NCM 105

CARE OF CLIENTS WITH

MALADAPTIVE
PATTERNS OF
BEHAVIOR


Prof. Melchor Felipe Q. Salvosa
Prof. Dodie A. Dichoso
Course description
The course is designed to focus on
health and illness across the lifespan
of clients, population groups with
acute and chronic psychosocial
difficulties and psychiatric illnesses.
Course Objectives
At the end of the course, and given actual clients
with maladaptive patterns of behavior, the
student shall be able to:
1. Utilize the nursing process in the care of
individuals, families in community and hospital
settings.
Assess client/s with his/her/their condition
through mental status examination, physical
examination, interpretation of diagnostic
procedures.
Identify actual and potential nursing diagnosis.
Plan appropriate nursing interventions with
client/s and family for identified nursing
diagnosis.
Implement plan of care with client/s and family.
Evaluate the progress of his/her/their clients
condition and outcomes of care.
Course Objectives
2. Apply knowledge and understanding of
maladaptive patterns of behavior in providing
safe and quality care to clients.
3. Increase self-awareness and therapeutic
use of self in the care of clients.
4. Ensure a well-organized and accurate
documentation system.
5. Relate with client/s and their family and the
health team appropriately.
6. Observe bioethical concepts/ principles,
core values and nursing standards in the
care of clients.
7. Promote personal and professional growth
of self and others.

Prelim
I. Overview of psychiatric nursing
A. Evolution of mental health-
psychiatric nursing practice
B. The mental health nurse
1. Role
2. Essential qualities
C. Interdisciplinary team
D. The mental health illness
continuum
II. Mental health-psychiatric nursing
practice
A. Personality theories and determinants
of psychopathology: Implications for
mental health-psychiatric nursing
practice
1. Psychoanalytic
2. Behavioral
3. Interpersonal
4. Cognitive
5. Humanistic
6. Psychobiologic
7. Cognitive
8. Psychosocial
9. Psychospiritual
10.Eclectic
B. General assessment
considerations
1. Principles and techniques of
Psychiatric nursing interview
2. Mental status examination
3. Diagnostic examinations
specific to psychiatric patients

C. Building nurse-client relationship
1. Nurse-client interaction vs. nurse-
client relationship
2. Therapeutic use of self
3. Therapeutic communication
a. Characteristics
b. Techniques
4. Goals in the one-to-one
relationship
5. Phases in the development of
nurse-client relationship
D. Documentation in psychiatric
nursing practice
1. Problem-oriented recording
a. SOAP
2. Narrative recording
3. Process recording
E. Therapeutic modalities,
psychosocial skills and nursing
strategies
1. Biophysical /somatic
interventions
a. Electroconvulsive and other
somatic therapies
b. Psychopharmacology
2. Supportive Psychotherapy
a. Nurse-patient relationship
therapy
b. Group therapy
c. Family therapy
3. Counseling
4. Mental health teaching/client
education
5. Self-enhancement,
growth/therapeutic groups
6. Assertiveness training
7. Stress management
8. Behavior modification
9. Cognitive restructuring
10. Milleu therapy
11. Play therapy
12. Psychosocial support
interventions
13. Psychospiritual Interventions
14. Alternative Medicine /Therapies
F. Concept of Anxiety
1. Defining characteristics of
Anxiety
2. Levels of Anxiety
3. Manifestations of Levels of
Anxiety
a. Physiologic
b. Psychologic
4. Ego Defense Mechanisms
a. Four levels of Defense
G. Crisis
1. Types of crisis
2. Phases of Crisis Development
3.Characteristics of Crisis
4. Crisis Intervention
MENTAL HEALTH
Is a state of emotional,
psychological, and social wellness
evidenced by:
Satisfying interpersonal
relationships
Effective behavior and coping
Positive self-concept
Emotional stability
Self-awareness

COMPONENTS OF MENTAL
HEALTH
Autonomy and Independence-can work
interdependently without losing autonomy
Maximization of Ones Potential-oriented
towards growth and self-actualization
Tolerance of Lifes Uncertainties-can face
the challenges of day-to-day living with hope &
positive look
Self-esteem-has realistic awareness of her
abilities and limitations
Mastery of the Environment-can deal with
and influence the environment
Reality Orientation-can distinguish the real
world from a dream, fact from fantasy
Stress Management
Factors influencing a persons
mental health
Individual factors include a persons biologic
makeup, sense of harmony in life, vitality,
ability to find meaning in life, emotional
resilience or hardiness, spirituality, and
positive identity
Interpersonal factors include effective
communication, ability to help others,
intimacy, and a balance of separateness
and connection.
Social/cultural factors include a sense of
community, access to adequate resources,
intolerance of violence, and support of
diversity among people.
Mental Illness
Historically viewed as possession by
demons, punishment for religious or social
transgressions, weakness of will or spirit,
and violation of social norms
Today seen as a medical problem, although
some stigma from previous beliefs remains
Mental Disorder/Mental Illness
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

Factors contributing to mental
illness
Individual factors include biologic
makeup, anxiety, worries and fears, a
sense of disharmony in life, and a loss of
meaning in ones life
Interpersonal factors include ineffective
communication, excessive dependency
or withdrawal from relationships, and
loss of emotional control.
Social and cultural factors include lack of
resources, violence, homelessness,
poverty, and discrimination such as
racism, classism, ageism, and sexism.
DIAGNOSTIC AND
STATISTICAL
MANUAL OF MENTAL
DISORDERS
(DSM-IV-TR)

The DSM-IV-TR is a taxonomy published by APA
and is used by all mental health professionals.
It describes all
mental disorders according to
specific diagnostic criteria.
The DSM-IV-TR is based on
a multiaxial classification
system:
Diagnostic and Statistical Manual of Mental
Disorders, 4th edition, Text Revision
The DSM-IV-TR has three
purposes:
To provide a standardized
nomenclature and language for all
mental health professionals
To present defining characteristics or
symptoms that differentiate specific
diagnoses
To assist in identifying the underlying
causes of disorders
A multi-axial classification
Axis I is for identifying all major
psychiatric disorders except mental
retardation and personality disorders.
Examples include depression,
schizophrenia, anxiety, and
substance-related disorders.
Axis II is for reporting mental
retardation and personality disorders
as well as prominent maladaptive
personality features and defense
mechanisms.
Axis III is for reporting current medical
conditions that are potentially relevant
to understanding or managing the
persons mental disorder as well as
medical conditions that might
contribute to understanding the
person.
Axis IV is for reporting psychosocial
and environmental problems that may
affect the diagnosis, treatment, and
prognosis of mental disorders.
Included are problems with primary
support group, social environment,
education, occupation, housing,
economics, access to health care, and
legal system.
Axis V presents a Global Assessment
of Functioning (GAF), which rates the
persons overall psychological
functioning on a scale of 0 to 100.
This represents the clinicians
assessment of the persons current
level of functioning; the clinician also
may give a score for prior functioning
(for instance, highest GAF in past year
or GAF 6 months ago).
HISTORICAL
PERSPECTIVES OF
THE TREATMENT OF
MENTAL ILLNESS

Ancient Times
Those with mental disorders were
viewed as being either divine or
demonic depending on their behavior.
Individuals seen as divine were
worshipped and adored; those seen
as demonic were ostracized,
punished, and sometimes burned at
the stake.



Aristotle (382322 BC) attempted
to relate mental disorders to physical
disorders and developed his theory
that the amounts of blood, water, and
yellow and black bile in the body
controlled the emotions.
These four substances, or humors,
corresponded with happiness, calmness,
anger, and sadness.
Imbalances of the four humors were
believed to cause mental disorders
Treatment
aimed at restoring balance through
bloodletting, starving, and purging. Such
treatments persisted well into the 19th
century
Early Christian times (11000
AD)
Mentally ill were viewed as possessed
Priests performed exorcisms to rid evil
spirits. When that failed, they used
more severe measures such as
incarceration in dungeons, flogging,
starving, and other brutal treatments.
EXORCISM
FLOGGING
INCARCERATION
STARVING
Renaissance (13001600),
people with mental illness were
distinguished from criminals in
England.
Harmless were allowed to wander the
countryside or live in rural
communities,
More dangerous lunatics were
thrown in prison, chained, and starved
ST MARYS HOSPITAL
In 1547, the Hospital of St. Mary of
Bethlehem was officially declared a
hospital for the insane.
By 1775, visitors at the institution were
charged a fee for the privilege of
viewing and ridiculing the inmates,
who were seen as animals, less than
human
Period of Enlightenment and
Creation of Mental Institutions
1790s, a period of enlightenment
concerning persons with mental illness
began. Phillippe Pinel in France and
William Tukes in England formulated the
concept of asylum as a safe refuge or
haven offering protection at institutions
where people had been whipped,
beaten, and starved just because they
were mentally ill
Began the moral treatment of the mentally
ill.
In the United States, Dorothea Dix
(18021887) began a crusade to
reform the treatment of mental illness
promoted adequate shelter, nutritious
food, and warm clothing
Period of Scientific Study
Sigmund Freud (1856-1939) studied
the mind, its disorders and their
treatment
Emil Kraepelin (1856-1926) classify
mental illness according to their
symptoms
Eugene Blueler (1857-1939) coined
the term Schizophrenia
1950 with the development of
psychotropic
drugs
- Lithium (1949)
- Chlorpromazine (Thorazine) (1950)
MAOIs
Haloperidol (Haldol)
TCAs
Benzodiazepines
For the first time, drugs actually reduced
agitation, psychotic thinking, and
depression.
Deinstitutionalization began with the
Community Mental Health Centers Act
of 1963
Community mental health centers
served smaller geographic catchment
(service) areas that provided less
restrictive treatment located closer to
the persons home, family, and friends.
Deinsitutionalization had three
components:
Release of individuals from state
institutions,
diversion from hospitalization, and
development of alternative community
services
1990's
1. significant changes in the delivery of mental health
treatment were made.
2. manged care incorporated several new structures
and services:
- Case management: involved the assignment of a case
manger to coordinate services for individual clients and
collaborate with multidisciplinary team.
-critical pathways and care maps: served as clinical
management tools to disintegrate the organization ,
sequence and timing of interventions provided by a
treatment team for an identified client disorder.
-Population -based community care: focused on primary
preventive services and not just illness-based
care;included identification of high-risk groups and
education on lifestyle changes to prevent illness.

2000 to present
1. the recovery and rehabilitation
model, which was founded on the
beliefs of individual client
empowerment and control, focuses on
the prevention or reduction of
impairment in a client withs severe,
persistent mental illness.
Psychiatric Nursing in the Philippines
The National Center for Mental Health
(NCMH) was established thru Public
Works Act 3258.
It was first known as INSULAR
PSYCHOPATHIC HOSPITAL, situated
on a hilly piece of land in Barrio Mauway,
Mandaluyong, Rizal and was formally
opened on December 17, 1928.
This hospital was later known as the
NATIONAL MENTAL HOSPITAL, given
on November 12, 1986, it was given its
present name thru Memorandum
Circular No. 48 of the Office of the
President.

On January 30, 1987, NCMH was
categorized as a Special Research Training
Center and hospital under Department of
Health.
Today, NCMH has an authorized bed capacity
of 4,200 and a daily average of 3,400 in-
patients. It sprawls on a 46.7 hectare
compound with a total of 35
Pavilions/Cottages and 52 Wards.
The NCMH is a special training and research
hospital mandated to render a
comprehensive (preventive, promotive,
curative and rehabilitative) range of quality
mental health services nationwide.
Mental Illness in the 21st Century
56 million Americans have a mental illness
(DHHS, 2002)
Hospital stays shorter, but more numerous:
revolving door
Increased aggression among mentally ill
clients
An increased number of people with mental
illness are incarcerated
Mental Illness in the 21st Century
(contd)
Homeless population of persons with mental
illness, including substance abuse, is
growing
Most health care dollars still spent on
inpatient psychiatric care; community
services not adequately funded
Healthy People 2010 mental health
objectives strive to improve care of mentally
ill persons
Mental Illness in the 21st Century
(contd)
Community-based care includes community
support services, housing, case
management, residential services outside
the hospital
Cost containment efforts include utilization
review, HMOs, managed care, case
management
Cultural considerations: diversity increasing in
U.S. in terms of ethnicity and changing family
structures
PSYCHIATRIC NURSING
A specialized area of nursing
practice employing theories of
human behavior as its science and
purposely use of self as its art.

PSYCHIATRIC NURSING
Interpersonal process whereby the
nurse through the therapeutic use of
self assist an individual family, group
or community to promote mental
health, to prevent mental illness and
suffering, to participate in the
treatment and rehabilitation of the
mentally ill and if necessary to find
meaning in these experiences
BASIC PRINCIPLES OF
PSYCHIATRIC NURSING
Accept and respect the client
regardless of his behavior.
Limit or reject the inappropriate
behavior but not the individual
Encourage and support expression of
feelings in a safe and non-judgmental
environment. Increase verbalization,
decreases anxiety.
Behaviors are learned.
All behavior has meaning.

Psychiatric Nursing Practice
Psychiatric nursing practice emerged in 1873
when Linda Richards said, The mentally sick
should be at least as well cared for as the
physically sick
1882 was first formal training of nurses in
mental health
First psychiatric textbook in 1920
This is a relatively new field in comparison with
other areas
Psychiatric Nursing Practice (contd)
Standards of Psychiatric-Mental Health
Clinical Nursing Practice developed in
1973, revised in 1982, 1994, 2000
Psychiatric Mental Health Nursing
Phenomena of Concern: 12 areas of
concern that mental health nurses focus on
when caring for clients
AREAS OF PRACTICE
BASIC-LEVEL FUNCTIONS
Counseling
Interventions and communication
techniques
Problem solving
Crisis intervention
Stress management
Behavior modification
Milieu therapy
Maintain therapeutic environment
Teach skills
Encourage communication between
clients and others
Promote growth through role-modeling

Self-care activities
Encourage independence
Increase self-esteem
Improve function and health
Psychobiologic interventions
Administer medications
Teaching
Observations
Health teaching
Case management
Health promotion and maintenance
ADVANCED-LEVEL FUNCTIONS
Psychotherapy
Prescriptive authority for drugs (in many states)
Consultation
PSYCHIATRIC MENTAL HEALTH
NURSING PHENOMENA OF CONCERN
Actual or potential mental health problems
pertaining to
The maintenance of optimal health and well-
being and the prevention of psychobiologic
illness
Self-care limitations or impaired functioning
related to mental and emotional distress
Deficits in the functioning of significant
biologic, emotional, and cognitive symptoms
Emotional stress or crisis components of
illness, pain, and disability
Self-concept changes, developmental
issues, and life process changes
Problems related to emotions such as
anxiety, anger, sadness, loneliness, and grief
Physical symptoms that occur along with
altered psychological functioning
Alterations in thinking, perceiving,
symbolizing, communicating, and decision-
making
Difficulties relating to others
Behaviors and mental states that indicate
the client is a danger to self or others or has
a severe disability
Interpersonal, systemic, sociocultural,
spiritual, or environmental circumstances or
events that affect the mental or emotional
well-being of the individual, family, or
community
Symptom management, side
effects/toxicities associated with
psychopharmacologic intervention, and other
aspects of the treatment regimen
Student Concerns
Saying the wrong thing
What student will be doing
Fear of no one talking to student
Bizarre or inappropriate behavior
Physical safety
Seeing someone known to the student
Self-Awareness Issues
Everyone has values, beliefs, ideas; nurses
need to know what theirs are, not to change
them, but to prevent unknown or undue
influence on their nursing practice
Hints to increase self-awareness: keep a
journal, talk to trusted coworkers, examine
points of view other than ones own
INTERDISCIPLINARY TEAM
PRIMARY ROLES
Psychiatrist:
The psychiatrist is a physician
certified in psychiatry by the
American Board of Psychiatry and
Neurology, which requires 3-year
residency, 2-years of clinical practice,
and completion of an examination.
The primary function of the
psychiatrist is diagnosis of, mental
disorders and prescription of medical
treatments.

Psychologist:
The clinical psychologist has a
doctorate (Ph.D.) in clinical
psychology and is prepared to
practice therapy, conduct research,
and interpret psychological tests.
Psychologists may also participate
in the design of therapy programs
for groups of individuals.
Psychiatric nurse:
The registered nurse gains
experience in working with clients with
psychiatric disorders after graduation
from an accredited program of nursing
and completion of the licensure
examination. The nurse has a solid
foundation in health promotion, illness
prevention, and rehabilitation in all
areas, allowing him or her to view the
client holistically
The nurse is also an essential team
member in evaluating the effectiveness
of medical treatment, particularly
medications. Registered nurses who
obtain a masters degree in mental
health may be certified as clinical
specialist or licensed as advanced
practitioners, depending on individual
state nurse practice acts. Advanced
practice nurses are certified to prescribe
drugs in many states.
Psychiatric social worker:
Most psychiatric social workers are
prepared at the masters level, and they are
licensed in some states. Social workers may
practice therapy and often have the primary
responsibility for working with families,
community support, and referral.
Occupational therapist:
Occupational therapist may have an
associate degree (certified occupational
therapy assistant) or a baccalaureate degree
(certified occupational therapist).
Occupational therapy focuses on the
functional abilities of the client and ways to
improve client functioning such as working
with arts and crafts and focusing on
psychomotor skills.

Recreation therapist:
Many recreation therapists complete a
baccalaureate degree, but in some instances
persons with experience fulfill these roles.
The recreation therapist helps the client to
achieve a balance of work and play in his or
her life and provides activities that promote
constructive use of leisure or unstructured
time.
Vocational rehabilitation specialist:
Vocational rehabilitation includes
determining clients interests and abilities and
matching them with vocational choices.
Clients are also assisted in job-seeking and
job-retention skills, as well as pursuit of
further education if that is needed and
desired. Vocational rehabilitation specialists
can be prepared at the baccalaureate or
masters level and may have different levels
of autonomy and program supervision based
on their education.