anxiety based
on conscious acknowledgement of
GRIEF AND LOSS
 Loss is a universal experience

that occurs throughout life span
 Grief is a form of sorrow

involving feelings, thoughts, and
behaviors caused by
bereavement
GRIEF AND LOSS
 Responses to loss are strongly

influenced by one’s cultural
background
 The grief process involves a
sequence of affective, cognitive,
and psychological states as a
person responds to, and finally
accepts a loss.
Loss and grieving
 LOSS= something valuable is gone
 GRIEF= total response to emotional
experience related to loss
 BEREAVEMENT= Subjective
response by loved-ones
 MOURNING= behavioral response
GRIEF AND LOSS
Stages of Grieving (Kubler-Ross)
 Denial- refuses to believe that the
loss has occurred
 Anger- the individual resists the loss
and may “act out” feelings.
 Bargaining- the individual attempts to
make a deal in an attempt to
postpone the reality of loss.
 Depression- overwhelming feeling of
loneliness and withdrawal from
others
 Acceptance- the individual comes to
terms with loss, or impending loss,
psychological reactions to loss to the
loss cease, and the interaction to
Loss and grieving
Stages of Grieving (Kubler-Ross)
DABDA
DENIAL= refusal to believe
ANGER= hostility
BARGAINING= feeling of guilt, fear of
punishment
DEPRESSION= withdrawn behavior
ACCEPTANCE= comes to terms with
loss
Loss and grieving
Stages Behaviors
D Refuses to
believe that loss
A is happening
Retaliation
B Feelings of guilt,
punishment for
D sins
Laments over
what has
A happened
Begins to plan
like wills,
prosthesis
Death and Dying (Kozier)
AGE Beliefs
Infancy to 5 NO clear concept of
years old Death
5 to 9 years It is Reversible,
Understands temporary
DEATH is
sleep
FINAL but can be AVOIDED
9-12 years Death is INEVITABLE,
everyone will die someday
Understands own
12-18 years mortality
Fears a lingering Death
18-45 Attitude is influenced by
religion
45-65 years Experiences peak of death
anxiety
65 and above Death as multiple meanings
Nursing responsibilities
In Death and dying
 Nurses need to take time to
analyze their own feelings
about death before they can
effectively help others with
terminal illness
Nursing responsibilities
In Death and dying
 The major goals for the dying
clients are:
2. To maintain PHYSIOLOGIC
and PSYCHOLOGIC support
3. To Achieve a dignified and
peaceful death
4. To maintain personal control
Loss and Death
RESPONSIBILITIES
 Provide Relief from loneliness,
fear and depression
 Help clients maintain sense of
security
 Help clients accept losses
 Provide physical comfort

LOSS ,GRIEVING AND
DEATH
 DEATH CONCEPTS
 1-5 – IMMOBILITY AND INACTIVITY
Wishes and unrelated action
responsible for action
 5-10 – final but can be avoided
 9-12 – understands own mortality
and fears death
 12 – 18 – fears and fantasizes
avoidance
 18-45 – increased attitude
awareness
 45-65 – accepts mortality
KUBLER ROSS – STAGES OF
GRIEF
 D – SUPPORTIVE
 A- PROVIDE STRUCTURE AND CONTINUITY
 B – LISTEN AND ENCOURAGE
 D- ALLOW EXPRESSION AND PROVIDE FOR

SAFETY
 A- ENCOURAGE PARTICIPATION
Neurosis
 any long term mental or behavioral
disorder in which contact with reality
is retained the condition is
recognized by the patient as
abnormal. Essentially features
anxiety or behavior exaggerated
designed to avoid anxiety
 ( anxiety disorder ; hysteria to
conversion d/o, amnesia, fugue,
multiple personality and
depersonalization- Dissociative d/o
;oc d/o)
 Result of inappropriate early
Psychosis
 Mental or behavioral disorder
wherein patient looses contact
with reality
 Presence of delusions,
hallucinations, severe thought
disturbances, alteration of mood,
poverty of thought and abnormal
behavior
 (schizophrenia , major disorder
of affect ( mania –
depression), major paranoid
states and organic mental
Mental disorders
Neurosis Psychosis
 Does not require  Requires
hospitalization hospitalization
 Considered moderate  MAJOR reaction to
reaction to stress stress

 Reality testing is
 Reality testing
remains sound
GREATLY impaired
 Patient does not
 Patient feels
recognize he is ILL
suffering and wants  Patient denies
to get well
reality and
 Ignores reality
substitute
 Exploits symptoms something else
for secondary gain  NO secondary gain is
 Desires are not derived from the
externalized symptoms
 Desires and motives
 Personality remains
are often PROJECTED
Normal Anxiety Versus
Abnormal Anxiety
Normal Anxiety
 A protective response and innate
form of communication that the body
uses to mobilize its coping resources
to maintain homeostasis.
 Arises from a realistic apprehension
of a previously un-encountered
situation that has symbolic meaning
to the person
Normal Anxiety Versus
Abnormal Anxiety
PATHOLOGIC Anxiety
 A response to thoughts, feelings,
desires that if Conscious would be
UNACCEPTABLE to the individual;
that if known, would cause the loss of
approval or love from others
Anxiety Disorders
 The MOST common of all
psychiatric disorders
 Cause an individual to feel
frightened, distressed an uneasy
mostly without a specific cause
Anxiety Disorders
 Panic disorder (with or without
agoraphobia)
 Specific phobia
 Social phobia
 Obsessive-compulsive disorder
 Post traumatic stress disorder
 Acute stress disorder
 Generalized anxiety disorder
Anxiety Disorders
 Major manifestations for all
types:
2. Autonomic nervous arousal
3. Sense of doom
4. Depersonalization
5. Avoidant behaviors
6. Paresthesias
7. Recurrent attacks of intense
fear or discomfort
Anxiety Disorders
Global Manifestations of Anxiety
disorders
2. Biological- tachypnea,
tachycardia, diaphoresis
3. Behavioral- rituals, avoidance,
increased dependence, clinging
4. Motor- tension, pacing, tremors,
restlessness
5. Cognitive- Sense of doom,
Confusion, Helplessness, Intense
fear, powerlessness
Anxiety Disorders:
Epidemiology
 Affects 15% of the population
 Most common reason for seeking
medical help
 Highest in adults
 Cultural factors may influence
anxiety disorders
Anxiety Disorders:
Etiology
 Psychodynamic theory
 Existential theory
 Behavioral theory
 Developmental theory
 Biological theory-
neurotransmitter and genetic
causes
Anxiety Disorders:
Etiology
Theory Explanation
Psychodynamic Anxiety occurs
theory when the ego
attempts to deal
with psychic
conflict or
emotional tension
If ego defense
mechanisms will
fail to protect the
ego, immature
Anxiety Disorders:
Etiology
Theory Explanation
Existential theory Human existence

and its relationship
to God is the
concept of this
theory
Sense of
nothingness
results in
inadequate coping
Anxiety Disorders:
Etiology
Theory Explanation
Behavioral theory Anxiety occurs

when there is
danger perceived.
Intense anxiety is a
learned
maladaptive
response to stress
and anxiety
Anxiety Disorders:
Etiology
Theory Explanation
Developmental Anxiety initially

theory occurs with
separation from
early primary care
givers
Anxiety Disorders:
Etiology
Theory Explanation
Biological theory Very high cortisol

level
Dysregulation of
benzodiazepine
receptors in the
CNS
Hereditary
Anxiety Disorders:
related terms
 Phobia= a specific pathological fear
Phobia= a specific pathological fear
reaction out of proportion to the
stimulus , irrational fear
 Simple phobia= persistent fear of a

specific object/situation
 Agoraphobia= fear of open spaces
 Social phobia= fear of embarrassing

situation in public places
Anxiety Disorders:
related terms
 Phobias and related disorders
 The individuals recognize the fear
as irrational but they feel
inadequate or powerless to control
the fear
 There may be genetic component
 Behavioral theory suggests that a

phobia results form a conditioned
response in which a person learns
to associate a phobic object with
uncomfortable feelings: the
avoidance of the object will reduce
Anxiety Disorders:
related terms
 Obsession= an undesirable BUT
persistent thought or intrusive
idea that is forced into conscious
awareness
 Compulsion= performance of an
unwanted act or ritual that is
contrary to the person’s wishes
or standard. The behavior is
done in a stereotypical and
Anxiety Disorders:
related terms
 Obsessive -Compulsive disorder
Obsessive -Compulsive disorder
 Recurrent obsession and
compulsion that are severe enough
to be time consuming causing
marked distress or impairment of
functions
 Proposed etiology: Biologic
vulnerability, striatum dysfunction
theory and genetic vulnerability
 The most common obsessions are
repeated thoughts about
contamination, repeated doubts
 The most common compulsion
Anxiety Disorders:
related terms
 Obsessive -Compulsive disorder
 The client is WEL aware of his
unrealistic and inappropriate
nature of obsession and compulsion
 He uses the defense mechanisms of
: UNDOING and SYMBOLIZATION
 Indulgence in obsessive thoughts
and performance of the behaviors
causes temporary anxiety relief ( a
primary gain)
Anxiety disorders
 Post-traumatic stress disorders
(PTSD) = characterized by the
re-experiencing of the terror
associated with a psychologically
distressing event that was
actually experienced at an
earlier time.
 Former names: hysteria, war
shock, battle fatigue
 The event is usually beyond the
breath of normal human
Anxiety disorders
Post-traumatic stress disorders
 Major characteristics:
3. Persistent recurrent and

intrusive thoughts, flashbacks,
dreams and intense
psychological distress
4. Avoidance behaviors
(depersonalization)
5. Emotional numbing, hyper
vigilance and ANS arousal
Anxiety disorders
Generalized anxiety disorder=
characterized by unrealistic or
excessive anxiety, worry about
life circumstances
 Chronic anxiety, apprehensive
worrying, about 6 months
 Prevalence is 5 % in the general
population
 Women affected more than men
Anxiety disorders
Panic Disorder= sudden,
unanticipated intense anxiety
persisting for at least 1 month
 Profound fear and urge to escape
 Women more than men
 With agoraphobia= anxiety attacks

when in places or situation which
can be embarrassing
Nursing Process for
patients with Anxiety
Disorders
 Assessment
 Diagnosis
 Planning
 Implementation
 Evaluation
Nursing Process for
patients with Anxiety
Disorders
 Assessment
 Process begins with a complete
medical and physical examination
to RULE out underlying physical and
substance – related conditions
 Utilize the mental status
examination
Assessment: Anxiety
Disorders
 Assess activity process: Motor
restlessness, ritualistic behavior,
pacing, sleep pattern disturbances,
staying at home, avoidant behaviors
 Assess cognitive processes:

maintains reality testing,
verbalization of persistent thoughts,
nightmares
Assessment: Anxiety
Disorders
 Assess Emotional process: fearful,
feeling of anxiety, nervousness
 Assess Interpersonal process:

strained relationships
 Assess perception process: hyper-

alertness, low self-esteem
Assessment: Anxiety
Disorders
 Physiologic Assessment
 Tightness of stomach
 Tachycardia
 Anorexia
 Palpitation
 Shortness of breath
 Feelings of exhaustion
 Motor restlessness
 Alertness
Nursing Diagnoses: Anxiety
Disorders
 Ineffective individual coping
 Altered role performance
 Impaired social interaction
 Defensive coping
 Sleep pattern disturbances
 Altered thought process
 Anxiety
 Fear
 Powerlessness
Planning: Anxiety
Disorders
 The general nursing goals are to help
patients lower their anxiety, develop
functional pattern of adaptations and
develop awareness of the effects of
the disorders
Implementation: Anxiety
Disorders
Foster Activity process
 Allow the patient to carry out the
anxiety-releasing rituals for them to
develop security
 Provide time-limit to individual
rituals.
 Rituals may e schedule earlier so as
not to disrupt any hospital activity
 Help patient develop interests
outside himself by encouraging
involvement in activities
Disorders
Establish therapeutic relationship
with the client
 Teach the patient about the
etiology, course and treatment of
anxiety disorders
Disorders
Encourage verbalization of
concerns and feelings
 Utilize appropriate communication
techniques
 Convey warm, friendly and
emphatic attitude
 Introduce relaxation techniques and
other positive anxiety management
strategies
Disorders
Assist in Therapeutic modalities:
Cognitive and behavioral Therapy:
desensitization
Pharmacotherapy: use of the
anxiolytic drugs like
benzodiazepines
Disorders
Cognitive-Behavioral
Psycho- Therapy
Teaching the client and
education family about anxiety
disorders
Continuous Utilizing a diary or
symptoms recording of symptoms
monitoring
Breathing Teaching client how to
retraining do abdominal breathing
to control body
physiologic responses
Disorders
Cognitive-Behavioral
Cognitive- Therapy
Teaching the client to
restructuring challenge the
exaggerated worries
and fears.
Exposure to Involves gradual
triggering exposure of the anxiety
anxiety provoking or fearful
(desensitizati event
on)
Interventions for the client
with OCD
 Convey acceptance of the client
 Allow time to perform rituals
because ANXIETY will increase if
the client cannot perform the
compulsive behaviors
 Encourage LIMIT setting on
ritualistic behaviors
 The best time to interact with
client is AFTER completing the
ritualistic behavior
with OCD
 Assist the client in listing all of
the objects and places that
trigger anxiety
 Introduce coping techniques to
deal with the anxiety situations
with PHOBIA
 DO NOT force the client to
approach the specific object or
situation
 Allow clients to verbalize
feelings prior to exposure to
object
 HELP client identify coping
measures to utilize whenever the
object/ situation is encountered
 Practice relaxation with the
clients
with PTSD
 Validate with the client that the
traumatic event can be
experienced with a high anxiety
response
 Allow VERBALIZATION of feelings
in all aspects of the traumatic
events
 Teach the patient coping
strategies to manage symptoms
of anxiety that accompanies the
Evaluation
 Client identifies own anxiety
responses
 Identifies stressors in past and
current life situations
 Utilizes coping strategies rather
than symptomatic behaviors
 Identifies and actively
participates in continued
treatment plan
Anxiety-related
Disorders
 Dissociative disorders
 Somatoform disorders
Anxiety-related
Disorders
 Dissociative disorders
 Alteration in conscious awareness
which includes periods of
forgetfulness, memory loss for past
stressful events and feelings
disconnected form daily events
Anxiety-related
Disorders
Dissociative Characteristics
disorders
Dissociative Sudden inability to
amnesia recall important
personal
Dissociative fugue information
Sudden
unexplained flight
form home with an
inability to recall
events from the
past
Anxiety-related
Disorders
disorders
Depersonalization Feeling detached
disorder from one’s
Dissociative thoughts
Presence and body
of two or
identity disorder more distinct
personalities, each
with its own
pattern of
perceiving,
relating to and
thinking about the
Anxiety-related
Disorders
disorders
Dissociative Disorder that does
disorders not not fit the criteria
specified
Dissociative Disorders
 Etiology:
2. Trauma= these disorders are
generally associated with
traumatic events that the
individual deals with them by
“splitting” or dissociating self
from the memory
3. Abuse- severe traumatic
abusive event during childhood
More common in women than men
NURSING MANAGEMENT
 Establish a trusting relationship
and provide support during
times of depersonalization and
amnesia
 Encourage client to disclose and
discuss feelings
 Teach client to perform anxiety-
reducing techniques when the
painful events are re-
experienced
NURSING MANAGEMENT
3. Pharmacotherapy: usually not
employed
4. Psychotherapy: psychodynamic
therapy with hypnosis to bring
the conscious awareness of the
traumatic events
5. Group therapy
Psychosomatic Disorders
 Disorders characterized by somatic
complaints for which no organic
cause could be demonstrated
 Usually result from emotional factors
Characteristics:
2. Involve the organ system innervate
by the autonomic nervous system
3. Physiologic changes accompany
emotional responses that are
intense
4. Symptoms are physiological rather
than symbolic, the emotions beings
expressed through the viscera
5. Persistent psychosomatic reactions
may produce structural organic
changes over time
Characteristics:
5. The somatic symptoms afford
generous secondary gains for
the for the patients in terms of
attention
Somatoform disorders
 Refer to a group of psychiatric
disorders whose symptoms are
severe enough to cause global
impairment
 The clients often present with
multiple, recurrent clinically
significant somatic complaints,
usually colorful and exaggerated
hut lacking in factual basis
 The condition is characterized by
PRIMARY GAIN (relief of anxiety)
and SECONDARY gain (special
attention)
 The individual becomes totally
focused on the physical
symptoms which can severely
restrict activities
 The person visits MULTIPLE
health care providers and may
undergo unnecessary procedures
ETIOLOGIES
1. Psychodynamic theory=
utilization of the mechanism to
convert psychic energy to
physical manifestations.
Conversion represents the
symbolic resolution of the
anxiety
ETIOLOGIES
2. Neurobiologic theory-
neurotransmitter dysregulation.
There is deficient communication
between the brain hemisphere
resulting to difficult expression
of emotions, and distress is
expressed as physical symptoms
ETIOLOGIES
3. SOCIO-cultural factors- higher
among low SES
Types of Somatoform
disorders
Types Characteristics
Somatization History of multiple

Disorder physical
complaints without
Hypochondriasis organic basis
Unrealistic fear of
having a serious
Body dysmorphic disease
Pre-occupation
disorder with an imagined
defect in the
normal appearing
person
Types of Somatoform
disorders
Types Characteristics
Pain disorder Chronic pain in

many anatomic
Conversion sites
Loss or change in
disorder physical
functioning that
cannot be
associated with
any organic cause
and seems to be
associated with
NURSING MANAGEMENT
2. Mainstay treatment is a long
term relationship with a health
care provider to prevent the
patient from seeking multiple
providers with multiple
recommendations
3. Assist in psychotherapy as part
of the treatment plan
4. Family Education

Psychiatric Nursing - Foundations

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Psychiatric Nursing - Foundations

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Psychiatric

 Psychiatric Diagnostic Tests

 Psychiatric Nursing Diagnosis

 Grief and Loss

3. Freud- -Psychosexual theory

 Mental health programs

Interpersonal Harry Stack

Spiritual Theory FOWLER

 Freud believes that “repressed”

According to this theory,

Oral 0-18 Site of gratification: Mouth

Oral 0-18 Major task: Weaning

 Mental illness and

 Concrete operational (7-12)

 Negative punishment- withdrawing

 Child carries out actions to

 Stage 6 Age :older

 Maintain appropriate limits

 Covey empathy not sympathy

 Maintain honest and therapeutic

3. Message- the information

5. Feedback- receiver’s response

Exploring Tell me more

False reassurance It’s going to be alright

Invalidation I cannot talk now, I’m

 Assess developmental status and

 Sentence completion test

 Thematic aperception test

 Sleep pattern disturbance

 Altered thought process

 Maintain self-care activities

 Psychotherapy: Family, Milieu,

4. Decision making authority is

 To enhancing group teaching and

 Time and place of meeting

 Adventitious= fires, earthquakes

 The person becomes dependent and

 2. Threat to the individual’s

 There are four PHASES of Crisis

 To help him deal with the here and

5. Resolve family problems

6. Help family find ways to cope with

 Nurses must also learn to

 ADAPTATION- the process

 It provides stimulus for

4. RESPONSE based models

 Views the person and

 Transactional theory of stress

 Disadvantage: does not

Stage 2 RESISTANCE PHASE

Stage 3 EXHAUSTION PHASE

Anterior Pituitary Gland

 Cognitive appraisal, Economic

 Pupils dilate to increase visual

 Sweat production (diaphoresis)

 Heart rate or pulse rate increases

 Skin becomes pale (Pallor)

 Mouth may become dry, urine

 For serious threats, there is

 Increased muscle tension to

 Increased blood sugar

 Moderate- perception narrowed,