PSYCHIATRIC NURSING

Nurse – Client Relationship (2-way) Offering self – Let me sit here with you for 5 mins.
- Series of interaction between the nurse & SMART
client Active listening – ah huh, yes, no
Goal – Positive behavioral change Exploring – You said Ana was the best, Can you
Elements of Therapeutic Relationship describe her?
T - rust Broad openings – Where would you like to begin?
R - apport Making observation – I noticed you have combed your
U – nconditional positive regard (Acceptance) hair today.
S – et limits (Reinforce safety precautions) Summarizing – In the past 15 mins, we have talked
T – herapeutic use of self (Theracomm) Encouraging description of perception – What are the
Therapeutic Behaviors voices telling you?
1. Genuineness – sincerity and honesty Presenting reality – I know that the voices are
2. Concreteness – ability to identify one’s feelings frightening you but there are no voices here.
3. Respect – consideration of client as unique Seeking clarification – Do you mean…?
Phases of Therapeutic Relationship Reflecting -
 Pre-Interaction/Orientation Restating – Rephrashing “You feel depressed?
- No contact with the client General leads – Go on…
- Data from secondary sources (Chart, Journals, Focusing – Let us look at it more closely…
Books) Non-Therapeutic Communication – common pitfalls
- Develops Self-Awareness Giving advise – patient must discover the solution
 Interaction/Orientation Talking about self – we must talk more about patient
- Establishes Trust than nurse.
- Assess the client Telling the client is wrong – it triggers dispute,
- Establishes mutual agreement challenge
- Informing about termination False reassurance – unrealistic statements
 Working Asking WHY – it demands an answer, arouses deep
- Longest phase seated feelings *except suicidal – needs direct
- Achieving goals, sharing facts, resolves the questioning
problem Spheres
- Highly Individualized ID – Pleasure, irrational thoughts --- Anti-Social PD
 Termination EGO – reality based
- Moving towards independence Superego – Conscience, Ego Ideal --- OCPD
- Observe for regressive behaviors Defense mechanisms
Therapeutic Communication  Repression – unconsciously forgetting (di sadya)
- Dynamic process of exchanging information. traumatic events
- Verbal and Non-verbal Techniques  Suppression – consciously forgetting (sadya)
Therapeutic Communication: Elements  Reaction formation - plastic
1. Sender (Encoder) - the source of message  Rationalization – making excuses
2. Message- the information transmitted  Projection – blaming others
3. Receiver (Decoder) - recipient of message  Introjection – blaming self/exact replica
4. Feedback- receiver’s response to the message  Compensation – weak one aspect, strong another
5. Barriers – inhibits the communication process aspect
NON- VERBAL COMMUNICATION  Denial – unacceptance of truth
1. Proxemics- “physical space” (3-6ft/ 1 arm and half)  Displacement – channeling of anxiety
2. Kinetics- body movements (gestures, facial  Regression – going back to previous dev stage
expressions and mannerisms) Enhances the  Undoing – hugas kamay, trying to relieve guilt
credibility of what you are saying.  Conversion – anxiety – physical symptoms
3. Touch- intimate physical contact (Consent)  Intellectualization – reasoning in detailed manner
4. Silence – agreeing, listening, encourages pt. to talk
 Substitution – unavailable – available (Ex. Doctor to
5. Paralanguage- “voice quality” (tone, inflection) or
Nurse)
how a message is delivered
 Sublimation – unacceptable – acceptable (Basagulero
Verbal Communication
to Boxer)
- Therapeutic, appropriate, simple, adaptive,
 Identification - Idolization
concise, credible.
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Crisis Inappropriate – incongruent to
 Maturational or developmental – Blunted – little response
expected/predictable Restricted – display one type of expression
 Situational – unexpected, unpredictable Labile – unpredictable, rapid mood swings
 Adventitious or social – calamities/ Acts of God Apathy – absence of emotion/expression (flat)
Stages of death and dying Ambivalence – 2 opposing feelings (mixed emotions)
D-enial – Shock, Disbelief, Unacceptance of truth Anhedonia – absence of pleasure
A -nger – Projection (Blame others) Euphoria – extreme pleasure
B-argaining – bargain (unrealistic offer) STRESS
D-epression – suicidal (dangerous) – Prioritize Safety Stage I (Alarm Reaction) – Determining that there is
A-cceptance – moving forward/on stress.
Stage II (Stage of Resistance) – Utilize resources to
Disturbances of Appearance solve problem.
 Automatism – repeated purposeless behaviors ------------------------Problem
 Psychomotor retardation – slowed movements Solved-----------------------------------------
 Waxy flexibility – maintenance of awkward posture Stage III (Stage of Exhaustion) – Utilize all resources but
 Catatonia – maintenance of awkward posture and the problem is not solved.
go back to previous position.
 Echopraxia – purposeless imitation Anxiety (Unknown) vs. Fear (Known)
Levels of Anxiety
Disturbances in Communication Mild – GOOD ANXIETY; logical thinking, increase
 Mutism – (mute) concentration and alertness: Problem solving approach
 Negativism – they always say “no” Moderate – Decrease attention span, selective
 Circumstantiality – beating around bush, with inattentiveness: Relaxation Techniques (DBE),
answer Encourage verbalization of feelings, MEDICATIONS
 Tangentiality – beating around bush, no answer (Anxiolytics)
 Stilted language – flowery Severe – Loud and rapid speech, difficulty of focusing
even with attention, distorted perception, REMAIN
 Flight of ideas – slightly related, with meaning
WITH THE PATIENT
 Loose association – not related phrase, no meaning
Panic – suicidal attempts, fixed eyes, hysterical/mute,
 Perseveration – persevere; stick with one topic only
decrease stimuli, stay with client, PAPER BAG
 Echolalia – parrot-like imitation of speech
(hyperventilate)
 Palilalia – stereotype words/Last syllable
Physiological changes in Anxiety
 Verbigeration - senseless repetition of same words
Mild – shaking of feet
 Coprolalia – shit talks, curse, bad words
Moderate – butterflies in stomach, nausea, vomiting,
 Neologism – new words diarrhea
 Blocking – sudden cessation of thought Severe – DOB, chest pain, palpitations
 Word salad – mixture of unrelated words Panic – hysterical, restless, irritable, suicidal
 Clang association - Rhyming Neurotransmitters
Dopamine/Epi/Norepi - Excitatory
Disturbances in Perception Serotonin – Inhibitory in nature -Excitatory in Synapse
 Delusions – fixed false “beliefs” Synapse – neurotransmitter exchange
 Magical thinking – preschooler thinking Antidepressants – excitatory – SSRI
 Paranoia – extreme suspiciousness GABA – balancer
 Religiousity – obsession in religious ideas
 Phobia – irrational fear Anxiety Related Disorders
 Obsession – persistent thought 1. Generalized Anxiety Disorder
 Compulsion – persistent action - “worry worm”, pacing
 Preoccupation-idea with intense desire
 Thought broadcasting – others know what I am - no apparent reason
thinking - Anxiety for 6 months and above
 Delusions of reference – always talk of the town - no phobias, panic attacks or OC
 Ideas of reference – sometimes talk of the town manifestations
Affect: Expressions S/sx:
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- palpitations: SNS stimulation  Social Phobia – fear of socializing with others
 Simple Phobia – specific types Ex. Acrophobia
-
Headache, Insomnia, Chest pain
– heights
Management:
Management:
- assist in problem solving (independence) - Systemic desensitization: Gradual exposure
- teach coping behaviors Counterpart: Flooding – sudden
- DOC: Benzodiazepines/Anxiolytics: exposure
“pam/lam” - Breathing exercises
2. Panic Disorder - Thought Stopping: Diversional act Ex. Rubber
band
- Recurrent, unpredictable
- Guided Imagery – Conditioning Ex. Seaside,
Panic attacks:
Beach
o Trembling
6. Obsessive Compulsive Disorder
o Racing heart (Tachycardia)- SNS Stimulation
 Obsession – thoughts
o Chest pain
 Compulsion – action
o DOB - Aware, real obsessions and compulsions
o Choking sensations OCD OCPD
o Numbness Anxiety Disorder Personality Disorder
Management: Real obsessions & No OC, Perfectionist,
- assist in problem solving compulsion rigid
- teach coping behaviors Management:
- DOC: Benzodiazepines - Aversion Therapy: pain/punishments (set
- Other meds: Beta Blockers: blocks SNS-> Dec limits)
Anxiety - DOC: SSRI
MAOIs, SSRI (Antihistamines – if with - Give time for ritualistic behaviors unless
addiction to Benzodiazepines) dangerous
3. Acute Stress Disorder - Establish limits
- S/Sx after 2 days up to 4 weeks - Diversional Activities Ex: Wash hands
Management: - SLRC: Set limits, Reality, Consistency
- Progressive review of trauma -> acceptance
- DOC: Benzodiazepines
4. Post-Traumatic Stress Disorder (PTSD)
- S/Sx are more than 4 weeks
- Recurrent FLASHBACKS (intrusive thoughts)
- Re-experiencing of the trauma
- Def mech: Displacement
S/Sx:
- General numbing -> Somatic (bodily)
symptoms) MOOD DISORDERS
- Irritability, Aggressiveness, Depression
- Anger: self/others Major Depression Bipolar
- Social withdrawal -> Group therapy Problem Overdependence/ Mask of
Management: Loss Depression
- Assist in gaining control over angry impulses Defense Introjection Reaction
(acceptance) Mechanis Formation
- DOC: Benzodiazepines m
- Other Meds: Beta-blockers, Antihistamines S/Sx o Anhedonia oHyperactivit
5. Phobic Disorder o Psychomotor y
- Persistent irrational fear retardation oManipulativ
- Fear is unreasonable proportion to actual o Negative S/Sx e
danger oInattentive
3 Main Types Attitude Kind Firmness Matter of Fact
 Agoraphobia – fear of open places -> always Therapy
near exit, stay at home. Activity Counting seashells, Breaking
Writing leaves,
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Modelling
clay, Walking
Therapy Group Therapy, Solitary
Non-competitive Therapy, Non-
competitive
WOF: Suicide- near nurse station, Food: Finger
open door, irregular visit Foods
Schizophrenia - Increase Dopamine
Types of Schizophrenia
 Catatonia – Abnormal motor behavior
S/Sx
- Catatonia Waxy flexibility
- Mutism Negativism
Defense mechanism: Repression
Nursing Diagnosis: Impaired motor activity
Management: Circulation - needs ROM exercises
- Nutrition (spoon feeding/tube feeding is done)
 Disorganized Schizophrenia - Bizarre behaviors
S/Sx: Bizarre
- Thought, Movements, Speech: neologisms
Defense mechanisms: Regression
Nursing Diagnosis: Impaired Social Functioning
Management: ADL assistance
 Paranoid Schizophrenia - Extreme suspiciousness
S/Sx: Delusions Hallucinations Flight of ideas
Defense mechanisms: Projection (Paranoid)
Nursing Diagnosis: Potential injury directed to
self/others (they are hostile, aggressive)
Management: Safety - due to potential injury directed
to self/others
- Nutrition - they feel there are — motives
against them, Give sealed foods