Psychiactric Nursing Overview

1. Psychiatric Nursing: core, heart, basis, art of nursing

1. Interpersonal process
1. Communication
2. Caring
2. Goals

1. Dealing with emotional responses to stress and crisis

2. Satisfying basic needs
3. Learning more effective ways of behaving
4. Developing a healthy lifestyle
5. Achieving a realistic and positive self-concept

3. Responsibilities

1. Therapeutic relationship
2. Therapeutic environment

4. Uses nursing process

1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation

5. Roles

1. Counselor
2. Teacher
3. Advocate
4. Leader, coordinator, manager

1. Theoretical Models of Treatment

1. Medical-biologic Model

1. Oriented to diagnosing mental disturbances as medical diseases with specific classifiable

manifestations

1. Diagnosis
1. History
2. Physical
3. DSM classification of disorders
2. Causes.

1. Biochemical
2. Psychological conditions
3. Psychophysiological conditions
4. Structural problems

3. Focus
 1. Accurate diagnosis
2. Selection of treatment modalities
3. Nurse's role is supportive, not therapeutic

1. Treatment

1. Physical or somatic
2. Interpersonal

2. Nursing Interventions

1. Assist doctor with somatic treatments

2. Prepare/teach client
3. Assist in interpersonal treatments of clients

2. Psychoanalytical Model (Sigmund Freud)

1. Oriented to uncovering childhood trauma and repressed feelings that cause conflicts in later
life

1. Psychopathology

1. Alterations in psychosocial behavior

2. Stress related behaviors

2. Structure of the mind

1. Id: contains instinctual primitive drives
2. Ego: mediates demands of primitive id and self-critical superego
3. Superego: values and mores that guide behavior
4. Conscious: ability to recall or remember events without difficulty
5. Unconscious: memories and thoughts that do not enter awareness

3. Freud's psychosexual stages

1. Oral 0-1 years
2. Anal 1-3 years
3. Phallic (oedipal) 3-6 years
4. Latency 6-12 years
5. Genital 12-young adult

4. Treatment modalities: clarify meaning of unconscious and conscious events,

feelings and behavior to gain insight
1. Transference (unconscious projection of feelings onto others)
2. Countertransference
3. Free Association
4. Dream Analysis
5. Catharsis (talking it out)
5. Nursing Interventions

1. Guidelines for understanding human behavior

2. Determine adaptive/maladaptive personality traits
3. Individualize teaching based on psycho-sexual development

3. Psychosocial Developmental Model: (Eric Erikson)

 1. Psychosocial tasks that are accomplished throughout the life cycle; an individual who
experiences failure in any stage is likely to have greater difficulty achieving success in
future stages of development
2. Uses an interdisciplinary approach to treatment; wellness is on a continuum

ERIKSON'S STAGES OF DEVELOPMENT

STAGE TASK BEHAVIOR
Trust Hopefulness, trusting
Infancy
vs vs
(0-18 mos)
Mistrust Withdrawn, alienated
Self-control
Autonomy
Early childhood vs
vs
(18 mos-3 yrs) Compliance and compulsiveness,
Shame, doubt
uncertainty
Initiative Realistic goals: explores, tests reality
Late childhood
vs vs
(3-5 yrs)
Guilt Strict limits on self-worry
Industry Explores, persistent, competes
School age
vs vs
(5-12 yrs)
Inferiority Incompetent, low self-esteem
Identity Sense of self
Adolescence
vs vs
(12-20 yrs)
Role diffusion Confusion, indecision
Intimacy Commitment in love/work/play
Young adulthood
vs vs
(20-25 yrs)
Isolation Superficial, impersonal
Generativity Productivity, caring about others
Adulthood
vs vs
(25-65 yrs)
Stagnation Self-centered and indulgent
Integrity Sense of accomplishment
Old age
vs vs
(65 yrs-death)
Despair Hopelessness, depsression
ERIKSON'S STAGES DEFINED
STAGE DEFINITION
INFANCY(0-18 mos) Babies learn to trust one consistent caregiver
"Trust vs. Mistrust" (not necessarily the mother)
Learning independence and self control: how
EARLY CHILDHOOD (18 mos - 3 years)
to affect the environment with direct
"Autonomy vs. Shame & Doubt"
manipulation
Personal exploration and selling goals that
LATE CHILDHOOD (3 - 5 years)
influence the environment: evaluating
Initiative vs. Guilt
own behavior
SCHOOL AGE (5 - 12 years) Developing sense of self & competency:
Industry vs. Inferiority learning to create and manipulate
Integrating life experiences for a sense of self
ADOLESCENCE (12 - 20 years) (trying new roles to see "what fits"; peer
Identity vs. role diffusion pressure creates tumultuous rebellions:
examines own sexual identity
 Develop intimate or committed relationships:
YOUNG ADULTHOOD (20 - 25 years)
commit to work/ profession; seek balance in
Intimacy vs. isolation
life
Establishing and guiding next generation
ADULTHOOD (25 - 65 years)
"giving back" to society with
Generativity vs. Stagnation
creativity; productivity and concern
Life review (necessary); accepting one's life
OLD AGE (65 years - death)
as fulfilling; worthwhile. successful: providing
Integrity vs. despair
a legacy

4. Basic Human Needs Model (Maslow): a hierarchy of needs; a belief that needs are fulfilled in a
progressive order

1. Levels

1. Physical

1. Air
2. Food
3. Sleep
4. Sexual expression

2. Safety

1. Avoiding harm
2. Feeling secure

3. Love and belonging

1. Group identity
2. Being cared about
3. Caring for others
4. Play

4. Self-esteem

1. Self-confidence
2. Self-acceptance

5. Self-actualization

1. Self-knowledge
2. Satisfying, interpersonal relationships
3. Environmental mastery
4. Stress management

2. Treatment

1. Interdisciplinary: shared roles

2. Developmental: interpersonal view of the self
3. Goal: fill needs in progressive manner

3. Nursing Interventions
 1. Use needs and psychosocial development for assessment
2. Prioritize care based on needs according to hierarchy
3. Help client fulfill needs to relieve stress
4. Help client advance through stages to become more able to fulfill own needs
5. Help client develop new behaviors to reduce stress and prevent recurrences of
mental illness and dysfunction

5. Behaviorist Model (behavior modification): "maladaptive behavior is learned"

1. Changes behavior by using learning theory: replaces nonadaptive behavior with more
adaptive behavior
2. Treatment

1. Reconditioning: unlearning learned or maladaptive behavior

2. Reinforcement: increases the probability of positive behavior recurring

1. Positive reinforcement: per contract. use rewards to increase or reinforce

desired behavior (for example: adding something such as food, attention,
phone privileges)
2. Negative reinforcement: per contract, extinguish undesirable behavior by
removing aversive consequences (for example: removal of imposed
restrictions)

3. Positive punishment: decrease behavior by adding aversive consequences (for

example: quiet time)
4. Negative punishment: decrease behavior by withdrawing a reward (for example.
privilege, such as an outing or calls)

3. Main uses

1. Children
2. Severely regressed individuals
3. Personality disorders
4. Anxiety disorders such as phobias
5. Eating disorders
6. Mentally disabled clients

4. Nursing Interventions
1. Assess behavior
2. Implement specific behavioral interventions either negative or positive reinforcement
(contracts, roleplay, progressive relaxation)
3. Emphasis is on positive reinforcement as a primary nursing intervention
4. Evaluate progress; change behavioral interventions specific to client need

6. Community Mental Health Model (psychosocial rehabilitation): individual interacting with

environment

1. Uses interdisciplinary team approach; nurse works as case manager and supervises the
team
2. Emphasis is on providing treatment services in the least restrictive setting
3. Treatment Modalities
1. Primary prevention: maintenance and promotion of health by teaching (for example:
risk factors, medication management, health promotion and wellness)
2. Secondary prevention: early diagnosis and treatment (for example: crisis
 intervention, partial hospitalization, acute care hospitalization)
3. Tertiary prevention: rehabilitation, follow-up to avoid permanent disability (for
example: psychiatric "Day Care")
4. Nursing Interventions

1. Holistic care
2. Therapeutic use of self in the nurse/client relationship
3. Uses primary, secondary, tertiary prevention
4. Identify client needs, strengths, and community resources

1. Treatment Modes

1. Crisis Intervention

1. Definitions

1. Crisis: a sudden, disequilibrating event in one's life when previous methods of

problem solving are ineffective
2. Crisis intervention: brief treatment used to help clients cope with or adapt to
stressors

2. Type of crisis

1. Situational (unanticipated; for example: death, divorce, being fired)

2. Transitional (maturational, anticipated; for example: birth, marriage)
3. Cultural/social (for example: war)

3. Responses to crisis

1. Physiological (nervous system)

2. Psychological (panic, fear, helplessness)
3. Behavioral (extremes; talkative to withdrawn)

4. Principles of crisis management

1. Requires prompt intervention in calm, controlled atmosphere

2. Focus on client strengthens positive coping skills
3. Time limited (6-8 weeks)

5. Nursing Interventions

1. Provide therapeutic interventions to keep client focused on immediate problem

2. Set specific goals for resolution
3. Help client develop more adaptive coping behaviors; sense of mastery
4. Reinforce client's own responsibility to act (collaborate)

1. Group Therapy

1. Definition: collection of 7-10 individuals interacting together with a shared purpose

2. Dynamics and concepts

1. Content: work is done to problem solve and fulfill the group functions and goals
2. Process: what is happening in the group; interactions, seating, participation
 3. Cohesiveness: feeling of belonging, helpfulness, problem solving, sharing
4. Norms: standards of behavior adhered to by group

3. Nursing Interventions

1. Assume leadership role

2. Promote problem solving
3. Direct group towards common goals and tasks.
4. Set limits and prevents scapegoating within group
5. Clarify issues and promote consistency
6. Support members

4. Types of groups

1. Supportive, therapeutic
2. Psychotherapy
3. Task groups
4. Teaching groups
5. Peer support
6. Self-help groups

1. 12 Step (Alcoholics Anonymous (AA), Al-anon, Alateen, Overeaters

Anonymous)
2. Recovery, Inc.
3. Ostomy Clubs

1. Family Therapy

1. Definition: psychotherapy in which the focus is on the family as the unit of treatment, not
just one individual
2. Concepts

1. Systems approach: member with the manifestations, illness

2. Scapegoating: the object of blame or displaced aggression, usually one member of
the family
3. Family involvement is necessary for treatment

3. Nursing Interventions

1. Help family reestablish communication between members

2. Help family redefine roles and rules
3. Clarify ambiguous communication patterns between family members
4. Support individual family members
5. Teach family problem solving techniques
6. Help the family accept differences among the members

1. Milieu Therapy

1. Definition: management of the client's environment to promote a positive living experience

 and facilitate recovery (holistic approach)
2. Concepts

1. Client government: groups and meetings between client and staff to promote shared
responsibility and cooperation
2. The environment in the facility is as close to the "real world" as possible and has
potential for therapeutic value

3. Nursing Interventions

1. Guidance in developing new ways of relating and learning to cope more effectively
2. Help client maintain strengths
3. Management of day-to-day activities
4. Provide a positive, therapeutic environment through environmental manipulation
5. Assist in developing effective relationship and coping skills

1. Adjunctive Therapies

1. Definition: therapies used to aid assessment, increase social skills, encourage expression
of feelings and provide opportunities to raise self-esteem, relieve tension and be creative
2. Types:

1. Dance: movement
2. Recreational: picnic, volleyball
3. Occupational: painting, hand work
4. Art: clay, painting, drawing
5. Alternative therapies: pet therapy, reminiscence therapy, music therapy

1. Interdisciplinary Team Approach

1. Definition: A team with members of different disciplines involved in a formal arrangement to

provide client services while maximizing educational interchange
2. Members of the team:

1. Nurse
2. Primary Care Provider
3. Social Work
4. Psychologist
5. Case Manager
6. Occupational Therapist
7. Recreational Therapist
8. Job Coaches
9. Mental Health Technicians

3. Nursing interventions: The nurse works collaboratively with the interdisciplinary team to
promote and maintain health

4. Mental Health & Mental Illness Continuum

1. Mental Illness

1. Inability to cope/manage stress

2. Development of maladaptive behavior
 3. Disruption in ability to relate successfully with others
4. Inability to meet basic needs in a socially acceptable way

1. Mental Health

1. Positive attitude toward self

2. Growth, development, self-actualization, autonomy
3. Ability to cope with stress
4. Reality perception and environmental mastery

1. Defense Mechanisms

1. Definition: unconscious operations used to defend against anxiety or stress

and relieve emotional conflict
2. In contrast, coping mechanisms are conscious efforts to deal with daily
frustrations and conflicts
3. Unconscious defense mechanisms

1. Sublimation: directing energy from unacceptable drives into socially

acceptable behavior (for example: aggressive person becomes a star
football player)
2. Isolation: splitting-off response in which person blocks feeling
associated with unpleasant experience (for example: planning out
funeral details of a loved one)
3. Reaction formation: involves displaying overt behavior or attitudes in
precisely the opposite direction of unacceptable conscious or
unconscious impulses (for example: feeling compassion for a person
you dislike)
4. Undoing: a compulsive response that negates or reverses a previous
unacceptable act (for example: washing hands [of guilt] after touching
germs)
5. Compensation: putting forth extra effort to achieve in areas of real or
imagined deficiency (for example: an unpopular student excels as a
scholar)
6. Projection: attributing own thoughts or impulses to another person
(for example: "You made me take a wrong turn.")
7. Introjection: incorporating the traits of others (for example: a
depressed client causes the nurse to become depressed)

1. Suppression: deliberate forgetting of unacceptable or painful

thoughts, impulses, acts
2. Repression: unconscious, involuntary forgetting of unacceptable or
painful thoughts, impulses, feelings, or actions (for example:
forgetting what was on a difficult exam)
3. Denial: avoidance of disagreeable reality by ignoring or refusing to
recognize it
4. Rationalization: offering a socially acceptable or logical explanation
for otherwise unacceptable impulses, feelings, and behaviors (for
example: "I failed the NCLEX-RN because it is a poor test.")
5. Regression: going back to an early level of emotional development
(for example: becoming dependent on someone else for all
decisions)
6. Fixation: Being stuck in a particular level of development
7. Displacement: transferring painful feelings to a neutral object (for
example: you're angry at your brother so you kick the dog)

5. Nurse & Client Relationship: an interpersonal, collaborative helping process and organized
sequence of events leading toward a mutually identified goal

1. Characteristics

1. Professional vs. social

2. Purposeful
3. Nonjudgmental
4. Designated setting and time
5. Organized sequence of events
6. Goal directed to facilitate client's growth vs. reciprocal

1. Collaborative contract that outlines and clarifies role expectations

2. Confidential

1. Phases of the nurse/client relationship

1. Preinteraction phase

1. Gather data from secondary source

2. No prejudgment
3. Assess nurse's feelings
4. Assess client's feelings

2. Orientation phase: assessment

1. Introduction: purpose, roles, responsibilities

2. Establish trust

1. Honest
2. Nonjudgmental
3. Empathetic
4. Offer self

3. Assess client

1. Orientation
2. Activities of daily living (degree of ability lo perform)
3. Physical status
4. Memory (recent and remote)
5. Emotional state
6. Intellectual capacity
7. Family history
8. Spiritual history
9. Alcohol and drug history (OTC and prescription)
10. Identify problem

4. Formulate contract

1. Time of meeting
2. Confidentiality
3. Focus: goals that arc behaviorally stated

3. Working phase: planning and intervention

1. Establish specific collaborative goals

2. Explore thoughts, feelings, actions
3. Establish nursing diagnosis
4. Problem solve

KEY INFORMATION
 1. Communication tools

1. Listening: nonverbal, use eye contact

2. Offering self: "I'll stay with you."
3. Focusing: on "here and now" and on the client
4. Broad openings: "How are things going today?"
5. Clarifying: "What does that mean to you?”
6. Reflecting: directing back ideas, feelings, and content, "You
feel tense when you fight."
7. Empathy: stating a feeling implied by the client
8. Summarizing: "Today we have discussed..."
9. Silence: sitting, conveying nonverbal interest
10. Sharing perceptions: "You seem angry"
11. Restating: repeating the main thought "You are sad"
12. Validating: "Are you saying..."
13. Giving information (for example: answering a direct question,
teaching)

1. Communication blocks

1. False reassurance: "Don't worry."

2. Agreeing and disagreeing: "I think you did the right thing."
3. Advice: "You should . . ."
4. Judging: "That was good."
5. Belittling: "Everyone feels like that."
6. Defending: "All the doctors here are great."
7. Approval: good or bad
8. Focus on nurse: "I feel that way, too."
9. Changing the subject
10. Ignoring a client
11. Changing client's words or assuming feelings

4. Termination phase: termination begins on admission or first contact. The

nurse prepares the client for this eventuality during the first meeting

1. Evaluation of behavioral goals

2. Transfer to other support systems
3. Assess for separation reactions such as regression, acting out,
anger, withdrawal
4. Help express and work through feelings
5. Be alert to nurse's response to separation
6. Do not promise to continue the relationship or schedule future
appointments

LESSON 2
Anxiety

1. Definition: anxiety and apprehension are tension in response to a perceived physical or psychological threat
(internal or external) resulting in feelings of helplessness and uncertainty
2. Responses
1. Psychological
1. Fear
2. Impending doom
3. Helplessness
4. Insecurity
5. Low self-confidence
6. Anger
 7. Guilt
2. Defense mechanisms

1. Displacement
2. Regression
3. Repression
4. Sublimation

1. Physiological: nervous system

1. Dry mouth
2. Elevated vital signs
3. Diarrhea
4. Increased urination
5. Palpitations
6. Diaphoresis
7. Hyperventilation
8. Fatigue
9. Insomnia
10. Sexual dysfunction
11. Irritability
12. Fidgeting, pacing
2. Behaviors

1. Fight or flight response

2. Talkative, giggly, angry, withdrawn

LEVELS OF ANXIETY
LEVEL PHYSIOLOGIC COGNITIVE BEHAVIORAL CHANGES NURSING
RESPONSE STATE INTERVENTIONS
Mild Slight Perceptual field can *- Restlessness (inability to *- Listen
(+) discomfort, restlessness; be heightened; work toward goal) *- Promote Insight,
tension relief; fidgeting, learning can occur *- Examine alternatives problem solving
tapping
Moderate Increased pulse, Perceptual field * Focus on immediate *- Calm, rational
(++) respirations, shakiness, narrows: selective events discussion
voice tremors, difficulty in attention *- Benefits from guidance of - Relaxation
concentrating, pacing others exercises
Severe Elevated BP tachycardia, Perceptual field - Feelings of increasing +- Listen
(+++) somatic complaints, greatly reduced; threat; purposeless activity *- Encourage
hyperventilation, attention scattered; * - Feeling of impending doom expression of
confusion cannot attend to feelings
events even when * - Concrete activity
pointed out Reduce stimuli
(channel energy into
simple tasks)
Panic - Immobility or severe - Perceptual field - Mute or psychomotor *-
(++++) hyper- activity; cool, closed agitation Isolate from stimuli
clammy skin; pallor: *- * - May strike out physically or * - Stay with client
dilated pupils; severe Hallucinations or withdraw * - Remain very
shakiness delusions may - Loss of control calm
*- Prolonged anxiety can occur * - Decrease
lead to exhaustion * - Effective demands
decision making is * - Protect client
 impossible safety
* - Do not touch
client
* Important

Maladaptive Resposes to Anxiety

1. Anxiety disorders: characterized by fear that is out of proportion to external events; attacks lasting minutes to
hours

1. Panic disorders

1. Definition: sudden onset of intense apprehension, fear or terror (panic attacks)

2. Physical Manifestations

1. Dyspnea
2. Palpitations
3. Chest pain
4. Faintness, dizziness
5. Fear of dying or going crazy (out of control)
6. Choking
7. Depersonalization or derealization
8. Hyperventilation

1. Nursing Interventions

1. Stay with client and remain calm

2. Reassurance and support
3. Remove anxiety-producing stimuli
4. Have client take deep breaths
5. Distract client from anxiety producing stimuli
6. Provide a paper bag for hyperventilation

1. Phobic disorders

1. Definition: persistent or irrational fear of a specific object, activity, or situation

that leads to avoidance (for example: fear of flying)
2. Types

1. Agoraphobia: fear of being away from a safe place or person in which

there is no escape
2. Simple: irrational fear of object or situation
3. Social (Social anxiety disorder): irrational fear that social situations
expose one to possible ridicule or embarrassment

1. Defense Mechanism

1. Repression
2. Displacement
3. Avoidance
 2. Nursing Interventions

1. Teach client relaxation techniques

2. Avoid major decision making
3. Utilize behavior modification techniques
4. No competitive situations
5. Provide gradual desensitization experiences
6. Assist client in verbalizing thoughts and feelings of anxiety

1. Obsessive-compulsive disorders (OCD)

1. Definition: recurring obsessions or compulsions

1. Obsessions: recurring thoughts of violence, contamination, doubt, and

worry that cannot be voluntarily removed from consciousness.
2. Compulsions: recurring, irresistible impulse to perform acts (for example:
touching, rearranging, checking, opening and closing, washing)
3. Obsessions and compulsions may occur together or separately
4. Client's attempt to reduce anxiety

1. Characteristics

1. Irrational coping to handle guilt

2. Feelings of inferiority and low self esteem
3. Compulsion to repeat act
4. Repeating act prevents severe anxiety
5. Defense Mechanisms

1. Displacement
2. Undoing
3. Isolation
4. Reaction formation

1. Nursing Interventions: nursing interventions are aimed at reducing client

anxiety.

1. Distract: substitute
2. Do not interrupt compulsive act
3. Schedule time to complete ritual; gradually decrease the time and
number of times ritual performed
4. Provide safety
5. Maintain structure, schedules, activities
6. Demonstrate acceptance of individual
7. Encourage expression of feelings
8. Antianxiety medications may be used to relieve manifestations

1. Post Traumatic Stress Disorder

1. Description: Significant, recognizable stressor or trauma outside the usual

range of experience; results in recurrent subjective reexperiencing of the
 trauma.
2. Characteristics

1. Recurrent and intrusive

2. Distressing dreams
3. Intense psychological stress
4. Avoidance of stimuli

1. Nursing Interventions

1. Teach relaxation techniques

2. Assess for suicide potential
3. Encourage client to express feelings

1. Somatoform disorders: physical manifestations and complaints without organic impairment (no real
pathology, for example: soldiers paralyzed during war with no real injury)

1. Conversion disorders (hysteria)

1. Definition: alteration in physical function that is an expression of an unconscious psychological

need
2. Characteristics of manifestations

1. Sensory: blindness, deafness, loss of sensation in extremities

2. Motor: mutism, paralysis of extremities, ataxia, dizziness
3. Visceral: headaches, difficulty breathing
4. Convulsive disorder with a typical seizure response
5. Little concern about manifestations: la belle indifference
6. Defense mechanism: repression of conflict and conversion of anxiety into
manifestations
7. Primary gain: suppressing conflict
8. Secondary gain: sympathy or avoidance of unpleasant activity gained

1. Nursing Interventions

1. Redirect client away from manifestations

2. Encourage client to express feelings
3. Utilize stress reduction techniques
4. Teach client relaxation techniques
5. Understand the symptoms are real to the client
6. Engage client in schedule of daily activities to decrease time spent
focusing on symptoms and counter secondary gain

1. Hypochondriasis

1. Definition: exaggerated preoccupation with physical health, not based on real

organic disorders, not pathology
2. Characteristics

1. Multiple manifestations
 2. Worried/anxious about manifestations
3. Seeks medical care frequently from multiple health care providers

3. Nursing Interventions

1. Help client express feelings

2. Set limits on rumination
3. Do not feed into the manifestations

1. Psychophysiological/psychosomatic disorders (Stress-related disorders)

1. Definition: stress-related medical disorders with true pathology: psychosocial factors pre-dispose
client to episodes of illness and influence the progression of manifestations; can be fatal if not treated
adequately. These disorders are characterized by increasing anxiety in addition to the physical
manifestations. Clients are often first treated in medical facilities.
2. Defense Mechanism

1. Repression
2. Introjection

1. Types

1. Migraine
2. Ulcerative colitis
3. Peptic ulcer
4. Eczema
5. Cancer
6. Rheumatoid arthritis

1. Nursing Interventions

1. Care for physical signs

2. Educate client about body/mind relationship
3. Teach client relaxation techniques (for example: biofeedback imagery,
progressive relaxation)
4. Assist client to express thoughts and feelings
5. Encourage self health promotion and regulation activities (for example:
relaxation, exercise)
6. Promote positive lifestyle changes

1. Dissociative disorders (hysterical neuroses)

1. Definition: splitting off an idea or emotion from one's consciousness; "psychological flight" from
anxiety (common with abused children)
2. Types

1. Multiple personality
2. Psychogenic fugue
3. Psychogenic amnesia
4. Depersonalization
 1. Nursing Interventions

1. Assess client to rule out organic pathology

2. Help client recognize when dissociation occurs
3. Help client express feelings
4. Initiate individual, group, and family psychotherapy

1. Somatic treatment for maladaptive responses to anxiety, insomnia, and stress-related conditions

ANTIANXIETY AGENTS
CHEMICAL CLASS GENERIC NAME TRADE NAME MEDICATION ALERTS
Benzodiazepine - chlordiazepoxide - Librium - Benzodiazepines: Warn clients
compounds - diazepam - Valium about sedating effects,
- oxazepam - Serax - Avoid activities requiring mental
- clorazepate - Tranxene alertness
- lorazepam - Ativan - Monitor for signs of drug
- alprazolam - Xanax dependence.
- clonazepam - Klonopin - Withdrawal up to two weeks; risk
- clomipramide HCL - Anafranil for seizure.
- Anafranil, commonly used for
OCD, should be cautiously used in
clients with cardiovascular disease
and is potentially
fatal in overdose
Mephenesm-like meprobamate Miltown, Equanil
compounds
Sedating hydroxyzine Vistaril, Atarax Antihistamines tend to cause drying
antihistamines and sedation
Beta-blockers propranolol Inderal
(SSRI) Selective paroxetine Paxil Shown to be effective with Social
Serotonin Reuptake Anxiety Disorder. Allow 2-3 weeks
Inhibitors to note effects
Anxiolytics buspirone BuSpar BuSpar-non-sedatmg, allow 2-3
weeks to note effects. Do not use
concurrently with alcohol or history
of hepatic disease
KEY INFORMATION

Antianxiety medications are not a cure for anxiety, but a temporary means to reduce anxiety. Antianxiety
medications can be highly lethal in overdose. Monitor suicidal clients closely. Elderly clients are easily
sedated and at risk for fall with benzodiazepines

let's take a look at some of the

0:02
theoretical models that impact on the
0:04
practices
0:05
of psychiatric nursing there are six of
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them that i would like to review with
0:09
you
0:10
the first is the medical model and this
0:12
model is probably one that's very
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familiar to you because you've seen it
0:16
in med surg settings
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as well as in psych settings it's
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frequently used in
0:21
inpatient psychiatric units but it's
0:24
oriented to diagnosing disturbances
0:27
as diseases with classifiable symptoms
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we obtain a history we do a physical
0:35
and we use the diagnostic and
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statistical manuals that comes out from
0:39
the american psychiatric association
0:42
this lists the diagnoses and all their
0:44
symptoms for psychiatry
0:47
the causes of illnesses either are
0:49
psychological
0:50
psychophysiological or structural
0:52
problems problems that may occur within
0:54
the brain
0:56
the treatments that we use in a medical
0:58
model include somatic treatments such as
1:00
medications
1:01
electroconvulsive shock therapy we also
1:05
look at interpersonal skills
1:07
the nursing care is broad we assist the
1:10
doctor
1:11
with the somatic treatments we prepare
 1:13
the patients we teach the patients about
1:15
these treatments
1:17
and we also assist in the interpersonal
1:19
treatments and rehabilitation of the
1:21
patient
1:22
the second model i would like to review
1:24
with you is the psychoanalytical model
1:27
this model we need to give credit to
1:30
freud
1:31
he revolutionized psychiatry around the
1:34
turn of the century
1:35
when he took psychiatry from the realm
1:38
of demon possession
1:40
to really looking at internal processes
1:43
in the person's mind
1:44
as perhaps causes of psychological
1:47
problems
1:48
he gave us a number of concepts that
1:51
have been
1:52
very prevalent not only in psychiatric
1:54
circles but even
1:55
among the lay public he identified
1:58
certain structures of the mind and i'll
2:00
quickly review them for you
2:02
the id which is the seat of all our
2:06
instinctual drives
2:07
that's the thing that makes you want to
2:09
do what you want to do
2:11
when you want to do it the ego is our
2:14
problem solving structure of the mind it
2:17
puts some breaks on our
2:18
id it says wait a minute there might be
2:21
some consequences of what you want to do
2:23
just because you want that piece of
2:24
candy you better not take it because
2:26
your mom's going to yell at you
2:28
the super ego is our conscience which
2:30
usually develops when we're around four
2:32
to five years of
2:33
age and the conscience is our shoulds
2:36
our arts
2:37
and those things are the things that we
2:40
internalize from our parents
2:42
and other significant others in our
2:44
environment who tell us what we should
2:46
do what makes us a good child a bad
2:48
child
2:50
freud also introduced us to the concept
2:52
of the conscious
2:53
and the unconscious the conscious is all
2:57
includes all those things that we are
2:59
able to recall or remember
3:01
without any difficulty the unconscious
3:04
includes all those memories and thoughts
3:07
which do not enter
3:08
awareness the focus of psychoanalysis
3:12
is to uncover the unconscious memories
3:16
bring them to awareness and to deal with
3:18
them
 3:19
freud also suggested some stages of
3:21
psychosexual development
3:24
the nurse's role in the treatment a
3:26
psychoanalytical treatment is very
3:28
minimal
3:29
the psychoanalyst's role is formal
3:31
foremost
3:33
and in that treatment between the
3:35
psychoanalyst and the patient
3:37
there are certain concepts that are
3:39
important for you to know
3:40
transference is the unconscious
3:43
projection
3:44
of feelings onto others such as the
3:46
nurse or the therapist
3:48
now this can occur in other settings
3:50
other than a psychoanalytical therapy
3:52
session
3:53
the patient begins to treat to feel
3:56
about to respond
3:58
to the nurse or someone else as if they
4:01
were
4:02
someone significant in their perhaps
4:04
earlier life
4:06
counter transference is
4:09
a similar process that occurs between
4:11
the professional
4:12
and the patient whereas i the nurse
4:15
begin to treat a patient
4:16
as if they were someone else
4:19
transference is helpful to therapy
4:22
because the nurse or the doctor can then
4:24
say to the patient
4:26
look at what you're doing you are
4:28
treating me in a way that is unjustified
4:30
by our experiences
4:32
counter-transference is not helpful to
4:34
therapy
4:36
nurses doctors social workers who are
4:38
engaged in
4:39
a counter transference process really
4:42
need to seek some supervision to work
4:44
that out
4:45
dream analysis is an important part of
4:47
psychoanalysis
4:49
as well as catharsis that's the concept
4:51
which really means
4:53
that you are freeing yourself you'll be
4:55
able to
4:57
bring up unconscious memories talk about
5:00
the feelings and the emotions that are
5:02
attached to them
5:03
and feel free of the impact that those
5:05
memories have on you
5:08
the nursing care is primarily supportive
5:10
rather than therapeutic

let's look at the adolescent period

0:02
because that has particular importance
0:04
for psychiatry
 0:06
12 to 20. that's the age range
0:09
the task is identity versus role
0:12
diffusion
0:13
this is the time and many of you will
0:16
still remember
0:17
your own period of adolescence many of
0:18
you may have your own adolescent
0:21
children who are going through this so
0:22
you're experiencing it in a different
0:24
way
0:25
but or you may have taken care of a
0:27
client in the hospital who was an
0:29
adolescent
0:30
this is a very tumultuous time for the
0:33
adolescent
0:34
it's a time of trying on new behaviors
0:37
and perhaps shaking off some of the
0:40
values the behaviors the roles
0:42
that very much were approved by parents
0:45
so that the adolescent seems to be
0:47
saying to society
0:49
i don't want to do anything that the
0:51
grown-up world does
0:52
i want to dress the way i want to dress
0:54
i want to do the things i want to do
0:56
i want to associate with the people that
0:58
i want to associate with
1:00
it's a period of rebellion it's a period
1:03
of trying on to see
1:05
what fits what do i really believe in
1:08
what do i want to put my energy in in
1:11
terms of my life work
1:14
so it's it's a period when many people
1:17
get
1:17
stuck or fixated and for instance in one
1:21
of the major disorders which we'll talk
1:22
about later schizophrenia
1:24
most schizophrenics have their first
1:26
episode during the period of adolescence
1:29
so they really have never achieved a
1:31
sense of identity
1:33
sometimes i meet people who are adults
1:36
by
1:36
age but their behaviors seem like they
1:39
are still very much
1:41
in the adolescent period they don't know
1:43
where they're going
1:44
they're not really sure what's important
1:46
to them what they value
1:48
this is a very very important area
1:51
groups peer support and peer pressure
1:54
are very important to the adolescent
1:59
as the individual matures and grows the
2:02
next stage
2:03
young adulthood the stage of intimacy
2:06
versus isolation
2:07
usually that's the period when people
2:09
develop a committed relationship
2:12
that committed relationship may or may
 2:14
not
2:15
involve children initially but the
2:17
individual is developing a balance in
2:20
their life
2:21
among love work and play interests
2:24
that's very important for mental health
2:27
adulthood is the period of generativity
2:29
versus stagnation
2:31
generativity giving back make a
2:33
commitment a commitment to society to
2:36
community to children it's a very
2:39
important stage
2:40
having children is not essential to meet
2:43
that task
2:44
people need it by volunteer activities
2:46
by making commitments to their job their
2:48
vocation but it is an important stage
2:51
it's a stage when the adult begins to
2:54
realize
2:55
they have received much both from from
2:58
parents
2:58
teachers and other important people and
3:01
it's time to begin to give back
3:03
to make sure that the next generation is
3:05
taken care of
3:08
the last stage is the stage of later
3:11
adulthood
3:12
or the elderly population and it's the
3:15
stage where the task is integrity versus
3:17
despair
3:18
where people begin to do life reviews
3:21
very important when we're dealing with
3:22
the elderly patient
3:24
whether the patient's in a psychiatric
3:26
unit or whether they are
3:28
in a med surg unit we are looking at or
3:32
helping
3:32
the patient to look at what they
3:36
feel about their own life do they
3:38
believe it was a success
3:40
did it have meaning and purpose was it
3:42
okay it was the best they could do
3:44
or do they come with a sense that no i
3:48
was a failure i could have done this i
3:50
could have done that
3:51
hopefully what we would like to see
3:53
people arrive at
3:54
is the conclusion that it was the best i
3:57
could do
3:58
i won some i lost some but overall it
4:00
was a good life
4:02
when we are working with the elderly
4:04
person it's important to remember that
4:06
reminiscence or life review is an
4:09
important and critical
4:10
component of our nursing intervention we
4:13
want people to
4:14
talk about their memories to show us
4:16
picture albums
 4:18
to describe what their earlier
4:20
experiences were like and to try and put
4:23
these experiences in a broader
4:25
perspective

the next thing i would like to discuss

0:02
with you
0:03
are the treatment models that are used
0:05
in psychiatry and psychiatric nursing
0:08
the first which has tremendous
0:10
importance
0:11
uh in psychiatry today for a number of
0:14
reasons
0:14
one is that insurance companies will
0:17
only pay for short-term
0:19
care two most people who seek care
0:22
don't want to spend years in therapy
0:25
they want their problem to be dealt with
0:27
and they want to get on with living the
0:30
treatment modality that responds in that
0:32
way
0:33
that short term that's usually less
0:35
expensive
0:36
that helps people deal with the
0:37
immediate problem is crisis intervention
0:41
crisis intervention is brief treatment
0:44
used to aid patients through a stressful
0:46
situation
0:47
and then to move on to deal with their
0:50
life
0:51
a crisis usually is started with some
0:54
sudden stress or it may be accumulation
0:56
of stresses
0:58
it could be things such as losing a job
1:01
relocation the birth or the death of a
1:04
family member
1:06
divorce separation anything that comes
1:10
as a sudden shock that disrupts
1:13
the patient's life course
1:16
they feel at that particular time the
1:19
patient feels
1:20
unable to use their normal problem
1:22
solving skills
1:24
the stress produces physiological
1:27
symptoms
1:27
they feel nervous jumbled up they can't
1:31
sleep well
1:32
they may feel panicky helpless
1:35
they're unable to think straight clearly
1:38
in fact they'll say to you i just can't
1:40
think straight i can't decide how i'm
1:42
going to approach this anymore
1:44
they are unable to concentrate and
1:46
they're really
1:47
very inefficient in terms of getting
1:49
tests done
1:50
and solving problems the principles of
1:53
intervention
1:55
are based on the following things first
1:57
of all crises are usually self-limiting
 2:00
they usually are over in six to eight
2:02
weeks
2:04
so that when we're in the midst of a
2:05
crisis and that this pertains to me as
2:08
well as you and patients that we deal
2:10
with
2:10
we think we're in the midst of it it's
2:12
never going to get better again
2:14
our life will never be okay again but in
2:17
truth
2:18
there is some um value in the old adage
2:21
the time
2:22
heals because crises do pass
2:25
and things do get better and if the
2:28
person is supported adequately
2:30
they may leave that crisis a lot better
2:33
able to cope
2:34
than when they entered the crisis so
2:36
crises are
2:37
time limited six to eight weeks
2:40
promptness of intervention
2:42
facilitates successful resolution of the
2:45
crisis
2:46
as help providers or health providers we
2:50
focus on the problem that the patient
2:52
presents to us
2:53
we deal with the problem not necessarily
2:56
the causes which may be deep rooted they
2:58
may go back to childhood trauma
3:01
crisis does not deal with in-depth
3:04
insight therapy
3:05
but it focuses on the problem at hand
3:09
there's a great need for support and
3:11
empathy so we are reassuring to the
3:13
patient
3:14
we communicate respect for the patient's
3:17
ability to solve problems
3:19
now initially we may need to be very
3:22
directive with the patient
3:23
because they're anxious they're scared
3:25
they don't feel like they can think
3:27
clearly
3:27
so initially we may meet with them many
3:30
times frequently
3:31
three to four times a week initially but
3:33
quickly
3:34
we begin to cut down the frequency of
3:37
our meeting time because we are
3:39
communicating to the patient
3:41
you can handle this you have the
3:43
resources to handle this problem
3:45
i am only a facilitator to help you
3:48
solve your own problems
3:50
we encourage the patient to take
3:52
responsibility for the problem
3:54
we help the patient assess their own
3:57
strengths and coping responses
4:00
what did you do in the past to solve
4:02
problems what has worked for you in the
 4:04
past
4:04
what has it worked what supports are
4:07
available do you have family members you
4:09
can draw on
4:10
and as a nurse we begin to
4:14
engage them in the patient in a
4:15
collaborative effort
4:17
where we say to them let's call this
4:20
person and see what kind of assistance
4:22
they can give you
4:22
to get through this particular crisis
4:27
crisis intervention is a very effective
4:29
way of treating patients
4:31
some patients when the crisis is
4:33
resolved will choose to remain
4:35
in long-term individual therapy but the
4:38
crisis intervention
4:39
is done they may go to a different type
4:42
of a provider for that
4:43
long-term therapy

the next type of therapy i want to

0:02
mention is family therapy
0:05
family therapy is psychotherapy where
0:07
the focus
0:08
of treatment is the family not the
0:11
individual
0:12
now normally when a family comes into
0:15
therapy
0:16
they usually come to a therapist and say
 0:19
we have these problems because of this
0:23
child or i have these problems because
0:25
of my husband
0:27
many times people don't go into family
0:29
therapy seeking family therapy
0:31
they go in asking for help to deal with
0:34
a particular member of the family
0:37
and that's an important concept in
0:39
family therapy
0:40
ip or identified patient
0:43
it's the member with obvious symptoms
0:46
now frequently in families
0:48
um one patient or one member of the
0:50
family will display most of the symptoms
0:53
one child will be truant we'll be in
0:55
trouble with the law we'll be doing
0:57
all kinds of our berry behaviors the
1:00
rest of the family seems fine
1:02
and everybody in the family will say
1:04
we'd be just fine
1:05
if this child would just straighten up
1:08
the therapist's role then
1:10
is to help the family take their focus
1:14
off of that child and look at what is
1:17
going on in the family
1:18
that supports or encourages that child
1:21
to act
1:21
out in this way what's the communication
1:25
like in the
1:26
family what are the problem-solving
1:28
skills like in the family
1:30
is the family able to tolerate
1:32
differences
1:34
or does everybody have to think and act
1:36
and believe the same
1:37
as every other member of the family is
1:40
communication
1:41
clear or is it ambiguous the family
1:44
members put each other in double
1:46
uh double buying situations and i'll
1:49
give you an
1:49
example of that just recently i
1:53
i want you to know i did this in a
1:55
humorous way it wasn't because i was
1:56
deliberately putting my spouse in a
1:58
double bind situation
2:00
but i bought him two ties and they were
2:02
polka dot ties and i knew he wasn't
2:04
crazy about either of them
2:06
but he finally wore one of them and i
2:08
said oh you didn't like the other one
2:10
and he said to me i really didn't like
2:12
either of them
2:14
but when i my response to him made him
2:17
damned if he did
2:18
and damned if he didn't and parents do
2:20
that to children many
2:22
times an example might be a mother who
2:25
says to her young child come here and
 2:27
give me a hug
2:28
the child runs over to give mom a hug
2:30
but when he does
2:31
mom stiffens and so the child is left
2:34
with confusion
2:36
does she really love me and want to hug
2:37
me
2:39
and if she did why did she get stiff
2:42
like that most people when they hug you
2:44
you know they get warm and cuddly and
2:46
unfold you but mom doesn't do that
2:48
so the child is left with confusion what
2:51
do i make of this
2:52
i don't know how to understand this and
2:54
so what happens with little children
2:56
when they are faced with double buying
2:58
situations
2:59
is that they begin to turn away they
3:02
don't seek out situations
3:04
where they're going to be confused so
3:07
they don't go to mom anymore for the
3:08
hugs the kisses that normally children
3:11
would
3:11
would seek out so family therapy
3:15
helps families look at what are you
3:18
doing within your family unit
3:20
that might make one person or all of you
3:23
unhappy
3:24
what can you do as a family to be freer
3:27
to
3:27
to accept each other uh better to
3:30
communicate better and to be a haven for
3:33
each other and not a place where people
3:35
are afraid to come home

the next type of therapy is milieu

0:02
therapy or environmental therapy
0:06
it's the management of the patient's
0:08
environment to promote a positive living
0:10
experience
0:11
and the nurse's role is very very
0:13
important in this type of therapy
0:16
the nurse who is responsible for
0:18
managing the environment
0:20
makes sure that patients have
0:21
responsibilities for instance
0:25
patients don't come into hospitals and
0:26
expect a vacation
0:28
they are responsible for maintaining
0:30
their own living space
0:32
perhaps for keeping clean um the
0:35
day room where everybody gathers to
0:37
watch tv
0:38
there may be responsibilities around
0:40
meal times
0:41
there may be responsibilities for
0:43
setting rules for the whole unit
0:46
many times milieu therapy involves a
0:48
patient government
0:49
where patients and staff together
0:51
collaborate
0:52
to decide the rules for the unit the
0:55
privileges for patients
0:56
and the consequences when the rules are
0:58
broken
1:01
the last mode of therapy that i want to
1:03
mention are the expressive therapies
1:06
and these are very important adjuncts to
1:08
what we do in nursing
1:10
these are the therapies that include
1:12
things such as
1:13
dance therapy art therapy there's a
1:16
whole range of them
1:18
they are very very important many
1:21
patients are unable to express
1:23
their feelings their thoughts in a
1:25
coherent way
1:27
they're not even aware of how they feel
1:30
maybe out of as a result of years of
1:32
being told that they shouldn't feel a
1:34
certain way
1:35
that their feelings don't have value
1:37
they no longer know how to express that
1:39
they're sad or they're angry
1:41
so art therapy dance therapy provides
1:44
them a modality
1:46
where they can express on paper or
1:48
through movement
1:49
or some other form their deepest most
 1:52
innermost feelings
1:53
that are important to release and to
1:56
express
1:57
but might not ever come out in
2:00
words so that these types of therapies
2:03
are
2:03
important adjuncts to what we do in
2:06
nursing
2:07
they build self-esteem they help the
2:09
expression of feelings
2:11
they facilitate communication they give
2:14
us
2:15
a view into the patient's inner world
2:17
that we might not have
2:19
if we depended solely upon the patient's
2:22
ability to
2:23
express him or herself

the next thing that i want to cover with

0:02
you
0:03
is the mental health and mental illness
0:05
continuum
0:07
we usually are very clear when we see
0:10
one a person acting in a bizarre way
0:14
if we see somebody talking to themselves
0:16
or dressed inappropriately
0:19
you may have your own terms for
0:20
describing that person but through the
0:23
years people like that have been
0:25
described as crazy
 0:26
loony um
0:30
uh out of step lots of ways that we
0:34
describe people like that they're
0:35
stigmatized and discriminated against
0:38
but they stand out because of their
0:40
differentness
0:41
they may act in very bizarre
0:44
unexplainable ways to
0:46
to most of us they stand apart from the
0:49
rest of society because of their
0:51
differentness
0:52
we are clear that those people are
0:55
different and many times we will say
0:57
those are the mentally ill people then
0:59
we usually have a pretty good idea of
1:02
who the mentally healthy people are
1:04
sometimes we're not always right about
1:06
that people can
1:07
wear masks and look healthy and inside
1:11
be a turmoil
1:12
of pain but but normally when we look at
1:15
mental health
1:16
we're looking at a balance people have a
1:19
balance in their life
1:21
among areas of work and play
1:24
relationships their spiritual emotional
1:27
and physical health is balanced
1:29
now this doesn't mean that they don't
1:31
have crises everybody has crises
1:34
what it means is that they are able to
1:36
respond appropriately to crises
1:39
the crises don't boil them over and
1:41
devastate them
1:42
but crises may be a time of growth
1:46
the group of people that we sometimes
1:48
have difficulty categorizing are the
1:50
people in the middle of the continuum
1:52
the people who are not quite we think
1:54
mentally healthy
1:55
but are not really displaying bizarre
1:58
behavior
1:59
those people in the middle are sometimes
2:01
referred to as the worried well
2:03
they function in society but they may
2:06
have what we call
2:06
hang-ups or worries that are particular
2:09
they may not be founded on reality
2:11
but they have a lot of concerns they get
2:13
into problems interpersonally
2:15
these are the people who may be in
2:17
long-term supportive therapy
2:19
the people in the abnormal end are the
2:22
people we usually see in the inpatient
2:24
psychiatric units
2:25
and who attend the community mental
2:27
health centers the normal people
2:29
probably never go into therapy for any
2:31
reason
what i'd like to spend a little more
0:02
time with
0:03
is the defense mechanisms defense
0:05
mechanisms are very important for you to
0:07
understand
0:09
they are important again for psychiatric
0:11
nursing but they are also
0:12
important in all areas of nursing
0:15
because it's not just psychiatric
0:16
patients
0:17
who use these mechanisms to defend
0:19
themselves against
0:20
anxiety but it's all of us it's you it's
0:23
me
0:24
it's our med surg patient it's our
0:26
coronary patient
0:27
it's our alcoholic patient it's our new
0:30
mother
0:30
it's everybody uses defense mechanisms
0:33
and it helps us to understand the
0:35
patient
0:36
if we understand the mechanisms they use
0:39
first of all what are defense mechanisms
0:42
they are for the most part
0:44
unconscious operations used to protect
0:48
ourselves
0:49
against anxiety anxiety feels lousy
0:52
always feels bad and so if it's
0:55
if it's a lot of anxiety if it's very
0:57
intense
 0:58
we'll do what we can to minimize it so
1:01
we can manage it
1:03
let's go through the list of defense
1:05
mechanisms
1:06
the first one is sublimation it's when
1:09
we direct
1:10
energy from an unacceptable drive
1:13
into an acceptable outlet for instance
1:16
sports activities
1:17
are acceptable ways of sublimating
1:20
aggression
1:22
those of you who are into aerobics if
1:24
you find that you really seek that
1:26
out after a really rough day you were
1:28
sublimating perhaps your frustration or
1:30
your anger
1:32
bad feelings that happened during the
1:34
day that you weren't able to express
1:36
it's a positive defense mechanism
1:40
isolation this is a response in which
1:43
in which the person blocks the feeling
1:46
that's associated with the traumatic
1:48
event
1:49
and sometimes we'll see this from
1:50
patients or not necessarily patients but
1:53
anybody
1:54
you'll be talking to them and they'll be
1:55
relaying a story to you
1:57
that really gets you in your gut you
2:00
feel upset when you hear it
2:02
they're talking about either an early
2:04
childhood trauma
2:05
or some stress in their own family but
2:08
they say it without emotion
2:10
and you say to them oh that must that's
2:12
awful how are you coping with that
2:15
they show no emotion and they say oh
2:17
it's no big deal
2:18
i'm it's all over i it's done with and
2:22
you have this sense of disbelief
2:24
because you know that the trauma is too
2:26
great
2:27
not to have had some residual feeling
2:29
attached to it that's isolation
2:32
reaction formation this involves
2:35
displaying
2:36
an overt behavior or attitude that's
2:39
directly contradictory to what you
2:42
really feel
2:44
my sense when someone does this is that
2:46
it's always too much
2:48
like someone might act very very sweet
2:50
and kind
2:51
to somebody that they can't stand and
2:54
the sense you get is the listener
2:57
or the observer is it's not real it's
2:59
not genuine
3:00
that's reaction formation undoing
3:04
that is when we try to negate or reverse
 3:08
a previous unacceptable thought or
3:10
action
3:11
an example might be a mother who who
3:14
bakes
3:14
cookies for her child that she's just
3:16
spent
3:18
or someone who washes their hands
3:21
compulsively
3:22
to wash away a feeling of guilt
3:26
or contact with germs
3:29
or some some other such thing but we try
3:32
to undo
3:33
something that we did before
3:36
the next defense mechanism is
3:38
compensation
3:39
where we put forth extra effort to
3:42
achieve in an area where we have a real
3:44
or
3:44
imagined deficiency
3:48
an example of that might be someone who
3:51
is a not good at sports
3:54
but who excels in scholastics so that
3:57
they have
3:57
overachieved in one area to compensate
4:00
for another
4:02
projection i would put a star next to
4:04
this one because it's very
4:06
important when we look at some of the
4:08
later
4:09
major disorders such as paranoia
4:12
projection is a defense mechanism
4:14
where the individual transfers
4:17
their own internal feelings to someone
4:20
else
4:21
i feel insecure but i'm unable to deal
4:23
with that
4:24
therefore you feel insecure or you were
4:27
out to get me
4:29
what is the basis for suspicious
4:32
behavior
4:33
projection underlies suspicious behavior
4:36
the person has difficulty accepting
4:38
their own feelings of fear
4:40
inadequacies insecurities and therefore
4:43
they project them
4:45
onto another person
4:48
introjection is where an individual
4:50
incorporates the traits of another
4:53
person
4:53
into their own feelings for instance
4:56
as nurses you may have already
4:59
experienced that when you talk with a
5:01
depressed patient
5:03
many times you leave that situation
5:05
feeling depressed
5:06
now i use that as a barometer i think
5:09
that's how
5:10
um help helpful to me with i'm in an
5:12
interaction with somebody
 5:14
and i go away with feelings i didn't
5:16
start out with
5:17
it makes me then look at what went on
5:20
between us
5:21
if i leave feeling depressed and i
5:23
didn't begin feeling depressed
5:25
then i need to look at why did i
5:27
interject those feelings
5:29
was the patient depressed and i didn't
5:31
pick it up am i leaving feeling confused
5:34
and i wasn't confused before perhaps the
5:37
patient wasn't communicating very
5:38
clearly to me
5:39
and i introjected their confusion
5:43
you might introject anxiety in a sense
5:47
feelings are contagious in that way
5:49
because other people
5:50
introject the feelings of
5:53
others and they spread it in a way

suppression is the only

0:03
conscious defense mechanism and the
0:06
example i can give you if you
0:08
saw gone with the wind was scarlet
0:09
o'hara when she said i'll think about it
0:12
tomorrow
0:13
it's the deliberate putting out of your
0:15
mind of unpleasant events
0:17
and basically saying i can't deal with
0:19
that now but i will deal with it later
 0:22
sometimes that's a very positive
0:24
strategy
0:26
because it says i'm up to my limit today
0:29
i can't manage it i'll wait till i'm
0:31
better able to deal with it
0:35
repression is the unconscious
0:38
involuntary forgetting of unacceptable
0:41
feelings thoughts and impulses
0:45
we see repression a great deal when
0:47
people have had traumatic childhood
0:50
experiences
0:51
and in long-term therapy sometimes
0:54
these experiences bubble up out of their
0:58
unconscious
0:59
and they become part of their awareness
1:02
but for years they were repressed
1:04
this is coming out in the literature
1:07
very much when we look at
1:09
the stories of abused women who were
1:12
abused as
1:12
children many times they have no
1:15
conscious
1:16
memory of being sexually abused at three
1:19
and four
1:20
but they have recurring painful dreams
1:24
that they can't even put into words and
1:26
it's only in therapy
1:27
that they're able to articulate what the
1:30
meaning of those dreams are
1:32
those experiences are repressed they
1:34
didn't consciously decide to forget them
1:36
they were so painful that their mind
1:40
did it for them denial
1:43
involves the assertion that what is
1:45
obviously true
1:47
is not and one of the best examples i
1:50
can give you
1:51
is the alcoholic patient you're treating
1:54
him in the emergency room
1:56
this is his third arrest for dwi
2:01
and he says to you with absolute
2:04
certainty
2:05
i do not have a problem with alcohol i
2:08
can stop drinking
2:09
anytime i choose to this is denial
2:14
rationalization is when the patient
2:17
offers a good excuse
2:19
for for something that happened for why
2:21
they failed
2:23
for why something they didn't succeed
2:25
for instance
2:26
a good one for you all to remember would
2:28
be i didn't
2:29
pass the nclex because it was a lousy
2:32
exam
2:33
rather than i didn't study for it or i
2:36
didn't prepare
2:38
that's rationalization regression
2:41
is going back to an earlier level of
 2:43
behavior
2:44
when perhaps certain things were more
2:46
acceptable
2:47
now one of the most common forms of
2:49
regression for many of us
2:51
is taking taking a nap you come home
2:53
you've had a stressful day
2:56
you're really not so much physically
2:58
tired as you are emotionally drained and
3:00
you want to shut the world out
3:02
and you just lay down and take a nap
3:04
that's a form of regression there's
3:05
nothing wrong with it
3:07
many people do it but it's closing the
3:10
world
3:10
out it's kind of regrouping your forces
3:12
again so that you're able to cope when
3:14
you wake up
3:16
fixation is when people are stuck at a
3:19
particular level of development
3:21
it could be a level defined by ericsson
3:24
trust versus mistrust or one of freudian
3:27
stages
3:28
but they do not progress in their
3:29
emotional development
3:32
displacement is when we transfer our own
3:35
painful feelings
3:36
to somebody else it's usually a safer
3:39
somebody or a safer object
3:41
let me give you an example you're at
3:43
work your head nurse is
3:45
unfair you perceive her to be unfair she
3:48
makes unrealistic demands to you
3:50
she criticizes you all day and never
3:53
gives you any
3:54
uh recognition for the difficult
3:56
assignment that you have accomplished
3:58
today that you had the most challenging
4:00
patient on the whole unit
4:01
and all you hear all day is criticism
4:04
what you really feel like doing is
4:05
smacking her in the face
4:07
but you're not going to do that because
4:08
you know that'll land you probably in
4:10
jail
4:11
and without your job so what you do is
4:14
you might have a number of things to do
4:15
you go home and you yell at your kids
4:18
you yell at your husband you kick the
4:20
car
4:21
you slam doors there's a lot of ways
4:24
that we can displace our anger
4:26
because the place that it belongs with
4:29
the head nurse
4:31
we are not able we don't feel we're able
4:33
to express it
4:34
and we probably aren't at that given
4:36
time because we would express it
4:37
inappropriately
 4:38
so displacement is when we take painful
4:41
feelings and we place them on a safer
4:43
object
4:43
usually our kids can't stand up to us
4:46
and sometimes i feel sorry for mine
4:47
because they get
4:48
the results of some pretty bad days but
4:52
displacement is something we all use
4:54
it's a mechanism that goes hand in hand
4:56
with projection many times
4:58
when people are upset and they're not
5:00
able to deal with those feelings as
5:02
residing within themselves they project
5:04
them onto others and they displace their
5:06
own feelings onto other

the nurse patient relationship has some

0:03
phases that are predictable the first
0:06
stage
0:07
is the pre-interaction phase it's the
0:09
stage when you come on a unit or you
0:11
read a chart
0:12
and that's all you know about the
0:13
patient the nurse the head nurse says oh
0:15
you're assigned to
0:17
jessie smith down the hall who's that
0:20
chronic schizophrenic who we've seen in
0:22
here 10 times
0:24
that's what you know about jesse and
0:28
depending on your past experiences with
 0:30
her you already have
0:31
some preconceived notions about what
0:33
jessie is like
0:36
if they say to you jesse came in the
0:38
night before a combative and she
0:40
put one of our other nurses in the er
0:43
you're going to go into jesse's room
0:44
with some anxiety
0:46
so the pre-interaction phase is are the
0:49
feelings and the thoughts that we have
0:51
about a patient
0:52
before we ever meet them and those are
0:54
influenced by past
0:55
experiences what we know about this
0:57
particular patient
0:58
and what people tell us about the
1:00
patient the patient also goes through a
1:02
period of pre-interaction
1:04
what's my nurse going to be like will i
1:07
trust her will she be better than that
1:08
one i hit and put in the emergency room
1:11
will i like her so
1:14
this this is a mutual uh sense of
1:18
anticipation there's some anxiety both
1:20
for the patient's part of the nurse's
1:22
part
1:23
every new experience produces this
1:27
the orientation phase which is the next
1:29
phase of the nurse patient relationship
1:31
is primarily a phase of assessment we
1:34
are getting to know the patient
1:36
we are gathering data about all the
1:38
areas of the patient's
1:39
life about their their social their
1:42
physical their psychological
1:44
their mental their spiritual their
1:46
cognitive abilities their family history
1:49
all of those things that seem to have
1:50
relevance to the problem that brought
1:52
them to the hospital are areas that
1:54
we're concerned with
1:56
so we are gathering data trying to get
1:58
to know the patient
1:59
we are also spending time with them
2:01
interacting with them
2:02
helping them get to know us we are
2:05
establishing trust
2:06
we are showing them that we are
2:08
trustworthy and dependable
2:10
we are also establishing a contract
2:13
contract
2:13
we do in all areas of nursing but it
2:16
takes on a different
2:17
uh meaning and significance in
2:19
psychiatry
2:20
when people have uh when patients
2:23
frequently have
2:24
trouble with trust issues the contract
2:28
sets up a
 2:32
a formal trust agreement
2:36
where i say to the patient i will be
2:38
here for you
2:39
every day at two o'clock in this
2:42
particular setting
2:44
and we will meet for 20 minutes now if
2:47
the patient's not there
2:49
i still need to be there the patient may
2:51
walk by and check to see if i'm there
2:54
the patient is checking to see am i
2:56
trustworthy
2:58
do i keep my word do i follow through
3:00
with what i say i'm going to do
3:02
very important in psychiatry in that
3:05
search
3:06
it's equally important when we say to a
3:08
patient in the morning
3:10
i am your primary nurse for today
3:13
you can depend on me to answer all your
3:17
questions
3:17
if you have problems i will respond to
3:19
them you can call me i will be in here
3:22
throughout the day
3:23
when that patient asks you to check on
3:25
something you need to get back to that
3:28
patient because that
3:29
also shows your trustworthiness your
3:32
responsiveness your dependability

now there's one more phase of the nurse

0:02
patient relationship
0:03
and that's the termination or evaluation
0:05
phase
0:06
it's the last phase of the relationship
0:09
where we summarize
0:10
what has what we have accomplished with
0:12
the patient what still needs to be
0:13
accomplished
0:14
but also what the relationship has meant
0:17
to us as a nurse
0:18
and hopefully we ask the patient what it
0:20
is meant to them
0:22
the termination phase is a very
0:24
difficult phase for nurses in general
0:26
and it because we don't like to say
0:28
goodbye and sometimes
0:30
we'll avoid saying goodbye i'll see you
0:32
later and i'll keep in touch
0:34
that is something to be avoided at all
0:36
costs because we are not going to keep
0:38
in touch
0:39
life goes on we are going to be dealing
0:41
with many many more patients and we
0:44
really need to tie up the loose ends
0:46
with this patient
0:47
and let them move on and we need to move
0:49
on
0:50
so we summarize what we've accomplished
0:52
make clear what needs to be accomplished
0:55
and say goodbye now the the preparation
 0:58
for the termination phase
1:00
should have begun way back in the
1:03
orientation phase when we established
1:05
the contract
1:06
because we say to the patient then i
1:08
will be working with you for this day
1:11
or this month or this year but we have
1:14
established with the patient
1:15
at the beginning what the length of our
1:18
relationship will be
1:21
let me just summarize what i have
1:23
covered in this first overview of
1:25
psychiatric nursing we've covered a lot
1:27
of
1:27
material but it really is the core of
1:30
all that will follow
1:31
we looked at what the heart of
1:33
psychiatric nursing is it's an
1:34
interpersonal
1:35
caring process that involves a focus on
1:38
communication
1:39
the main tool is the nurse herself or
1:41
himself
1:43
it's a collaborative process that uses
1:45
the nursing process
1:47
our practice to psychiatric nurses is
1:49
impinged upon
1:50
by by many theoretical models
1:54
to name a few the medical model the
1:56
 psychoanalytical model
1:57
erickson's model maslow's model
2:01
the community mental health model those
2:03
are all models that impact on our
2:05
practice
2:06
we also have a number of therapeutic
2:08
modalities that we use
2:10
including individual therapy crisis
2:12
intervention
2:13
family group the expressive therapies
2:17
we need to be familiar with each of
2:18
these so that we can use them
2:20
appropriately we looked at the
2:22
difference between mental health and
2:24
mental illness and how the defense
2:26
mechanisms are used
2:28
to protect all of us mentally ill
2:30
wherever we fall in that continuum
2:32
to protect us against anxiety and lastly
2:36
we've taken a look at the nurse patient
2:37
relationship the stages of the
2:39
relationship
2:40
and the communication techniques both
2:43
those that facilitate good communication
2:45
and those that are blocks to
2:48
communication
2:50
ends the first portion of our
2:51
psychiatric nursing review

Schizophrenia
1. Definition: group of psychotic disorders characterized by regression, thought disturbances(including
delusions and hallucinations), bizarre dress and behavior, poverty of speech, abnormal motor behavior,
and withdrawal

1. Manifestations

1. Delusions: fixed false beliefs; can be paranoid, grandiose, or somatic delusions

2. Hallucinations: sensory perceptions without any environmental stimuli (for example: hearing
voices, seeing spiders, smelling foul)
3. Illusions: misidentification of actual environmental stimuli; client may see an electrical cord as a
snake
4. Ideas of reference: personalizing environmental stimuli (for example: client believes static on
telephone is wiretapping)
5. Neologisms: made up words
6. Circumstantiality: can't come to point, includes nonessential details
7. Blocking: interrupt flow of speech due to distracting thoughts, words, ideas, subjects
8. Regressive behavior: behavior appropriate at earlier stage of development
9. Echolalia: repetition of words or phrases heard from another person
10. Clanging: repeating words or phrases that sound the same but not related
11. Pressured speech: words rush out quickly
12. Poor interpersonal relationships
13. Declining ability to work, socialize, care for self

1. Types

1. Disorganized: incoherent, severe thought disturbance, shallow, inappropriate, often silly behavior
and mannerisms
2. Catatonic (psychomotor)

1. Stupor: lessening of response

2. Excitement: increase in activity
3. Waxy flexibility: bizarre posturing
4. Negativism: doing the opposite of what is being asked
5. Mutism: continuous refusal to speak
6. Severe withdrawal

3. Paranoid (can be dangerous)

1. Hallucination: grandiose or persecutory

2. Delusions: persecution and grandeur
3. Emotions: angry, suspicious, argumentative, mistrust, excessive religiosity of a punitive
nature

4. Undifferentiated
1. Mixed characteristics
2. Meets criteria of more than one type

1. Nursing Interventions
1. Provide physical care
2. Promote client safety
 3. Increase client trust with a 1:1 nurse/client relationship
4. Orient to reality
5. Provide structure to the day
6. Involve family
7. Interactions should be simple and concrete; often nonverbal and short
8. Help work through regressive behavior
9. Decrease bizarre behavior, anxiety, agitation, aggression
10. Deal with hallucinations
1. Distract client
2. Do not confront; do not deny
3. Point out that you do not share the same perception, but acknowledge that the
hallucination is real to client
4. Seek to establish feelings
5. Avoid leaving client alone (client will hallucinate more)
6. Engage client in activities (for example: current events discussion groups)

1. Nursing Focus
1. Provide least restrictive environment, avoid restraining
2. Provide care in a firm matter-of-fact manner that allows participation
3. Provide consistency, positive reinforcement, and unconditional acceptance of client

Paranoid Personality Disorder

1. Definition: insidious development of a permanent and unshakable delusional system accompanied by

preservation of clear and orderly thinking
2. Characteristics
1. Projection: unacceptable feelings are attributed to others
2. Delusions of grandeur and/or persecution
3. Ideas of reference (for example: personalizing environmental stimuli)
4. Resistance to treatment
5. Loneliness and distrust (failed Erikson's Stages)
6. Refusal to eat
7. Suspiciousness and fear
8. Emotional expressions are appropriate to content of delusional system
9. Argumentative and hostile

1. Nursing Interventions
1. Persecutory delusions

1. Do not argue or confront

2. Interject reality when appropriate
3. Get to feeling level
4. Discuss topics other than delusions

2. Aggression and hostility

1. Help client express self verbally

2. Set limits and offer alternatives
3. Keep at a safe distance
4. Don't respond with aggression; use calm controlled tone
5. Use direct, simple statements
6. Keep other clients away
7. Decrease stimulation with time out
 8. Have back up and use speed when restraining
9. Seclude as last resort
10. Provide outlet for aggression
11. Monitor

1. Fear of being poisoned

1. Serve food in containers

2. Medications should be wrapped or in containers
3. Do not covertly put meds in juice
4. Open meds in presence of client

1. Nursing Focus

1. Attempt to de-escalate client's aggression, allow opportunity to gain control

2. Avoid verbal and nonverbal communication that could be interpreted as a threat
3. Respect the client's personal space and avoid touching as they may strike out in response to fear
and anxiety

Pervasive Developmental Disorders

1. Autistic Disorders

1. Characteristics

1. Lack of interest in human contact

2. Compulsive need for following routines; distressed by slight environmental changes
3. Abnormal or no social play
4. Autoerotic behavior (for example: rocking. excessive masturbation)
5. Abnormal nonverbal communication
6. Self-mutilation (for example: head banging)
7. Impaired ability to form peer relationships
8. Abnormal production of speech and content
9. Obsessional attachments to inanimate objects
10. Impaired ability to form peer relationships

1. Nursing Interventions

1. Assess social and physical aspects of client

2. Assess family understanding and coping
3. Facilitate communication (verbal and/or nonverbal)
4. Maintain optimum level of functioning and prevent regression

1. Attention Deficit/ Hyperactivity Disorder

1. Characteristics

1. Fails to complete task

2. Easily distracted
3. Difficulty concentrating
4. Acts before thinking, impulsive
 5. Has difficulty sitting still

1. Nursing Interventions

1. Assist to communicate effectively

2. Set stage for improving ego function
3. Help learn more adaptive coping behaviors
4. Initiate supportive and educative methods for assisting parent and child
5. Promote client safety when head banging or other self-destructive behaviors are exhibited
6. Techniques to use:

1. Play therapy
2. Cognitive-behavioral
3. Family therapy
4. Psychopharmacology: methylphenidate (Ritalin)

Medications: antipsychotics (for schizophrenic and paranoid behavior patterns); compliance is a problem
secondary to adverse reactions

1. Block dopamine receptors

1. Target positive manifestations

1. Negativism
2. Combativeness
3. Disorganization
4. Hallucinations, delusions
5. Hostility
6. Suspiciousness
7. Seclusiveness
8. Self-care deficits

2. Negative manifestations not affected

1. Apathy
2. Withdrawal
3. Insight
4. Lack of interest
5. Blunted affect
6. Judgment

ANTIPSYCHOTIC AGENTS
CHEMICAL CLASS GENERIC NAME TRADE NAME MEDICATION
ALERT
Phenithiazine, Chlorpromazine Thorazine
aliphatic
Phenothiazine, -thioridazine -Mellaril
piperidine -mesoridazine -Serentil
Phenothiazine, -fluphenazine -Prolixin
piperazine -perphenazine -Trilafon
-triflouperazine -Stelazine
Thioxathene, Thiothixene Navane
piperazine
Butyrophenone haloperidol Haldol
Dibenzoxapine -loxapine -Loxitane -Clozaril is an
-clozapine -Clozaril effective antipsychotic
especially in clients
not responding to
other neuroleptics
-Clozaril requires
weekly CBCs
Thienobenzodiazepine-olanzapine -Zyprexa Zyprexa is mirrored
-quetiapine -Seroquel after Clorazil with
-sertindole -Serlect fewer adverse
reactions. Does not
require weekly CBCs
Benzisoxazole risperidone Risperdal -Risperdal has fewer
EPS and targets
negative and positive
symptoms
-Can be used safely
in the elderly

ANTIPSYCHOTIC AGENTS’ ADVERSE REACTIONS

ADVERSE REACTIONS NURSING INTERVENTIONS MEDICATION ALERT

Sedation Most common in low-potency Sedation is common in
antipsychotics; ask primary Thorazine and Mellaril
care provider if entire dose can
be given at bedtime
Extrapyramidal effects (EPS): Report to the primary care EPS is usually associated
parkinsonian symptoms (for provider; specific medication with high potency
example: fine hand tremors, may be changed; (Stelazine, Navane, Haldol,
pill rolling, drooling, muscle antiparkinsonian medication is and Loxitane); least likely to
stiffness) given to control manifestations have EPS with Mellaril
Dystonia: muscle spasm of Report to primary care
the face and neck; eyes provider; usually an
rolling back in head antiparkinsonian medication is
given and the antipsychotic
medication is changed
Akathisia: restlessness, Call primary care provider; if
inability to sit still treated with antiparkinsonian
medications, may need to
change antipsychotic
medication
Tardive dyskinesia: lip Careful observation in early
smacking, sucking, tongue steps of treatment; discontinue
protrusion, jerking of the head medications at first sign to
and neck, extension and prevent permanent disability;
flexion of the fingers, back Abnormal Involuntary
and forth movement of spine, Movement Scale (AIMS) is
movement of the arms used to assess clients for
 permanent adverse reactions

Adverse reactions: anticholinergic

1. Blurred vision
2. Dry mouth
3. Constipation
4. Urinary retention
5. Drowsiness
6. Nervousness
7. Photosensitivity
8. Hypotension

Drugs to control extrapyramidal reaction (CNS)

1. Commonly used

1. Trihexyphenidyl (Artane)
2. Benztropine mesylate (Cogentin)
3. Diphenhydramine (Benadryl)