Psychiatric Nursing

Nurse-Client Relationship -🡪 (2way)

⮚ Series of interactions between the nurse and the client.

GOAL: Positive Behavioral Change

Questions:

When does Therapeutic Relationship meet -🡪 TRUST

Tool of the Nurse : SELF -🡪 Self Awareness

Transference : Patient relates to the Nurse (NORMAL)

Counter Transference : Nurse relate to the Patient (ABNORMAL)

Elements of Therapeutic Relationship

∙ Trust
∙ Rapport
∙ Unconditional Positive Regard
∙ Set Limit
∙ Therapeutic Use of Self

When is Trust establish? -🡪 When patient start sharing

Therapeutic Behaviors:

∙ Genuineness – sincerity and honesty

∙ Concreteness – ability to identify the clients feeling
∙ Respect – Consideration that a patient is a unique being

Phases of Therapeutic Relationship (4 phases)

1. Pre-interaction/ Pre-orientation

⮚ no contact with the client, data are form secondary source ( Chart, journals,
books, internet)

2. Interaction / Orientation

⮚ establish trust, assess the client mutual agreement (Contract) -🡪 informing

about TERMINATION
 3. Working – Longest phase (achieving goals and sharing facts

⮚ resolve the problems (PREPARATION FOR TERMINATION) 4.

Termination – (Last Phase) moving towards independence ∙

observe for regressive behaviors -🡪 (s/s coming back)

Therapeutic Communication (dynamic process of Exchanging Information) ∙

Compose of Verbal and Non-verbal

Elements of Therapeutic Communication:

1. Sender – encoder or source of the message

2. Message – actual information

3. Receiver – decoder or recipient of the message

4. Feedback – receiver’s response

***BARRIERS-🡪 Inhibits the communication process; ex. Noise, age, slow net

Verbal and Non-verbal Communication

(Non-verbal)

1. Proxemics – physical space or distance between nurse (s) and client

(r) - (3-6 ft or 1 arm and half)

2. Kinetics – body movements such as gesture, facial expression,

mannerism - enhance credibility of the message

3. Touch – an intimate physical contact – invasive (need

CONSENT) 4. Silence – encourages the patient to talk

5. Paralanguage – Voice quality (tone, inflection) how the message delivers.

(Verbal Communication)-🡪 Use TheraComm Techniques ∙ (Therapeutic,
appropriate, concise, simple, adaptive, credible) 1. Offering self –

Let me sit here with you for 5 minutes

∙ Specific
∙ Measurable
∙ Attainable
∙ Realistic
∙ Time bounded

2. Active Listening -🡪 ―ah huh‖, yes, no

3. Exploring – ex. You said Hannah was the best, Can you describe

her? 4. Broad Opening – where would you like to begin?

5. Making Observations – ―I noticed you have combed your hair today‖ 6.

Summarizing – In the past 15 minutes, we have talked about… 7.

Encouraging description of perception – ―What are the voices telling you‖

8. Presenting Reality – common in patient with illusion or hallucination 9.

Reflecting – ibalik ang tanung sa patient

10. Restating – ex. Patient : I am down

Nurse : Are you depressed?

11. General Leads – Go on…

12. Focusing – Let us look at it more closely

Non-Therapeutic Communication : Common pitfalls

∙ Giving advise
∙ Talking about self
∙ Telling the client is wrong
∙ False reassurance
∙ Asking why; (demanding) --🡪 except suicidal threatening
Spheres

1. ID – pleasure principle, irrational, pleasure seeking

2. EGO – reality base, balance
 3. SUPEREGO – conscience, ego ideal, guilt feeling

Defense Mechanism

1. Repression – Unconsciously forgetting (di sadya)

2. Suppression – Consciously forgetting (sadya)

3. Reaction Formation – Acting opposite how you truly feel (plastic) 4.

Rationalization – reasoning out

5. Introjection – blaming self / getting others personality

6. Projection – blaming others (verbal)

7. Displacement – Blaming of others w/ actions (object, person, animal) 8.

Compensation – small goals to big goals (going up) -🡪 achieve in other area (ex.

Weak in nursing but good in engineering) 9. Denial – Unacceptance of the truth

10. Regression – going back to early stage of development

11. Undoing – Doing something to relieve one’s guilt.

12. Conversion – Anxiety becomes physical symptoms. (stomach ache during exam)

13. Intellectualization – making excuses with detailed explanation to subject matter 14.

Substitution – (High to low) replace unattained goal to smaller goal. 15.

Sublimation – Unacceptable to acceptable behavior

16. Identification – idolization ( certain character)

Crisis --🡪 3 Classes

1. Maturation / Developmental
2. Situational
3. Adventitious / Social
Maturational – Expected, Normal part of life

Situational – Unexpected, Sudden

Adventitious / Social – Calamities, Social involvement, disaster

Stages of Death

1. Denial – Unacceptance, Shock / Disbelief

2. Anger – Projection / Introjection
3. Bargaining – Bargain
4. Depression – Suicidal tendencies
5. Acceptance – Final stage

Disturbances in Appearance

1. Automatism – Repeated purposeless behavior ( neuro transmitter) 2.

Psychomotor – Retardation -🡪 slowed movement (depressed person) 3.

Waxy flexibility (moldable) / Catatonia (back to previous position)– ⮚

Maintenance of an awkward posture

4. Echopraxia – Purposeless imitation (mirror like imitation)

Disturbances in Communication

∙ Mutism – mute
∙ Negativism – ―no‖
∙ Circumstantiality – beating around the bush (Segway- with answer but pa
ikot2)
∙ Tangentiality – beating around the bush (paikot2- di sinasagot ang tanung) ∙
Stilted language – flowery messages / words
∙ Flight of ideas – slightly related
∙ Loose association – no meaning at all, not related
∙ Perseveration – persevere (one topic only) ex. Nurse already moved to
another topic but the patient go back to the previous topic.
∙ Echolalia – Parrot like imitation of words (words repeated)
∙ Palilalia – repetition of stereotyped words/ last syllable
∙ Verbigeration – the same word speak repeatedly
∙ Coprolalia – Copro: feces, lalia: words---🡪 trash talking
∙ Neologism – creation of new words
∙ Blocking – sudden cessation of thoughts
 ∙ Word Salad – mixture of unrelated words
∙ Clang Association – Rhyming

∙ Jargons – gay lingo (new words but nagkakaintindihan)

Disturbance in Perception (how they perceive ideas)

∙ Delusions – fixed false ―belief‖

∙ Magical thinking – belief in myth/ magic

∙ Paranoia – extreme suspiciousness

∙ Religiosity – obsession of religious ideas

∙ Phobia – irrational fear

∙ Obsession – persistent thoughts

∙ Compulsion – persistent acts

∙ Preoccupation – idea with intense desire

∙ Thought broadcasting – others know what I am thinking (advance thinker) ∙

Delusion of reference – feeling of he’s the talk of the town, tv’s, radio

Affect

∙ Inappropriate – incongruent affect (inappropriate reactions) ∙

Blunted – little response

∙ Restricted affect – display one type of expression

∙ Labile mood – unpredictable mood

∙ Apathy – Flat affect (no reaction)
 ∙ Ambivalence – two opposing feelings ( happy and the same time afraid) ∙

Anhedonia – absence of pleasure (with emotion but not satisfied) ∙ Euphoria

– extreme pleasure (happiness)

Stress

∙ Stage one – Alarm Reaction

🡪 You have determined that there is stress

∙ Stage 2 – Stage of Resistance

🡪 You will utilize all of your resources to solve the problem

∙ Stage 3 – Stage of Exhaustion

🡪 You have utilized all of your resources but the problem is not solved

Anxiety (unspecific) vs Fear (specific)

⮚ Identify anxiety causing events

Mild - (good anxiety) increase concentration, logical thinking, increase alertness

🡪 Problem solving approach

Moderate - selective in inattentiveness, decrease attention span 🡪

Relaxation technique, encourage verbalization of feeling 🡪 Medications

Severe – do not know what to do/say, difficult of focusing even w/ assistance,

distorted perception: REMAIN W/ CLIENT

Panic – suicidal attempts, fixed eyes, hysterical, mute: Decrease stimuli

🡪 Stay with the client, PAPER BAG prevent (hyperventilate)

Neurotransmitters

Dopamine / Epi / Norepi- Excitatory

Serotonin – Inhibitory ---🡪 excitatory (synapse)

GABA (balancer) – Gamma aminobutyric acid

Anxiety Disorders

Generalized Anxiety Disorder (GAD)

-🡪 worry a lot

--> No apparent reason

-🡪 6 months anxiety

-🡪 no phobias, no panic attack, no OC manifestation

S/sx:

∙ Palpitations
∙ Headache
∙ Insomnia
∙ Chest pain

Management:

- Assist w/ problem solving

- Teach coping behaviors

- DOC: Benzodiazepines/ Anxiolytics – “pam/lam”

Panic Disorder

- Recurrent

- Unpredictable

- Panic attacks
🡪 (trembling, racing heart/tachycardia, chest pain, DOB, choking sensation,
numbness)
Management:

- assist in problem solving

- teach coping behavior

- DOC: Benzodiazepines/ Anxiolytics

Other meds:

- Betablockers- beta adrenergic blocking agents (heart, decrease anxiety)—―olol‖

- MAOI’s (Monoamine oxidase inhibitors), SSRI’s (Selective Serotonin Reuptake

Inhibitors)

Antihistamines – if with addiction to benzodiazepines

∙ Primary – anti allergic reaction

∙ Secondary – depressant

Acute Stress Disorder

- after 2 days to one month (4 weeks)

Management: Progressive review of the trauma

DOC: Benzodiazepines

PTSD (Post Traumatic Stress Disorder)

- more than 4 weeks

- Recurrent flashbacks (intrusive thoughts)

- Re Experiencing the TRAUMA

- Defense mechanism: Displacement

S/sx:

- General Numbing -🡪 Somatic Symptoms

∙ Irritability
∙ Aggressiveness
∙ Depression
∙ Anger
 ∙ Social withdrawal

Management:

- assist in gaining control over angry impulses -🡪 ACCEPTANCE

DOC: Benzodiazepines

Other meds: Beta Blockers, Anti histamines

Phobic Disorder

- Persistent irrational fear

- Fear is unreasonable proportion to the actual danger

Types of Phobia

∙ Agoraphobia – fear of open public places (always stay at home or stay next
the exit)
∙ Social Phobia – fear of socializing
∙ Simple Phobia – specific phobias

Management:

- Systemic desensitization (gradual exposure to the feared object or stimulus)

- Flooding – sudden exposure

- Breathing exercises

- Thoughts stopping (form of Diversion) ex. Rubber band (make star)

- Guided Imagery – conditioning

OCD (Obsessive Compulsive Disorder)

- they are aware of the disorder

- real obsession and compulsion

∙ Obsession -🡪 repetitive thoughts

∙ Compulsive -🡪 repetitive actions
Management:
 ∙ Aversion Therapy – PAIN

DOC: SSRI

- give time for ritualistic behavior unless dangerous

- establish limits

- Diversional activities

- Set limits

- Reality

- Consistency

Somatoform Disorders (psychological problem)

⮚ Doctor shopping / hopping

⮚ No identifiable physical origin
⮚ Precipitated by stress
⮚ Over the counter meds

GAIN:

Primary – alleviates anxiety personally

Secondary – getting emotional support/ benefits gained from having the symptom.

Conversion disorder – Involuntary alteration of physical function

⮚ Affects motor (ataxia)(paralysis), neuro (pseudoseizures), sensory

(blindness, deafness)

∙ Hypochondriasis -🡪 feeling of having serious disease even though none

exist (GI and Cardio)
∙ Labelle indifference – (+) med diagnosis, (-) s/sx (manhid) ∙ Body Dysmorphic
Disorder – feeling of having defect in physical appearance /physical anomaly
(loss of hair, nose not aligned, small penis) -🡪 plastic surgeries (one part only)
Factitious Disorder -🡪 You produce or exaggerate the symptoms

∙ Munchausen – gain attention to self (nagkunyari my sakit) ∙

 Munchausen by proxy – use others --🡪 HERO (uses by mothers)
(mother made sickness to daughter to become hero)

Nursing Diagnosis

∙ Chronic low self esteem

∙ Impaired judgment
∙ Ineffective coping
∙ Disturbed body image
∙ Social isolation

Management

- Decrease secondary gain by giving attention with or without

symptoms - Assess new physical complains for they may have organic

origin - Encourage independence

- Set limits on manipulative behaviors in a matter of fact (reality)

Mood Disorders

∙ Bipolar 1
∙ Bipolar 11
∙ Manic Disorder
∙ Major Depressive Disorder
∙ Cyclothymia
∙ Dysthymia

Positive – Sobra sobra

Negative – Kulang kulang

Mood Disorder

BP1 BP2 Manic Major Dep Cyclothymia Dysthymia Mania

Hypomania

Normal

Hypo depress

Major Depress
Major Depression

Problem: over dependent and loss

Def. mech : Introjection

S/sx: Anhedonia

Psychomotor retardation

Negative S/sx

Attitude therapy: kind firmness

Activity: Counting object or anything, writing

Therapy: group therapy

Non-competitive activity

WOF: Suicide

∙ put near Nurse Station

∙ Open door
∙ Irregular visit

Bipolar Disorder (Mask of Depression)

Def. Mech: Reaction Formation

S/sx: Hyperactivity

Manipulative
Inattentive

Attitude therapy: Matter of fact (reality)

Activity: Breaking leaves, Modeling clay

Walking (pagurin ang pt)

Therapy: Solitary therapy (Non-Competitive)

*Finger foods
Schizophrenia (Excessive Dopamine ) more than 6months

caused: Genetic

3 Main Types

1. Catatonic 2. Disorganize 3. Paranoid

Catatonic: Abnormal motor behavior

S/sx:

- Catatonia
- Waxy flexibility
- Mutism
- Negativism

Defense Mech: Repression

Nursing Diagnosis: Impaired motor activity

Management: Circulation (passive range of motion), nutrition

Disorganized: Bizarre behavior

S/sx:

- Thoughts
- Movements
- Speech (neologism)
Def. Mech. : Regression

Nursing Diagnosis: Impaired social functioning

Management: ADL Assistance

Paranoid : Suspiciousness / ideas of reference

-🡪 extremely suspicious
S/sx:

- Delusion
- Hallucinations
- Flight of ideas

Def. Mech: Projection

Nursing Diagnosis: Potential for injury directed to others

Management: Nutrition, safety

Personality Disorders

Cluster A: Eccentric

- Paranoid: Extreme suspiciousness and distrust

- Schizoid: Social withdrawal, problems in maintaining relationships, aloof
- Schizotypal: Bizarre behaviors, ―silly laughing‖, magical thinking

Management:

- Antidepressant
- Low dose antipsychotic

Cluster B: Dramatic / Erratic

- Antisocial: No guilt, no remorse, disregard laws, rules, no conscience

(<18 y/o: conduct disorder)

- Borderline: suicidal tendencies, fear of being alone, manipulative, body

mutilation.
- Histrionic: ―I love the attention‖, attention seeker, seductive, dramatic,
excessively emotional.

- Narcissistic: ―I love my self‖, Grandiosity, Need constant admiration from

others, exaggerated sense of being important.

Management: Anticonvulsants, lithium, MAOI’s

Cluster C: Anxious / fear

- Avoidant: ―I avoid coz I hate criticism‖ (Low self-esteem),

- Dependent: ―I cant live without you‖, over reliance, submissive - OCPD
(Obsessive Compulsive Personality Disorder): Unaware of condition, no real
obsessions and compulsive, perfectionist, rigid, inflexible

Management:

DOC: Benzodiazepines