PSYCHIATRIC NURSING:

NURSING PROCESS IN PSYCHIATRI- MENTAL HEALTH CARE Prelim | Midterm | Finals

BACHELOR OF SCIENCE IN NURSING - 3RD YEAR
_____________________________________________________________________________________________________

NURSING PROCESS IN PSYCHIATRIC-MENTAL HEALTH CARE

NURSING PROCESS
➢ series of organized steps designed for nurses to provide excellent care.

ASSESSMENT
➢ first step and involves critical thinking skills and data collection
➢ Data may come from the patient directly or from primary caregivers who may or may not be direct relation family
members.
➢ Charts and other patient’s records may populate data in and assist in assessment.
○ SUBJECTIVE
■ involves verbal statements from the patient or caregiver
○ OBJECTIVE
■ measurable, tangible data such as vital signs, intake and output, and height and weight

DIAGNOSIS
➢ formulation of a nursing diagnosis by employing clinical judgment assists in the planning and implementation of
patient care
➢ clinical judgment about responses to actual or potential health problems on the part of the patient, family or
community.
➢ encompasses Maslow's Hierarchy of Needs and helps to prioritize and plan care based on patient-centered
outcomes.
○ Basic Physiological needs:
■ Nutrition (water and food), elimination (Toileting), airway (suction)-breathing (oxygen)-circulation
(pulse, cardiac monitor, blood pressure) (ABC's), sleep, sex, shelter, and exercise.
○ Safety and Security:
■ Injury prevention (side rails, call lights, hand hygiene, isolation, suicide precautions, fall
precautions, car seats, helmets, seat belts), fostering a climate of trust and safety (therapeutic
relationship), patient education (modifiable risk factors for stroke, heart disease).
○ Love and Belonging:
■ Foster supportive relationships, methods to avoid social isolation (bullying), employ active
listening techniques, therapeutic communication, and sexual intimacy.
○ Self-Esteem:
■ Acceptance in the community, workforce, personal achievement, sense of control or
empowerment, accepting one's physical appearance or body habitus.
○ Self-Actualization:
■ Empowering environment, spiritual growth, ability to recognize the point of view of others,
reaching one's maximum potential.

PLANNING
➢ goals and outcomes are formulated that directly impact patient care based on EDP guidelines
➢ assist in ensuring a positive outcome
➢ provide a course of direction for personalized care tailored to an individual's unique needs
○ Goals should be:
■ Specific
■ Measurable or Meaningful
■ Attainable or Action-Oriented
■ Realistic or Results-Oriented
■ Timely or Time-Oriented

IMPLEMENTATION
➢ involves action or doing and the actual carrying out of nursing interventions outlined in the plan of care
➢ requires nursing interventions such as applying a cardiac monitor or oxygen, direct or indirect care, medication
administration, standard treatment protocols and EDP standards.

EVALUATION
➢ final step of the nursing process is vital to a positive patient outcome
➢ reassess or evaluate to ensure the desired outcome has been met
➢ may frequently be needed depending upon overall patient condition

PSYCHOSOCIAL ASSESSMENT
➢ an evaluation of an individual's mental health and social well-being
➢ assesses self-perception and the individual's ability to function in the community.
➢ to understand the patient to provide the best care possible and help the individual obtain optimal health
➢ Components
○ Client initial information - patient’s name, address, and age, gender, etc.
1.
 PSYCHIATRIC NURSING:
NURSING PROCESS IN PSYCHIATRI- MENTAL HEALTH CARE Prelim | Midterm | Finals
BACHELOR OF SCIENCE IN NURSING - 3RD YEAR
_____________________________________________________________________________________________________

○ Presenting problems
○ Present and Past Health History
■ Existing and past medical & mental illness
■ Hospitalizations
■ Medications & other treatment
■ Physiologic and self-care problem
○ Relevant Family History
■ Family physical and mental health problems
■ Use and abused of drugs by the family
○ Response to mental health problems
■ Relationship change
■ Role change
■ Lifestyle change
■ Self-concept change
○ Risk assessment on suicidal or homicide
■ Ideation: “Are you thinking about killing yourself?”
■ Plan: “Do you have a plan of killing yourself?”
■ Method: “How do you plan to kill yourself?”
■ Access: “How would you carry out this plan?”
■ Where: “Where would you kill yourself?”
■ When: “When do you plan to kill yourself?”
■ Timing: “What day or time of day do you plan to kill yourself?”
○ Psychosocial development of the patient
■ Childhood - describe nurturing
■ Adolescence - describe peer group
■ Use and abused of drugs by the family
○ Manifestations seen in patients with mental disorders includes the following:
■ Disturbances in affect
● Euthymic – normal
● Inappropriate affect – disharmony between thought and emotional response
● Flat affect – no emotion attached to the content of speech
● Blunt affect – decrease emotional response
● Elated affect – extreme and inappropriate joyfulness associated with increased motor
activity and speech
● Depressed affect / dysphoric affect – pathologic feeling of sadness
● Anger/Aggression – pathologic feeling of hostility
● Anxious – grieve feeling of apprehension
● Labile affect – change of emotion from happiness to tearfulness in a very short span of
time
■ Disturbance in thoughts
● Delusion – false belief that cannot be corrected by reasons
○ Persecutory delusions – false belief that others are against him or will harm him
○ Nihilistic delusion – false belief that one denies existence of self or part of self
○ Thought Broadcasting – false belief that one’s thought can be read by others
○ Thought Withdrawal – false belief that one’s thought is taken by others
○ Thought Insertion – false belief that others inserted thoughts or ideas into his
mind
○ Ideas of Reference – false belief that situations or event in the environment are
directly projected into the client
○ Grandiosity – false belief that one is superior and powerful
○ Self-depreciation – false belief that one feels unworthy, ugly or sinful
○ Somatic delusion – false belief pertaining to body image or function
■ Obsession – a persistent and irresistible thought that a person is driven
to think again and again
■ Hypochondria – a morbid belief that one is sick
■ Perseverance – a tendency to emit the same verbal or motor response
again and again
■ Circumstantiality – patient provide a lot of details before finally answering
the question
■ Tangentially - verbal production is not at all related to the question
■ Thought blocking – sudden stoppage of thought without apparent
reasons
■ Neologism – coining new words Ex; “His BAGELGELS is in the river”
■ Loose association – patient verbal production is impossible to follow due
to lack of organization
2.
 PSYCHIATRIC NURSING:
NURSING PROCESS IN PSYCHIATRI- MENTAL HEALTH CARE Prelim | Midterm | Finals
BACHELOR OF SCIENCE IN NURSING - 3RD YEAR
_____________________________________________________________________________________________________

■ Word salad – extreme form of loose association, wherein there is no two

words that connect together to form any logical association
■ Clang association – patient speaks in rhymes
■ Flight of ideas – over productivity of talk and verbal skipping from one
idea to another Ex: “I like the color blue. Do you ever feel blue? Feelings
can change day to day. The days are getting longer”
■ Poverty of ideas – patient has few ideas and focus only on negative
aspects
■ Disturbances in perception
● Illusion – false interpretation of the external stimulus. Person falsely interprets or
perceives a real environmental stimulus. It may involve any senses
● Hallucination – false sensory perceptions that occur in the absence of an actual external
stimuli and it may involve any of the senses
○ G – Gustatory Hallucination > taste
○ O – Olfactory Hallucination > smell
○ V – Visual Hallucination > sight
○ A – Auditory hallucination > hearing
○ T – Tactile Hallucination > touch
● Depersonalization – a feeling of detachment from the environment and self
● Derealization – a feeling of altered reality
○ Disturbance motor behavior
■ Catatonic stupor
● Stupor – client is unresponsive to the surroundings but is conscious
● Rigidity – client assumes position and will not move when effort is made to change
his/her position
■ Waxy flexibility – client maintains his position which he has been originally placed
■ Catatonic excitement
● Hyperactivity – presence of motor restlessness and extreme over activity
● Impulsiveness – unpredictable and sudden outburst of activity
● Compulsion – unwanted urge to perform repetitive action
■ Automatism – unconscious uncontrollable undirected activity
● Echopraxia – client imitates actions of others
● Echolalia – client repeats words/statements of others
■ Stereotype – repetitive persistent motor activity or speech
● Verbigeration – constant repetition of same words
● Mannerism – persistent motor behavior
■ Tics and spasm – unconscious twitching or jerking of muscles usually above the shoulder which
are involuntary
○ Disturbance in memory
■ Amnesia – complete absence of memory
● Anterograde amnesia – forgetting recent events
● Retrograde amnesia – forgetting further events
■ Paraamnesia – incomplete absence of memory
● Confabulation – fabricating stories to fill up lapses of memory cause by
● Blackout – amnesia experienced by alcoholics about behavior during drinking bouts
● Deja Vu – familiarity of events, situations or places that are unfamiliar
● Jamais vu – unfamiliarity of events situations or places that are familiar
● Deja intendu – familiarity of sounds that are unfamiliar
● Jamais intendu – unfamiliarity of sounds that are familiar
● False memory – recollection of and belief in an event that did not actually occur
● Lethologica is a psychological disorder that inhibits an individual’s ability to articulate their
thoughts by temporary forgetting key words, phrases or names in conversation. It is
temporary inability to remember a name or proper noun
MENTAL STATUS EXAMINATION
➢ series of observations and examinations on the patient’s behavior, thinking, emotion and cognitive functions at
one point in time
➢ Focused questions and observations can reveal "normal" or pathological findings
➢ combined with personal and family histories and Psychiatric Review of Systems, forms the data base from which
psychiatric diagnoses are formed.
➢ Components
○ Appearance and behavior
■ Appearance
● Describe the general physical appearance of the client
● Appropriateness of clothing
● Personal hygiene, grooming, and cleanliness
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 PSYCHIATRIC NURSING:
NURSING PROCESS IN PSYCHIATRI- MENTAL HEALTH CARE Prelim | Midterm | Finals
BACHELOR OF SCIENCE IN NURSING - 3RD YEAR
_____________________________________________________________________________________________________

● Apparent age, body built, height, weight

● Any abnormalities in physical appearance
■ Behavior
● Cooperative? Resistant? Suspicious? Aggressive? Restless? Agitated? Hyperactive?
Hypoactive?
● Social skills: friendly, shy, withdrawn
● Amount and type of motor activity: psychomotor agitation or retardation,
● Tremors, or restlessness
● Presence of disturbances in motor behavior
● Presence of disturbances in motor behavior
○ Thinking
■ Thought Content- what the client is saying
● delusions, hallucinations,
● helplessness, hopelessness, worthlessness
● suicidal or homicidal thoughts
● Suspiciousness, obsessions, denial, phobia
■ Thought process – how the client is thinking
● Bizarre, impaired, logical, magical
● Ambivalence, circumstantiality, tangentially,
● thought blocking, loose association, flight of ideas, perseveration, neologism and
● Presence of other thought disturbances
■ Thought clarity: - coherence, confusion or vagueness
■ Speech pattern: - amount, rate, volume, tone, pressure, mutism, stuttering, slurring
○ Orientation to the three spheres
■ recognize person, place and time
■ Level of consciousness
○ Intellectual functioning
■ Educational level: cognitive functions
■ Attention: ability to concentrate
■ Retention: ability to retain information
■ Abstract reasoning: ability to interpret or associate situation, proverbs or comments
○ Cognitive functioning
■ Comprehension
■ Interpreting information
■ Learning new information
■ Judgment
■ Perception
■ Problem solving
■ Making decision
■ Reasoning
Gordon’s Functional Health Patterns
➢ method devised by Marjory Gordon to be used by nurses in the nursing process to provide a more comprehensive
nursing assessment of the patient.
➢ 11 areas to assess through questions asked by the nurse and medical examinations to provide an overview of the
individual's health status and health practices that are used to reach the current level of health or wellness
Functional Health Pattern Before Hospitalization During Hospitalization

Health Perception/ health

management
Nutritional- Metabolic
Elimination
Activity- Exercise
Cognitive- Perceptual
Sleep- Rest
Self-Perception/ self-concept
Role- Relationship
Sexuality- Reproductive
Coping/ stress Reliever
Value- Belief
Other assessment tools
➢ Ethno-cultural and Spiritual assessment
○ assessment tools that it looks both culture and spirituality simultaneously
○ process allows a provider to place a patient within their cultural/spiritual context while recognizing their
individual uniqueness at the same time

4.
 PSYCHIATRIC NURSING:
NURSING PROCESS IN PSYCHIATRI- MENTAL HEALTH CARE Prelim | Midterm | Finals
BACHELOR OF SCIENCE IN NURSING - 3RD YEAR
_____________________________________________________________________________________________________

○ assists providers in establishing a trusting therapeutic alliance with their patients empowers the patient to
become a more active participant in their healing journey and helps patients to give voice to their own
sacred story
○ allows the provider to become familiar with the process and also to begin to recognize their own
cultural/spiritual story
➢ Personality Test
○ utilized to assess ones character or measure ones character traits
○ gather self-report information, wherein engaged parties reply to queries about their character or chose
objects which depict themselves, or they might take the form of projective tests, that claim to gauge
unconscious factors of an involved party's personality
■ Thematic apperception Test (TAT)
■ Projective Technique
■ Approach Control Test
■ Personality Processes
■ Unobtrusive Measure
■ Think-Aloud Protocol
■ Rorshach Inkblot Test
■ Picture-World Test
■ Overdetermination Test
■ Personality Assessment
➢ Psychological Assessment
○ typically performed by clinical psychologists in school, hospital, outpatient, or other settings
○ typically quite broad in scope, and may include many of the same formal assessment procedures used in
psychoeducational and neuropsychological evaluations
○ clarify diagnoses and inform treatment/intervention
➢ Intelligence testing
○ theory and practice of measuring people’s performance on various diagnostic instruments (intelligence
tests) as a tool for predicting future behavior and life prospects or as a tool for identifying interventions
(e.g., educational programs)
THERAPEUTIC COMMUNICATION
➢ ability to establish effective communication in nursing is imperative to providing the best care and patient
outcomes possible
➢ integral part in nursing and in developing a helping relationship
COMMUNICATION
➢ exchange of information, ideas, thoughts or feelings between two or more people
➢ basic component of human relationships, including nursing
➢ Modes of Communication
○ Verbal Communication uses methods such as talking and listening. But it could also be in the form of
writing, reading, storytelling and other forms of communication using words..
○ Non Verbal Communication uses other forms, such as gestures, facial expressions and touch. It also
include physical appearance, eye contact, posture, gait and others
○ Written Communication uses any forms of written materials such as books, journals, messages and
others.
➢ Process of Communication
○ Sender is a person or group who wishes to communicate a message to another. It can can be considered
the source-encoder. Encoding involves the selection of specific mode of communication to transmit the
message such as the language and words to use, tone of voice and gestures to use.
○ Message is what actually is said or written, the body language that accompanies the words, and how the
message is transmitted. Example of which is talking face to face, through telephone or writing a message
in your FB, Twitter, SMS, etc.
○ Receiver is a person who must perceive what the sender is intended to relate. All the senses are being
use to receive the verbal and nonverbal messages.
○ Feedback is the message that the receiver returns to the sender. It is also called the response.
➢ Things to consider during face-to-face communication
○ Pace and intonation is the manner of speech, as in the rate or rhythm and tone
○ Simplicity is the use of commonly understood words, brevity, and completeness
○ Clarity is saying precisely what is meant, and brevity is using the fewest words possible.
○ Timing and relevance involves sensitivity to the client’s needs and concerns.
○ Adaptability is altering spoken messages in accordance with behavioral cues from the client.
○ Credibility means worthiness of belief, trustworthiness, and reliability. Credibility may be is the most
important criterion of effective communication. You can foster credibility by being consistent, dependable,
and honest.
○ Humor can be a positive and powerful tool in the nurse–client relationship, but it must be used with care.
Humor can be used to help clients adjust to difficult and painful situations.
➢ Factors influencing communication
5.
 PSYCHIATRIC NURSING:
NURSING PROCESS IN PSYCHIATRI- MENTAL HEALTH CARE Prelim | Midterm | Finals
BACHELOR OF SCIENCE IN NURSING - 3RD YEAR
_____________________________________________________________________________________________________

○Personal space is the distance people prefer in interactions with others. Communication alters in
accordance with four distances, each with a close and a far phase.
■ Intimate: space takes 0 to 11⁄2 feet and communication is characterized by body contact such as
cuddling a baby, assisting a client who is blind or with difficulty walking, positioning clients and
others
■ Personal takes 11/2 to 4 feet. This is the distance commonly use between nurses and clients
during interaction and providing nursing care such giving medication, health teaching, sitting with
a patient and others .
■ Social takes 4 to 12 feet. Communication in this space is formal and is limited to seeing and
hearing.
■ Public takes 12 feet and beyond. People at this distance are seen at public distance where
communication requires loud, clear voice.
○ Boundary is the defining limit of an individual. To keep clear boundaries, the nurse must maintain the
professional boundary between the nurse – patient relationships. Professional boundaries are crucial in
the context of the nurse–client relationship. Keeps the focus on the client and avoids sharing personal
information. Avoid gift-giving or receiving, spending more time than necessary with a client, or the nurse
believing only he or she understands the client (Boyd, 2012). Observe the use of touch. Touching a client
can be comforting and supportive when it is welcome and permitted. The nurse should observe the client
for cues that show whether touch is desired or indicated.
○ Gender. Man and woman communicate differently and that they may interpret the same communication
different manner.
○ Values are the standards that influence behavior, and perceptions are the personal view of an event.
Because each person has unique personality traits, values, and life experiences, each will perceive and
interpret messages and experiences different way.
○ Interpersonal attitudes convey beliefs, thoughts, and feelings about people and events. Attitudes are
communicated convincingly and rapidly to others. Attitudes such as caring, warmth, respect, and
acceptance facilitate communication, whereas lack of interest, and coldness inhibit communication.
○ Attentive listening is listening actively and with mindfulness and using all the senses, and paying attention
to what the client says, does, and feels
○ Congruence. Communication is congruent where the verbal and nonverbal aspects of the message
harmonize with each other
➢ Techniques in Therapeutic Communication
○ Accepting - Conveying that nurse hears or is interested in what the client is saying
■ Ex: “yes” or simply nodding head
○ Acknowledge client’s non-verbal communication
○ Clarify and validate client’s statement
■ Ex: P - “I’m crazy”
■ N- “What do you mean you are crazy?”
■ P – “I can’t sleep. I stay awake all night”
■ N – “You have difficulty sleeping
○ Encourage expression of feelings
■ P – “I want to kill myself”
■ N – “Tell me of you’re feeling of wanting to kill yourself”
○ Encourage hope but not false reassurance
○ Exploring - Delving further into a subject or idea
■ Ex: ‘Tell me more about that …’
■ ‘Would you describe it more fully?’
■ ‘What kind of work?’
○ Focusing to concentrate on a single point
■ Ex: N – “This topic seems worth looking at more closely”
○ Giving information - Making available facts that client need
■ Ex: My name is ……
○ My purpose in being here is …..
○ Giving recognition - Acknowledging behavioral changes or indicating awareness
■ Ex: You’ve combed your hair today
○ Inform and present reality
■ Ex: P - “Eggs are flying saucer”
■ N – “Eggs are food to be eaten
○ Making observation - Verbalizing what the nurse perceives
■ Ex: “You appear tense”
■ “I’ve notice that you’re biting your lips”
○ Offering self - Making oneself available
■ Ex: I’ll sit with you for awhile
○ Offering general lead - Giving encouragement to continue
■ Ex: “Yes, o on” “And then?” “Tell me about it”
6.
 PSYCHIATRIC NURSING:
NURSING PROCESS IN PSYCHIATRI- MENTAL HEALTH CARE Prelim | Midterm | Finals
BACHELOR OF SCIENCE IN NURSING - 3RD YEAR
_____________________________________________________________________________________________________

○Restate or Feedback on what the client has said

■ Ex: P – “Do you think I should tell my husband what happened?”
■ N – Do you think you should tell your husband?”
○ Reflects on the feelings expressed
■ P – “No one wants me.”
■ N - “You mean you feel rejected?”
○ Silence but expresses being there
■ Nurse says nothing but continues to maintain eye contact and convey interest
○ Summarizing - Reviewing main points and conclusions
■ Ex: Let’s see, so far you have said ……
○ Use open ended questions
■ Ex: P – “What are you feeling right now”
○ Using broad opening - Allowing the client to take initiative in introducing the topic
■ Ex: Where would you like to begin?
➢ Non-therapeutic Communication Techniques
○ Agreeing/Disagreeing
■ Ex: “That’s right…” / “I don’t believe that”
○ Approving/Disapproving
■ Ex: “I like the way you comb your hair”
■ “It’s not nice to look the way you comb your hair
○ Advising
■ Ex: “I think you should…?
○ Asking why questions– asking client to provide reasons for thoughts, feelings, behaviors and events and
patient may become defensive
■ Ex: “Why do you think that you are crazy?”
■ “Why do you feel that way?”
○ Belittling feeling expressed – misjudging the degree of the client’s discomfort
■ Ex: P - “I have nothing to live for… I wish I was dead”
■ N – “I’ve felt that way before”
○ Challenging – demanding proof for the client
■ Ex: N- “But how can you be president of the United States?”
○ Changing topic
■ Ex: P – “I really want to die”
■ N – “Your mother did not visit you this week?”
○ Defending – attempting to protect someone or something
■ Ex: P – “My doctor is mean and uncaring
■ N – “I’m sure your doctor has your best interest in mind”
○ False reassurance – indicating there is no reason to worry or other feelings of discomfort
■ Ex: N – “Everything will be alright”
○ Giving Personal opinion or value judgment
○ Testing – appraising the client’s degree of insight
■ Ex: “Do you know what kind of hospital this is?”
○ Using denial – refusing to admit that a problem exists
■ Ex: P – “I’m nothing”
■ N – “Of course you’re something – everybody’s something”
➢ Components to developing therapeutic communication
○ Trust is a key factor in establishing a therapeutic relationship towards recovery process
○ Genuine interest. When the nurse is comfortable with himself or herself, aware of his or her strengths and
limitations, and clearly focused, the client perceives a genuine person showing genuine interest. The
nurse should be open, honest and display congruent behavior
○ Empathy is the ability to perceive the meaning and feelings of the client and to communicate that
understanding to the client. Empathy is one of the essential skills a nurse must develop
○ Acceptance is not just being nice to people. It is a principle of action in which a nurse perceive and work
with the patient as what he really is. She accepts congenial and uncongenial qualities, his constructive
and destructive attitude and his positive and negative feeling while maintaining a sense of patient’s innate
worth. Accepting behaviors are caring action of nurses on the client’s well-being such as, sensitivity,
comforting, attentive listening , honesty and non-judgmental acceptance
○ Positive regard. The nurse appreciates the client as a unique worthwhile human being who can respect
the client regardless of his or her behavior, background or lifestyle. Measures to convey respect and
positive regard to your client.
■ Calling client by name or whatever your client wishes to call him or her
■ Spending time with your client
■ Listening and responding openly and
■ Considering your client’s ideas and .preferences when planning care

7.
 PSYCHIATRIC NURSING:
NURSING PROCESS IN PSYCHIATRI- MENTAL HEALTH CARE Prelim | Midterm | Finals
BACHELOR OF SCIENCE IN NURSING - 3RD YEAR
_____________________________________________________________________________________________________

○ Therapeutic use of self is forming a trusting relationship that provide s comfort, safety and non-judgmental
acceptance of clients to help them improve their health status. Therapeutic use of self requires
self-awareness and the use of effective communication techniques
➢ Self-awareness is conscious knowledge of one's own character, feelings, motives, and desires. The process can
be painful but it leads to greater self-understanding
THERAPEUTIC RELATIONSHIP
➢ ability to establish a therapeutic relationship with clients is one of the most important skills a nurse can develop
➢ crucial to the success of interventions with clients requiring psychiatric care because the therapeutic relationship
and the communication within it serve as the underpinning for treatment and success
➢ defined as a helping relationship that's based on mutual trust and respect, the nurturing of faith and hope, being
sensitive to self and others, and assisting with the gratification of patient’s physical, emotional, and spiritual needs
through adequate knowledge and skill
➢ Effective verbal and nonverbal communication is an important part of the nurse-patient relationship, as well as
providing care in a manner that enables the patient to be an equal partner in achieving wellness
➢ Helping Relationship
○ Patient centered
○ Goal directed
○ Professional relationship
○ Time bounded
○ Structured – planned and follows a sequence (establishing, maintaining, terminating)
➢ Types of Relationships
Area of Differentiation Therapeutic Relationship Social/Intimate Relationship
Characteristics Personal but not intimate Personal or intimate
Goal Meet client’s need Doing favor for mutual benefit
Termination With limitation, defined in the Not defined
beginning
Identification of needs Present May not occur
Resources used Specialized professional skills for Variety during interaction
intervention
➢ Phases of Therapeutic Relationships
○ Pre interaction Phase.
■ It begins before the client first contact with the patient. The nurse gathers information. Such
information may include the client’s name, address, and age, medical and social history.
■ The nurse should consider his or her personal strength and limitation when working with the client
and in any area that might signal difficulty because of past experiences
○ Introductory Phase.
■ It begin when the nurse and the client first meet
■ The nurse establishes a relationship , develop trust and respect , setting goals, and security
within the nurse–client relationship
● Establish boundaries and acceptance
● Establish trust – consistent, congruent, honest, keeping prom genuine interest and
Respect
● Establish contract
○ Time, place and length of session
○ Who will be involved in the treatment plan
○ Client responsibilities and nurse responsibilities
○ Duration
○ Purpose of the meeting
● Nurse’s responsibility during NPI
○ Arrive on time
○ Maintain confidentiality
○ Assess client level of anxiety
○ Prepare client for termination and separation of the relationship
○ End on time
○ Document sessions
● Establishing relationships
○ Gaining the client’s trust
○ Establishing the boundary and expectations of the relationship.
○ Identifying problem.
○ Working Phase.
■ The nurse works with the client on the resolution of the patient’s identified problem.
■ Perform evaluation and redefine his or her goals as appropriate
○ Termination Phase.
■ The nurse summarizes with the clients his progress of the relationship and assessing the client’s
ability to handle situations independently
■ Nurse-client talks about the progress of the relationship
8.
 PSYCHIATRIC NURSING:
NURSING PROCESS IN PSYCHIATRI- MENTAL HEALTH CARE Prelim | Midterm | Finals
BACHELOR OF SCIENCE IN NURSING - 3RD YEAR
_____________________________________________________________________________________________________

■ Identify and deal with separation issues

■ Assess client emotional stability
■ Do not promise the client that the relationship will be continued
■ Refer and transfer client to other support system

Barriers to Therapeutic Relationships (Candy TRIES)

➢ C – Countertransference
○ Nurse transfers feelings to client of a significant person in her life
➢ T – Transference
○ Client transfers feelings to nurse of a significant person in her life
➢ R – Resistance and Avoidance
○ Development of ambivalent feelings for self-exploration or self-disclosure
➢ I – Inappropriate boundaries
○ Nurse-patient relationship should be maintained within the professional boundary
➢ E – Encouraging dependency
○ Nurse should help the client to function independently
➢ S – Sympathy
○ The nurse should develop empathy
TREATMENT MODALITIES
Somatic Therapy
➢ body-centered therapy that looks at the connection of mind and body and uses both psychotherapy and
physical therapies for holistic healing
➢ help people who suffer from stress, anxiety, depression, grief, addiction, problems with relationships,
and sexual function, as well as issues related to trauma and abuse, those who traditional remedies
have not been helpful for chronic physical pain, digestive disorders and other medical issues
➢ individual and group therapy settings
Electroconvulsive Therapy
➢ treat severe depression and other mental illnesses such as schizophrenia
➢ fastest and most effective ways to relieve symptoms in severely depressed or suicidal people or those
who have mania or other mental illnesses
➢ introduction of electrical current to the brain through an electrode attached to client’s temporal region
and produces grandmal seizures
➢ series of 6 – 15 treatments 3 x a week; maximum benefit is achieved in 12 – 15 treatments
➢ Forms of ECT
○ Unilateral
■ Electrode is attached to either sides
■ Results in less memory loss but more treatments may be needed
○ Bilateral
■ Electrodes are attached to both sides
■ Results in more rapid improvement but with increased short memory loss
➢ Indications
○ Clients who are severely depressed
○ Clients who are actively suicidal
○ Clients who does not respond to antidepressant
○ Clients who experience intolerable side effects of antidepressants
○ Use to prevent relapse of depression
➢ Contraindications
○ Hypertension and other cardiovascular diseases
○ Brain tumor
○ Pulmonary diseases (COPD)
○ Fracture
○ Fever of any kind
○ Glaucoma
➢ Preparations
○ Inform client
○ Secure consent
○ Complete physical exam
○ Cardiopulmonary exam
○ Dental records
➢ Nurse responsibilities
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NURSING PROCESS IN PSYCHIATRI- MENTAL HEALTH CARE Prelim | Midterm | Finals
BACHELOR OF SCIENCE IN NURSING - 3RD YEAR
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○
Pre-ECT
■ NPO 6 – 8 hours/ post-midnight
■ Take vital signs
■ Remove jewelries
■ Remove dentures
■ Loosen clothings
■ Dry client
■ Empty the bladder
■ Remove nail polish
■ Move bowel
■ Place client in a supine position comfortably in bed w/ firm mattress
■ Administer pre-medication as prescribed by the physician:
○ During ECT
■ Stay with the client
■ Provide emotional support
■ Assess any complications
○ Post ECT
■ Position client in a lateral position
■ Assess any injury
■ Take vital signs
■ Stay with the client and orient him as the client will experience confusion and shortterm
memory impairment
■ Offer food if client is fully awake and when gag reflex returns
➢ Deep Brain Stimulation
○ surgery to implant a device that sends electrical signals to brain areas responsible for body
movement
○ uses electric pulses to regulate brain activity
Supportive Therapy
Individual Therapy
➢ a method of bringing about change in a person by exploring his/her feelings, attitudes, thinking and
behavior
➢ one on one relationship between the therapist and the client
➢ Stages
○ Introduction
○ Working
○ Termination
➢ Purposes
○ To understand themselves and their behavior
○ To make personal changes
○ To improve interpersonal relationships
○ To get relief from emotional pain or unhappiness
Family Therapy
➢ a group therapy in which the client and his family members participate
➢ Goals
○ Understanding how family dynamics contribute to the client’s psychopathology,
○ Mobilizing the family’s inherent strengths and functional resources,
○ Restructuring maladaptive family behavioral styles
○ Strengthening family problem-solving behaviors.
➢ Educational focus
○ Example of disorders where family education can be used are schizophrenia, bipolar disorder,
clinical depression, panic disorder, and OCD.
○ The course discusses the clinical treatment of these illnesses and teaches the knowledge and
skills that family members need to cope more effectively.
○ It includes emphasis on emotional understanding and healing
Group Therapy
➢ number of persons who gather in a face to face setting to accomplish tasks that requires cooperation,
collaboration, or working together
➢ share a common purpose and are expected to contribute to the group to benefit others (altruism) and
receive benefit from others in return
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NURSING PROCESS IN PSYCHIATRI- MENTAL HEALTH CARE Prelim | Midterm | Finals
BACHELOR OF SCIENCE IN NURSING - 3RD YEAR
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➢ Therapeutic Results
○ Feeling of acceptance and belonging
○ Becoming aware that one is not alone and that others share same problems
○ Gaining new information, or learning
○ Gaining inspiration or hope
○ Gaining insight into one’s problems and behaviors and how they affect others
○ Giving of oneself for the benefit of others
○ Interacting with others
➢ Examples
○ Psychoeducation
■ Stress management,
■ Medication management,
■ Assertiveness training
■ Conflict resolution
■ Anger management
■ Problem solving
○ Self-Help
■ Alcoholic anonymous – alcoholics
■ Al- Anon – wives of alcoholics
■ Ala-teen – children of alcoholics
■ Overeaters Anonymous
■ One Day at a Time (a grief group)
○ Support groups- provide a safe place for group members to express their feelings of frustration,
boredom, or unhappiness and to discuss common problems and potential solutions
■ Those for cancer or stroke victims,
■ Person with aids,
■ Family members of someone who has committed suicide,
■ Mothers Against Drunk driving (MADD), Role Reversion
Psychotherapy groups
➢ managing the individuals’ emotional problem
➢ includes the application of the different theories:
○ Cognitive theory – Aaron T. Beck
■ Cognitive behavioral therapy was first developed and implemented by Albert Ellis in
1950’s. It used to restructure how a person perceives self or events in his or her life to
facilitate behavioral and emotional change
● Cognitive Restructuring – use to monitor automatic thoughts, then to recognize
the connection between thoughts, emotional response and behavior
● Thought stopping – used with patients who have obsessional thoughts
○ Obsession
○ Borderline
○ Panic
○ Aggression
■ Cue cards – used to help patient restructure thought patterns
● Thought Reframing – changing negative thoughts to a positive one
○ Behavioral theory – Skinner
■ Behavioral therapy is a strategy that help patients change behavior:
■ Positive feedback
■ Behavioral modification
■ Token economy
○ Psychoanalytic theory – Sigmund Freud
○ Psychosocial theory – Erik Erikson
Milieu Therapy
➢ purposeful use of the environment to enhance mental health of psychiatric patients
➢ Elements
○ Unit structure includes:
■ activity groups
■ social skills groups
■ physical exercise program
■ community meetings
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NURSING PROCESS IN PSYCHIATRI- MENTAL HEALTH CARE Prelim | Midterm | Finals
BACHELOR OF SCIENCE IN NURSING - 3RD YEAR
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■ psycho-educational program
○ Unit norms
■ Related to unit rules and policies
■ This includes rules concerning dressing, appearance, group meetings,
medications,visiting hour, telephone use, etc
■ This also includes norms of nonviolence, physical & emotional security, respect, privacy,
acceptance, independence and individual responsibility
○ 3. Limit setting
■ Is the art of clearly identifying acceptable and unacceptable behaviors
■ This includes self-destructive acts, physical aggressions, noncompliance,inappropriate
sexual behaviors
○ Unit modification
■ Purposeful arrangement of the environment
■ This includes physical arrangement of furniture, safety issues and orientation strategies
Therapeutic Activities as Adjunct Therapies to Patient Recovery
Remotivation Technique
➢ Remotivation Technique or therapy is founded in 1956 by Dorothy Hoskins Smith, a gifted English
teacher; it actually started in 1949 at North Hampton, Massachusetts where she works as a volunteer.
The therapy can be used in a ward situation regardless of the length of hospitalization, nature of illness,
and age of the patient. It is something done expertly and well that helps in the patient’s recovery and be
back in pre-hospitalization state
➢ Remotivaton technique is a very simple group therapy of an objective nature used in an effort to reach
the unwounded areas of patient’s personality & get them moving back into the reality
➢ Objectives
○ Develop the patient ability to communicate and share ideas and experience with other
○ Stimulate patient to think about something and talk about himself
○ Stimulate patient to be fellow explorer of the real world
○ Enhance feeling of recognition and acceptance to increase self-respect and selfesteem
○ Stimulate the patient’s interest in reality situation
○ Take the patient out of the dullness of the ward and from the “vegetative state”
○ Develop group harmony
➢ Duration
○ 45 – 60 minutes for once or twice per week. The therapy consists of 12 series of sessions.
○ Subjects to be considered
● Nature
● Industry
● History
● Sports
● Science
● Hobbies
● Literature
● Geography
■ Subjects to be avoided
● Family problem
● Sex
● Love
● Religion
● Politics
■ Steps of Remotivation Techniques:
● Climate of Acceptance
○ The leader opens the discussion by greeting the group in general and
expressing appreciation of the group’s attendance.
○ The leader gives his/her name and must ask participants to introduce
themselves.
○ After the introduction, the leader may comment on the weather, the
patient’s appearance or may give a pleasant compliment.
○ The general objective is to create a relaxed and comfortable atmosphere
in which the patients feel accepted
● Bridge to reality (15min)
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NURSING PROCESS IN PSYCHIATRI- MENTAL HEALTH CARE Prelim | Midterm | Finals
BACHELOR OF SCIENCE IN NURSING - 3RD YEAR
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○ The leader attempts to stimulate or help the patient get interested in the
reality oriented topic.
○ Ask bouncing questions that are short and easy to answer and may lead
to the topic for discussion.
○ ou may ask anybody who knows a poem about the topic of discussion
○ A poem appropriate for the topic may be used by reading the stanzas and
use them as focus of discussion until everyone has participated. The
poem and picture or visual aids will serve as a bridge between topics of
discussion of reality.
● Sharing the world we live in (15min)
○ Stimulating question leading to the topic
○ Leader should try to explore the topic under discussion
● Appreciation of the work of the world (15min)
○ The step is blended with step 3
○ Be sure to relate the patient so he will be able to think of himself in
relation into certain job
● Climate of appreciation (15min)
○ Leader should try to ask a summary about the topic w/c has discussed
○ Explore with the patient topic to be discussed in the next session
○ Express your appreciation to the patient for coming to the sessions and
participating in the activity
Music and Art therapy
➢ Music Therapy
○ is a technique of complementary medication that uses music to help patient overcome physical,
emotional, intellectual and social challenges. It is use in many setting including schools,
rehabilitation centers, hospitals, hospice, nursing homes, and community and even at home
○ Purposes:
■ To promote participation and social interaction
■ To improve reality orientation
■ To develop coping skills
■ To reduce stress
■ To help express feeling through music
➢ Art Therapy
○ is the therapeutic use of art making such as drawing, painting, clay art, and others
○ Purposes
■ To increase self-awareness
■ To cope with stress and traumatic experiences
■ To enhance cognitive abilities
■ To promote self-esteem
■ To promote self-discovery and personal fulfillment
■ To help express feeling through art
○ Steps in music appreciation through art:
■ Select appropriate music depending on your objective.
■ Prepare necessary materials needed such as crayons, bond paper, music player,
speaker and extension
■ Gather clients in a U-shape, seated in a bench with a table.
■ Greet the group in general and express appreciation of the group’s attendance.
■ The leader gives his/her name and must ask participants to introduce themselves.
■ Introduce the activity. You may introduce the activity by asking client about their favorite
music, the importance of music to them, types of music they know, etc.
■ Explain procedure of the activities.
■ Play the music. During the session, play the same music until all clients are done with
their drawing
■ Ask clients to comment and explain their drawing while student nurses listen and
analyze the explanation of their assigned client.
■ Collect clients drawing.
■ End the activity by thanking the participants and give brief explanation of what to expect
in the next session.
Occupational therapy
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NURSING PROCESS IN PSYCHIATRI- MENTAL HEALTH CARE Prelim | Midterm | Finals
BACHELOR OF SCIENCE IN NURSING - 3RD YEAR
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➢ discipline that aims to promote health by enabling people to perform meaningful and purposeful
activities. Occupational therapists work with individuals who suffer from a mentally, physically,
developmentally, and/or emotionally disabling condition by utilizing treatments that develop, recover, or
maintain clients' activities of daily living. The therapist helps clients not only to improve their basic motor
functions and reasoning abilities, but also to compensate for permanent loss of function. Any activity,
mental or physical, prescribed and guided to aid individual’s recovery from diseases or injury. Patient
may enjoy the activity because they exclude competition and pressure.
➢ Objectives
○ To develop the patient’s ability to grasp reality through activities of daily living
○ To provide opportunity for creativeness and produce something tangible out of patent’s own
thinking and imagination
○ To promote self-confidence and personal achievements.
○ To prepare client before discharge from the institution to have independent, productive, and
satisfying lives
➢ Process
○ Identify occupational performance issues
○ Assess factors contributing the identified occupational performance issue(s)
○ Consider the strengths and resources of both client and therapist
○ Negotiate targeted outcomes and develop an action plan
○ Implement the plan through occupation
○ Evaluate outcomes
➢ Activity Analysis
○ Activity analysis has been defined as a process of dissecting an activity into its component parts
and task sequence in order to identify its inherent properties and the skills required for its
performance, thus allowing the therapist to evaluate its therapeutic potential
➢ Activity suggested
○ Painting sketching ceramics cooking
○ Basketry weaving toy making picture frame
○ Sewing knitting flower making and many more
➢ Areas of practice in occupational therapy
○ Mental health
■ Facilitates maximum independence in activities of daily living (dressing, grooming, etc.)
■ Activities of daily living (medication management, grocery shopping, keeping a schedule,
employment, education, livelihood, etc.).
■ Increasing community participation, community access (grocery store, library, bank,
etc.), money management skills, engaging in productive activities to fill the day, coping
skills, routine building, building social skills, and childcare (Cara & MacRae, 2005).
○ Physical health
■ Schools, Community, inpatient hospital based child OT:
■ Acute care hospitals:
■ Inpatient acute care hospital setting for individuals with a serious medical condition(s)
usually due to a traumatic event, such as a traumatic brain injury, spinal cord injury, etc.
■ Inpatient rehabilitation (e.g., Spinal Cord Injuries)
■ Rehabilitation centers (e.g., Traumatic Brain Injury (TBI),[29] Stroke (CVA), Spinal Cord
Injuries, Head Injuries)
■ Home Health: geriatric population who have one or more of the following diagnoses:
Alzheimer’s disease, arthritis, depression, CVA, generalized weakness, COPD, or
Parkinson’s disease.
■ Outpatient clinics (e.g., Hand Therapy, orthopedics) Diagnoses seen by this practice
area include: fractures of the hand or arm, lacerations and amputations, burns, and
surgical repairs of tendons and nerves, tendonitis, rheumatoid arthritis and osteoarthritis,
and carpal tunnel syndrome
■ Productive Aging
○ Community. Community based practice involves working with people in their own environment
rather than in a hospital setting. It often combines the knowledge and skills related to physical
and mental health
Recreational Therapy
➢ Recreational therapy, also referred to as recreation therapy and therapeutic recreation, is a treatment
service that provides treatment and recreation activities to individuals with illnesses or disabling
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NURSING PROCESS IN PSYCHIATRI- MENTAL HEALTH CARE Prelim | Midterm | Finals
BACHELOR OF SCIENCE IN NURSING - 3RD YEAR
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conditions. Treatment may incorporate arts and crafts, animals, sports, games, dance and movement,
drama, music and community outings.
➢ Purposes:
○ Helps patient recover basic motor functioning, reasoning abilities, build confidence, and
socialize more effectively.
○ Improve or maintain physical, mental and emotional well-being
○ Help patients educe depression, stress and anxiety
➢ Process: The recreational therapy process begins with an individual assessment of their:
○ Strengths, interest, and values
○ Previous leisure activities and expectations
○ Available resources in your home and community
○ Social needs and relationships
○ Economic and other potential problem areas
○ Lifestyle adjustments necessary for healthy leisure functioning
➢ Activity and treatment ideas for Recreational Therapy includes
○ Arts/ Crafts/ Cooking 6. Leisure/ Education/ Academics
○ Dance/ Drama/ Music/ Writing 7. Social activities
○ Experiential 8. Warm up activities
○ Holiday and special events 9. Wellness and fitness
○ Humor and fun
Dance/movement therapy,
➢ Dance/movement therapy, usually referred to simply as dance therapy or DMT, is a type of therapy that
uses movement to help individuals achieve emotional, cognitive, physical, and social integration.
Beneficial for both physical and mental health, dance therapy can be used for stress reduction, disease
prevention, and mood management. In addition, DMT's physical component offers increased muscular
strength, coordination, mobility, and decreased muscular tension. Dance/movement therapy can be
used with all populations and with individuals, couples, families, or groups. In general, dance therapy
promotes self-awareness, self-esteem, and a safe space for the expression of feelings.
➢ The creative expression of dance therapy can bolster communication skills and inspire dynamic
relationships. It is commonly used to treat physical, psychological, cognitive, and social issues such as:
○ Physical Issues:
■ Chronic pain
■ Childhood obesity
■ Cancer
■ Arthritis
■ Hypertension
■ Cardiovascular disease
○ Mental Health Issues:
■ Anxiety
■ Depression
■ Disordered eating
■ Poor self-esteem
■ Posttraumatic stress
○ Cognitive Issues:
■ Dementia
■ Communication issues
○ Social Issues:
■ Autism
■ Aggression/violence
■ Domestic violence trauma
■ Social interaction
■ Family conflict
Nurses attitudes in psychiatric nursing care
➢ Nursing care involves the use of attitudes in giving patients the greatest opportunity to regain their
health and to learn good health habits.
○ Active friendliness
■ Means an attitude of interest in the immediate wellbeing of the patient, despite the
attitude the patient himself maybe presenting.

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NURSING PROCESS IN PSYCHIATRI- MENTAL HEALTH CARE Prelim | Midterm | Finals
BACHELOR OF SCIENCE IN NURSING - 3RD YEAR
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■ It is giving attention before the patient requests it. It means common sense and a
genuine interest in the patient as a person will guide the nurse in its use.
○ Passive friendliness
■ Implies an attitude of interest in the patients’ welfare but one, which does not seek him
out to reassure him of that friendliness. Rather, the nurse is friendly when the patient
approaches her at any time, shows an interest but allows, indeed encourages, the
patient to make the initial overtures.
■ This is often use for people who are frightened by active friendly attentions who
recognize some of their own emotional reactions and who will seek the friendship
attention, or companionship of the nurse when they need it but will be dismayed or
angered of the nurse interacts the attention.
○ Indulgence and Permissiveness
○ Some patients are so frightened of reality, even the reality of a protective place like the
psychiatric hospital, that it is necessary for us to accept behavior normally unacceptable in most
groups. It means that the nurse accepts without punishing minor infractions of the ward rules;
she may even instigate such infractions for example, by allowing the patient to sit by her desk
and read after “lights outs” at night.
○ Watchfullness
■ Use for patient who are suicidal
■ It implies more than watching the patient alone; the personnel must be aware of the
many tools of daily hospital life which can prove dangerous to the life of such persons
and frequent inspection should be made of the patients’ belongings as well as the
hospital ward itself, for any article secreted to aid the patient to escape, harm other or
commit suicide
○ Matter of fact
■ Patients for whom this attitude is necessary are often nagging and co plaintive and may
make frequent bids for sympathy whether because of physical pain or of some annoying
hospital routine. The nurse should ignore all such bids, go on about her routines and be
friendly toward the patient. She should avoid falling into the trap of arguing or defending
the hospital, the diet, kitchen or the doctor’s orders. “This is the way it is, so we accept it”
should be implied of her calm manner in carrying out the daily routines.
○ Kind firmness
■ Some patients are usually self-punitive, suicidal persons cannot accept overt
friendliness. They feel unworthy, guilty or fearful and active or even passive friendliness
adds to rather than lessens the burden of their guilt.
■ It implies a near sternness in the care of such patients but the nurse must be careful not
to use this attitude to express some of her own hostility. Firmness is a tool for the care of
the patient only not a release for the nurses’ own tensions.

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