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TABLE OF CONTENTS
PSYCHIATRIC NURSING
A specialized area of nursing practice employing theories of human behavior as its science and purposely use of self as its art. Includes the continuous and comprehensive services necessary for the promotion of optimal mental health, prevention of mental illness, health maintenance, management and referral of mental and physical health problems, the diagnosis and treatment of mental disorders and their sequela, and rehabilitation 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. 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 master’s 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
master’s 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 master’s level and may have different levels of autonomy and program supervision based on their education. 3 LEVELS OF PSYCHIATRIC NURSING (Levels of Health)
II. Secondary : Screening, Diagnosis & Immediate Treatment A. Screening
Denver Development Screening Test (DDST) #1 test for PDD Pervasive Development Ddisorder (PPD)
- Autism: Aage of onset (3 y.o.)
- ADHD: Aage of onset (6 y.o.) Diet: Finger Food (high caloric, high CHO) Rx: Ritalin (Methylphenidate); dextroamphetamine (Dexedrine)
- Conduct disorder: Aage of onset (6 y.o.) B. Suicide Prevention/Intervention Impending signs of Suicide
- Sudden elevation of mood/sudden mood swings
- Giving away of prized possessions
- Delusion of Omnipotence (divine powers) Used by SS ( S uicidal, S chizophrenia)
- When the patient verbalizes that the 2nd Gen^ TCA is working. less than 2-4 wks (telling a lie) Suicide Interventions : 1**. One-on-one supervision and monitoring
- No suicide contract – 24 hrs monitoring
- Patient is required to verbalize suicidal ideas**
- Non metallic/plastic/sharp objects: ex. belts, curtains
- Avoid dark places C. Case Finding (Epidemics)/ Contact Tracing (STDs) D. Crisis Intervention Objective: Tto return the client to its normal functioning or pre crisis level. Duration: (4-6 wks) Disorganization is a phase in the crisis state which is characterized by the feelings of great anxiety and inability to perform activities of daily living A patient in crisis is passive and submissive, so the nurse needs to be active and should direct the paient to activities that facilitate coping.
Types of Crisis:
- Developmental Maturation Crisis
- Adolescence (identity crisis)
- Mid-life crisis;
- Pregnancy
- Parenthood
- Situational / Accidental crisis –
- Most common: Ddeath of a loved one NSG DX: Ineffective Individual Ccoping/ Denial
- ex. murder, abortion , rape and fire
- Adventitious – calamity, disaster ex. World War I & II, epidemic, tsunami In a DISASTER 1st^ assess/survey the scene E. Emergency drugs and antidotes DRUGS/ DISEASE Action / Effect ANTIDOTES Heparin Anticoagulant Protamine Sulfate Warfarin (Coumadin) Anticoagulant Vit. K Mg Sulfate Anticonvulsants Calcium gluconate Nubain (best), Morphine Narcotics Naloxone (Narcan) Fibrinolytic / Thrombolytic Dissolves clot Amicar (Aminocaproic acid) *(Neuroleptic Malignant Syndrome’s (NMS) #1 Cardinal Sign : High Fever / Hyperthermia Dantrolene (Dantrium), Bromocriptine (Parlodel) Effect: antiparkinsonian, anti-prolactin, antipsychotic Hypertensive crisis (MAOI intoxication) Antidepressant intoxication Ca channel blocker Suffix:(-dipine) Anxiolytics, Sedatives – Suffix: zepam, -zolam Sedative hypnotic/ Minor tranquilizer Flumazenil (Romazicon) Tensilon (Endrophonium): Anticholinesterase intoxication, Pilorcarpine (Pilocar) intoxication : Miotic Anticholinesterase & Miotic Atropine Sulfate (ATSO4) III. Tertiary Objective: Rrehabilitation, which start upon admission A. **Occupational Therapy –
- Usually use behavior modification for PDD (Pervasive Developmental Disorders), anorexia & depression**
Labile Affect: Manic Depression or Bipolar Disorder T HOUGHT CONTENT: Self-concept? Areas of concern? Themes? Obsessions? Delusions? Hallucinations? Example: Ddelusion of grandeur (manic), delusion of omnipotence ( schizophrenia), delusion of persecution & delusion of reference (paranoid delusions) T HOUGHT PROCESS: Ability to understanding abstract/symbols? Example: Mmagical thinking and animism of Schizotypal personality S PEECH: Coherency? Relevance? Meaning? Quality/Quantity? Example : Slurring of Speech ( alcoholism) and pressured speech (manic depression or bipolar disorder) DSM V (Diagnostic and Statistical Manual for Mental Health) Axis I Clinical Syndrome (S&Sx) II Personality Disorders III Pathological Disorders IV Environmental & Psychosocial stressors V Global Functioning (assessment)] CONCEPTUAL MODELS OF PSYCHIATRIC TREATMENT PSYCHOANALYTICAL/PSYCHOSEXUAL MODEL. (Freud); Focus- Intrapsychic process (conflicts, anxiety, defense mechanisms, impulses). 0 BEHAVIORAL FRAMEWORK : Focus- learned behavior; Pavlov’s Theory: Classical Conditioning; Skinner’s Theory: Operant Conditioning. INTERPERSOAL MODEL (Sullivan and Peplau); Focus- Interpersonal relationships PSYCHOSOCIAL THEORY (Erik Erickson); Focus-Psychosocial tasks EXISTENTIAL MODEL / HUMANISTIC MODEL (Rogers); Focus- Conscious human experiences BIOMEDICAL MODEL (Meyer, Kraeplin, Frances); Focus – Disease approach, syndromes, diagnoses, etiologies. PSYCHOSOCIAL THEORY OF ERIC ERIKSON
Most commonly used theory by health professionals. Describes the human cycle as a series of eight EGO developmental stages from birth to death; Focus: PSYCHOSOCIAL TASKS throughout the life cycle. STAGES OF PSYCHOSOCIAL DEVELOPMENT: AGE PSYCHOSOCIAL TASKS Infancy (0-18 mo) Trust vs. Mistrust Toddler (18 mo-3 yrs) Autonomy vs. Shame and Doubt Preschool Age (3-6 yrs) Initiative vs. Guilt School Age (6-12 yrs) Industry vs. Inferiority Adolescence (12-20 yrs) Identity vs. Role confusion Early Adulthood (20-35 yrs) Intimacy vs. Isolation Middle Adulthood (35-65 yrs) Generativity vs. Stagnation Most common task of 40 y/o includes developing responsibility over their own lives Later years / Old Age (65 yrs) Integrity vs. Despair 76 y/o male who has a good ego integrity is preoccupied w/ death PSYCHOSEXUAL (PSYCHOANALYTICAL) THEORY OF SIGMUND FREUD Infancy: Oral Phase; Stage of the Id Toddler: Anal Phase; Stage of the Ego Preschooler: Phallic Phase; Stage of the Superego (conscience) Attachment of the child to the parent of the opposite sex and jealousy toward the parent of the same sex Oedipal Complex: Attachment of the son to his mother and jealousy toward the father. Electra Complex: Attachment of the girl to her father and jealousy toward the mother. Schooler: Latency phase; Stage of the Strict Superego Adolescent: Genital phase FREUDIAN THEORY COMPONENTS:
- LEVELS OF AWARENESS: Conscious Subconscious Watchman of the Personality Unconscious The one who molds the personality Storage bin of traumatic & meaningful memories. True desires & motives are here.
ID: Psychoanalytic term for that part of the psyche that is UNCONSCIOUS, the reservoir of INSTINCTS, primitive drives governed by the PLEASURE PRINCIPLE and is SELF - CENTERED. The Ids says, “ I want, what I want, when I want it”.
EGO: Psychoanalytic term for that part of the psyche that is CONSCIOUS, The “I”
that is shown to the environment and most in touch with REALITY and the MEDIATOR between the primitive, pleasure- seeking, instinctive drives of the ID and the self- critical, prohibitive forces of the SUPEREGO and is directed by REALITY PRINCIPLE. This is the thinking- feeling part of personality. The Ego says, “I would want to have it if only I can afford it;” “Not now, I am not yet ready; perhaps next week.”
SUPEREGO: Psychoanalytic term for that part of the psyche that RESTRAINS,
controls, inhibits and prohibits impulses and instincts, is self- critical, and is called the CONSCIENCE or EGO IDEAL. The Superego says, “I should not want that; It is not good to even wish for it.” ESSENTIAL ELEMENTS OF A NURSE- CLIEN T CONTRACT
- Names of RN and patient 5. Purpose of a relationship
- Roles of RN and patient 6. Meeting location / time
- Responsibilities of RN and patient 7. Condition for termination
- Goals / Expectations 8. Confidentiality FOUR PHASES OF NURSE- CLIENT RELATIONSHIP (NCR) A. Pre-interaction/Pre-orientation (For the Nurse)
- Stage of Self-Awareness Tto prevent Counter Transference #1 CORE VALUE OF Psychiatric Nursing B. ORIENTATION (INITIATION) Assessment of problems, needs, expectations of clients Identify anxiety level of self and client Set goals of relationship. Define responsibilities of nurse and client. Stage of testing. Establish boundaries of relationship. Stress confidentiality. **Contract – 2 famous psychiatric contracts:
- No suicide contract** Mmajor depression = emergency
TWO definitions of no suicide contract: A. 24 hrs monitoring B. Vverbalization to the nurse of all suicide ideas
- Diet contract Eeating disorder
- The start of termination phase : “Good morning, full name, RN, shift, session, date start & end.” C. WORKING PHASE Promote acceptance of each other Accept client as having value and worth as a unique individual.
- Stage of resistance
- Counter transference phase
- Most difficult phase -- NCP is on going
- Identification of the problem/exploration
- The #1 Psychiatric Core Value is Consistency Ffor manipulative patients Be consistent to patient with: BAAAM COPS B orderline C onduct d/o A ntisocial O oral/ eating disorder A lzheimer’s P aranoid A utistic S uicidal M anic Use therapeutic and problem- solving techniques Maintain PROFESSIONAL, therapeutic relationship Keep interaction reality- oriented- here and now Provide ACTIVE LISTENING and REFLECTION of feelings Use non- verbal communication to support client Recognize blocks to communication and work to remove them FOCUS on client’s: Confronting and working through identified problems Problems- solving skills Increasing independence Help client develop alternative, adaptive coping mechanisms Personal biases (manifestation by counter-transference & vice versa) are seen during working phase D. TERMINATION Plan for termination of relationship early the relationship
- Stage of Separation Anxiety Signs & symptoms: Rregression: Ttemper tantrums, thumb sucking, apathy, fetal position when crying.
me to do things differently.” RN’s response to elaborate feelings includes statement like, “Have you discussed this with your husband about how to cope with these problems? Tell me.” Appropriate response for an 80 y/o who says, “I told my children that I’m ready to die.” Includes statement like “Tell me about your feelings & I will stay w/ you.” d. Clarification – used in neologism and word salad SAM (seen in Schizophrenia, A lzheimer’s, M anic) “What do you mean by…?” (Used in Neologism and word salad) “ I could not follow you.” – (Used in flight of ideas and looseness of association) “The ground is watching us.”, appropriate intervention includes clarify the meaning of the word. Brilliant & charming patient says, “I’ll be better off dead.” Best response of the RN includes asking questions like, “Do you have plans of suicide”? Pt says, “I’d like to take you out & give you a good show.” best response by the RN is asking pt, “What do you mean by a good show?” e. Reality Orientation/Reality Testing
- Nsg Dx: Altered Sensory Perception
- Delusion; Hallucination, Illusion & delusion Client: “Help! Help! There are spiders on my back!” Nurse: “I don’t see spiders but for you that is real.” Alcoholic pt with delirium tremens states, “There are spiders crawling on my back”. The appropriate response of the nurse would be, “there are no spiders, its only part of your illness”. f. Giving Leads “Aha..then…mmmh… go on… yes…” g. Therapeutic Silence h. Paraphrasing/restating – repeating Repeats the MAIN IDEA; restate what the client says. (Patient: “I can’t believe I cannot go home today.” Nurse: “You can’t believe that you can’t go home today?”)’ i. Summarizing – recap
Nurse: “Today you have described your understanding of how you feel when you are upset with your son.” j. Validation – interpret Client: “I see a shadow.” Nurse: “You’re frightened.” A patient admitted to be listening to voices should be assessed by asking, “What does the voice tells you?” “I know that Prof. Draper tried to rape me, rape my mind...& he’s still trying to rape me”, correct of RN includes questions like “Are you frightened being unable to control your thoughts?” Post-menopausal woman says, “I’m pregnant by God in heaven.” Appropriate response by the nurse includes statement like, “You believe something special happened to you?’ “It must be frightening to feel that way.” is an appropriate response for a suspicious pt saying, “I think that my food is being poisoned” RN’s correct response of pt w/. OCD who checks door 10-15 times includes statement like, “It sounds as if you have much anxiety.” k. Open-ended question / broad openings Questions NOT answerable by ‘YES’ or ‘NO’; encourages further or broadened communication. “How are you?” “How’s your day?” “What are your favorite things?” BLOCKS TO THERAPEUTIC COMMUNICATION a. Never use why – it demands an explanation and also anxiety provoking b. Closed Ended Question – questions answered by “yes” or “no” Note: Tthe only therapeutic closed-ended question Ssuicidal pt. “Are you planning to commit suicide? ” – Confrontation c. False Assurance “Ddo not worry” Tto patient who are dying & w/ incurable illness “ You have the best doctor; everything will be all right.” “Relax that is nothing to worry about.” d. Agree/disagree – never argue with client “You are right in doing that.” / “You should not think that way.” e. Belittling the patient – CHANGING THE SUBJECT
Behavioral Treatments
- Desensitization – gradual exposure to the feared object -- #1 treatment for phobia
- Flooding/.Implosive Therapy – sudden exposure
- Relaxation Technique – light stroking = labor - Purse Lip Breathing Exercise = COPD/CAL (Chronic Airflow Limitation)
- Biofeedback – mind over matter. Ex. HPN ↓BP, palpitations, headache
- Guided Imagery (Child) & Visualization (Adult) GROUP THERAPY A. DEFINITION: Psychotherapeutic processes that occur in formally organized groups designed to change maladaptive or undesirable behavior. Knowledge of therapeutic modalities enhances the performance of nursing interventions during therapy. 8-10 patients are the optimal number of patients in a group. B. TYPES OF GROUPS
- Structured Goals: Ppre- determined Format: Cclear and specific Factual material: Ppresented Leader: Rretains control
- Unstructured
- Goals: Nnot pre- determined. Responsibility for goal is shared by group and leader
- Format: Discussion flows according to group members’ concern
- Materials and topics are not pre- elected.
- Leader: Nnondirective
- Emphasis: Mmore on FEELINGS rather than facts C. ADVANTAGE OF GROUP THERAPY
- Economical: Lless staff used.
- Increased feelings of closeness Reduction on feelings of being alone.
- With feedback group Corrects distortions of problems Builds self- image and self- confidence Increases reality- testing opportunities Gives info on how one’s personality and behavior appear to others
- With opportunities for practicing alternative behaviors and methods of coping with feelings
- Provides attention to reality and provides development of insight into one’s problems by expressing own experiences and listening to others in groups D. PRINCIPLES OF GROUP THERAPY
- Verbalization : Members express feelings and group reinforces appropriate communication. Desired outcome of group therapy includes verbalization of feelings rather than acting them out
- Activity: Provides stimuli to verbalization and expression of feelings.
- Support: Members gain support from one another through interaction, sharing and communication.
- Change: Members have opportunity to try out new and desirable behaviors in group, supportive setting to effect change. **E. PHASES OF GROUP THERAPY
- Initial Phase** Formation of group Setting and clarification of goals and expectations Initial meeting, acquaintance and interaction 2. Working Phase Confrontation between members→ Ccohesiveness Identification of problems→ Pproblem- solving processes **In a group therapy when one client says to another, “Maybe you’re taking on someone else’s problems.” this shows that they are in the working phase
- Termination Phase** Evaluation of goals attainment Support for leave- taking In group therapy if a client says, “Leave me alone & get away from me.”, best action of the RN is to maintain distance from the pt. Behavior indicating that goal is met after socialization in a group therapy includes participation of each group member telling the leader about specific problems DEFENSE MECHANISMS REPRESSSION SUPPRESSION
