PSYCHIATRIC NURSING
Content
Psychiatric Nursing
Mental Health
A state of emotional, psychological and social wellness evidenced by: a. Satisfying interpersonal relationships b. Effective behavior and coping c. Positive self concept d. Emotional stability
Factors that Influence Mental Behavior
Individual Factors Biologic makeup Autonomy, and independence Self-esteem Coping or stress management abilities Resilience or hardiness Interpersonal Factors Effective communication Helping others Intimacy Balance of separateness and connectedness Socio-cultural Factors Sense of community Intolerance of violence Diversity among people Mastery of the environment Positive yet realistic view of the world
Mental Illness
disharmony Is a sense of _____________ with the aspects of living that may be _________________ to the individual, distressing family, friends, and community.
APA (2000)
• “A clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom”.
Deviant behavior does not necessarily indicate a mental disorder!
6 Major Conceptual Approaches to Define Mental Health
1. Attitude toward the Individual Self Self-Concept: how a person views himself (4 Aspects): a. body image - physical b. personal identity – psychological aspect c. self-esteem - emotional d. role performance – expression of self-concept
6 Major Conceptual Approaches to Define Mental Health
Self-Acceptance: realistic concept of strengths and weaknesses Self-Awareness: noticing how self feels, thinks, behaves and senses at any given time (differs from introspection – evaluation of self)
6 Major Conceptual Approaches to Define Mental Health
2. Growth, Development and SelfActualization 3. Integrative Capacity
– Refers to balance of psychic forces: Id, Ego, Super Ego – Use of these attributes for good personal function – The ability to tolerate anxiety and frustration
6 Major Conceptual Approaches to Define Mental Health
4. Autonomous Behavior
– make own ____________ decisions regardless of pressure
5. Perceptions of Reality – how one perceives ________ & envt, people 6. Mastery of One’s Environment
– ability to _________, _________, adapt adjust and _________ appropriately according behave to culturally approved standards
& how he ________ to them reacts
Legal and Ethical Issues
Admissions of pts: a. Voluntary – pt willing b. involuntary inpatient – against own will c. involuntary outpatient Civil rights – right to consent to or refuse txt 1973 Patient’s Bill of Rights 1980 Mental Health Systems Act 1993 Social Security Act
Legal and Ethical Issues
Legal Issues 1. confidentiality 2. informed consent 3. right to refuse txt – emergencies, given meds, be secluded or restrained 4. seclusion 5. restraints – chemical or mechanical to control activity 6. incompetence – patient must have legal representation
Historical Review
Primitive: mentally ill possessed by demons as punishment for sin. Treatments: • trephine skull operations • starving • beating • abandoning in forests to be devoured by animals • burning at stake
Ancient to Middle Ages
• Sanatoriums – temples of Saturn for care of mentally sick in Egyptian civilization • Bible records of mentally ill • Golden Age of Greece – temple used as hospitals – plenty of fresh air, water and sunshine; riding walking, waterfalls as diversion for melancholic; starving, chains and flogging also done so those who refuse
• Romans – bleeding, purging, sulfur baths • Gheel in Belgium – start of Gheel colony by St. Dymphna
Reformation Era
• To almshouses, jails, dungeons – favorite therapeutic procedures: purging and bleedings • Bethlehem Royal Hospital in London (Bedlam: by King Henry VII) • Pinel, Phillippe and William Tukes– freed chained insane patients, started humane treatment
– Period of Enlightenment and Creation of Mental Institutions – Formulated the concept of asylum
• Esquirol – first regular teacher of psychiatry, followed Pinel
Development in the US
• • 1773 – Eastern Lunatic Asylum in Williamsburg, Virginia 1783 – Dr. Benjamin Rush: Father of American Psychiatry, organized first lectures
– Human treatment of the mentally ill – Invented the tranquilizer chair – Gyrator
Development in the US
• ________________________: Dr. Edward S. Cowles organized first course 1882, McLean Asylum, Waverly, Mass Dorothea Lynde Dix: aroused legislative action to establish & enlarge hospitals in US; d/t inhumane practices and filthy cells, jails & poorhouses
•
Other Developments
________________________: (French) Jean Martin Charcot Psychotherapy Emil Kraeplin ____________________: (German) Classification of mental disorders Sigmund Freud: Psychoanalysis, Psychosexual theory and neurosis
th 20
Century Developments
__________________: Psychobiology Dr. Adolf Meyer
A Mind that Found Clifford Beers: “______________________”
Itself Dr. Harry Sullivan: Interpersonal theory
20th Century Developments
1930’s: use of _______, __________ insulin Metrazol,
ECT
1946 US National Mental Health Act of ____: research and training, improvement, expansion of community health services Deinstitutionalization: shift from the community institution to the ___________
Development of Psychopharmacology
• In the 1950’s the development of psychotropic drugs were used to treat mental illness. • Chlorpromazine (Thorzine), an antipsychotic drug, and lithium, an anti-manic agent, were the first drugs to be developed. • 10 years later, monoamine oxidase inhibitors, haloperidol (Haldol), an antipsychotic; tricyclic antidepressants; and antianxiety agents (benzodiazepines), were introduced. • Because of these new drugs, hospital stays were shortened, and many people were well enough to go home.
Mental Illness in the 21st Century
• 56 million Americans have a diagnosable mental illness. • Many providers believe today’s clients are to be more aggressive than those in the past • 85% of the homeless population has a psychiatric illness and/or a substance abuse problem • The United States has the largest percentage of mentally ill citizens (29.1%) and provided care for only 1 in 3 people who needed it (Bijl et al., 2003). • Persons with minor or mild cases are most likely to receive treatment while those with severe and persistent mental illness were least likely to be treated.
History of Psychiatric Nursing Education
Linda Richards 1873 – __________________: first American psychiatric nurse 1882 – _______________________: first school McLean Hospital 1935 – ½ of Nursing schools in US required psych course Catholic Univ. of America Sch of Nsg Edu. 1943 – ___________________________________:
- start of specialization in Psych Nsg; 1950 _____ – National League for Nsg required Psych Nsg to be accredited
Major Contributors to Psychiatric Nursing
__________________ – wrote 1st textbook Harriet Bailey “Nrsg Mental Diseases” __________________– therapeutic nurse patient relationship w/ phases __________________– “Nursing Therapy”
Major Contributors to Psychiatric Nursing
__________________ – wrote 1st textbook Harriet Bailey “Nursing Mental Diseases” Hildegard Peplau __________________– therapeutic nurse patient relationship w/ phases June Mellow __________________– “Nursing Therapy” – Focused on psychosocial needs and strengths
Psychoanalysis
A form of psychodynamic psychotherapy therapist and client in which the ___________________ conscious explore the client’s ____________ unconscious and _______________ conflicts coping and ___________ patterns
Transference and Countertransference
• Transference occurs when the client displaces onto the therapist/nurse attitudes and feelings that the client previously felt in other relationships. • Counter-transference occurs when the therapist/nurse displaces onto the client attitudes or feelings from his or her past.
Founders of Psychoanalysis
Father of SIGMUND FREUD: ___________________ Psychoanalysis
Further explained the ANNA FREUD: ______________________ _______________________________ defense mechanisms
classified VAILLANT: ___________ the defense mechanisms in a hierarchy from _____________ to healthy psychotic
Primary Drives
• Eros
– Drive towards life – Instincts concerned with self preservation or survival of the fittest
• Thanatos
– Drive towards death – Aggression or hate which can be directed inward or outward
Theories of Personality Development
By Sigmund Freud
Personality
Personality – characteristic traits that are generally predictable in their influence on ____________, ____________, cognitive affective and behavioral patterns expressed through ______________ behavior Factors Influencing Personality:
1. hereditary 2. environment 3. training
A. Levels of Consciousness
1. Conscious
1. Functions when awake 2. Here and now 3. Easy recall of past experiences
A. Levels of Consciousness
2. Subconscious
1. Ideas and reactions are stored and partially forgotten 2. Prevents unacceptable disturbing memories from reaching conscious mind 3. “Tip of the tongue” experiences
A. Levels of Consciousness
3. Unconscious - greatest influence on personality - storehouse of memories, feelings throughout life - memories are not recalled - dreams, “slip of the tongue”, unexplained behavior
A. Levels of Consciousness
1. Conscious 2. Subconscious 3. Unconscious
B. Components of Personality or Drives
ID
• Primarily a sexual and aggressive drive • The first structure to develop in the personality
– Developed during infancy
• Pleasure principle to reduce tension
– Example a baby reflexively sucks to receive nourishment thus reducing her hunger. Also characterize by
• Primary process thinking which is imagery.
– Irrational and not based on reality. – Example, hallucinations of psychotic clients.
EGO
• CEO of the mind. • Toddler period • Mediates between the Id and Super Ego thus maintaining a reality orientation for the person.. • Reality principle. • Secondary process thinking which is
– logically oriented in time and distinguishes between reality and fantasy.
• Partially under conscious control. • What happens when ego cant mediate against the unconscious drives?
SUPER EGO
• Our conscience • 2 main functions- reward and punishment.
– Rewards good behavior and punishes bad behavior by creating guilt.. A residue of internalized values and moral training or early childhood..
• Pre-school age • Overly strict super ego may lead to extremes of guilt and anxiety
“Pleasure Principle”
“Reality Principle”
EGO
ID/
SUPEREGO
Resolving Conflicts
Stimulus Drive Response Resolution
Resolving Conflicts
Stimulus Drive Response Resolution
Hunger desire for ice cream
“I must have it now!”
Eats ice cream and feels satisfied momentarily. May become stimulus for guilt.
Resolving Conflicts
Stimulus Drive Response Resolution
Hunger, desire for ice cream
“I must NOT eat it.”
Does not eat. May become stimulus for sad or angry feelings.
Resolving Conflicts
Stimulus Drive Response Resolution
Hunger, desire for ice cream “I would like to have it
now, but I have just eaten a big meal. I will wait until later in the day and have a small portion.
Drive is reduced.
Pavlov
Classic conditioning (Behavior theory)
Application to Nursing
• Classic conditioning to initiate a behavior • Operant conditioning to ensure the behavior is repeated
Psychosexual Theory
By Sigmund Freud
Stages of Development
Oral Anal Phallic Latency Prepuberty & Adolescence Genital Birth – 18 mos. 18 mos – 3 years 3 – 5 years 6 – 12 years 12 – 15 years
15 years - adult
Fixation
Arrest of maturation at an earlier level of psychosocial development. It is behavior that should have been outgrown.
Oral Stage (0-18 mos.)
Critical Experiences Devt. Task Major Char: Weaning Establish Trust Autoeroticism, narcissism, omnipotence, pleasure principle, frustration, dependence
Other Possible Personality Traits
Fixation : passivity, gullibility, & dependence, the use of sarcasm, & the devt of orally focused habits (smoking and drinking)
Anal Stage (18 mos-3 yrs)
Critical Experiences Devt. Task Toilet training Developing sphincter control, Feeling of autonomy
Major Char:
Reality principle, fear of loss of object loved, approval & disapproval, Beginning superego development
Fixation: rel. to anal retentiveness (stinginess, rigid thought patterns, OCD) Or anal expulsiveness char (messiness, destructivenss, cruelty)
Other Possible Personality Traits
Toilet Training
Cues if Ready for Toilet Training:
1. 2. 3. 4. can stand alone can walk steadily can keep dry in interval of at least two hours can demonstrate awareness of defecating and voiding 5. are able to use words and gestures regarding TT and toilet needs 6. are desirous of pleasing the primary care giver
Toilet Training
Age in which Toilet Training is Achieved:
18 mos: 2 ½ yrs: 3 years: Bowel control Daytime bladder control Nighttime bladder control
Phallic Stage (3-5 yrs)
Critical Experiences Devt. Task Oedipal-Electra conflict (complex) Castration anxiety Establishing sexual identity Beginning socialization
Major Char:
Differentiation between the sexes, Superego more internalized
Unresolved outcomes may result in difficulties with sexual identity and with authority figures
Other Possible Personality Traits
Latency Stage (6-12 yrs)
Critical Experiences Devt. Task Peer growth experience Intellectual growth Group identification Identify with teacher and peers
Major Char:
Super ego influence in erotic interests, immense intellectual development
Fixations can result in difficulty in identifying with others and in developing social skills, resulting in a sense of inadequacy and inferiority
Other Possible Personality Traits
Adolescent Stage (12-15 yrs)
Critical Experiences Devt. Task Established heterosexual relationships Developing social control over instinct
Major Char:
Identity, turmoil, consideration of needs of others
Very modest, fear of exposing body parts for physical examination
Other Possible Personality Traits
Application to Nursing
• Anxiety has an important role in maladaptive behavior. • Nurses must understand the role of unconscious conflict in the motivation of behavior. • Nurses must be aware of the clients defense mechanisms.
Genital Stage (15 yrs-adult)
Critical Experiences Devt. Task Sexual maturity Resolving Dependence - Independence conflict
Major Char:
Other Possible Personality Traits
Heterosexual relationships
Inability to negotiate this stage could result in difficulties in becoming emotionally and financially independent, lack of strong personal identity and future goals, and inability to form satisfying intimate relationships
Psychosocial Theories
Erik Erikson
• Focused on personality development across the life span while focusing on social and psychological development in life stages. • Erikson believed that psychosocial growth occurs in sequential stages, and each stage is dependent on the completion of the previous stage/life task.
Application to Nursing
• Facilitate adaptive resolution of various developmental crises or tasks by using the nursing process to assess the client’s level of functioning and subsequent planning. • Provides basis for client centered nursing interventions.
• • • • • • • •
Trust vs. Mistrust (infant) Autonomy vs. Shame and Doubt (toddler) Initiative vs. Guilt (preschool) Industry vs. Inferiority (school age) Identity vs. Role confusion (adolescence) Intimacy vs. Isolation (young adult) Generativity vs. Stagnation (middle adult) Ego integrity vs. Despair (maturity)
Erikson’s Psychosocial Theory
Life Stage I. Trust vs. Mistrust (0 to 18 months) Adult Behaviors Reflecting Mastery Realistic trust of self & others Confidence in others Optimism and hope Shares openly with others Relates to others effectively Adult Behaviors Reflecting Developmental Problems Suspiciousness / testing of others Fear of criticism & affection Dissatisfaction & hostility Projection of blame & feelings Withdrawal from others OR Overly trusting of others Naïve and gullible Shares too quickly & easily
Erikson’s Psychosocial Theory
Life Stage II. Autonomy vs. Shame & Doubt (18 months to 3 yrs) Adult Behaviors Reflecting Mastery Self-control and willpower Realistic self-concept & self-esteem Pride and a sense of goodwill Simple cooperativeness Generosity tempered by withholding Delayed gratification when necessary Adult Behaviors Reflecting Developmental Problems Self-doubt / self-consciousness Dependence on others for approval Feeling of being exposed / attacked Sense of being out of control of the self and one’s life Obsessive-compulsive behaviors OR Excessive independence to defiance, Grandiosity Denial of problems Unwillingness to ask for help Impulsiveness – inability to wait Reckless disregard for safety for self & others
Erikson’s Psychosocial Theory
Life Stage III. Initiative vs. Guilt (3 to 5 years) Adult Behaviors Reflecting Mastery An adequate conscience Initiative balance w/ restraint Appropriate social behaviors Curiosity and exploration Healthy competitiveness Sense of direction Original and purposeful activities Adult Behaviors Reflecting Developmental Problems Excessive guilt / embarrassment Passivity and apathy Avoidance of activities / pleasures Rumination and self-pity Assuming a role as victim / selfpunishment Reluctance to show emotions Underachievement of potentials OR Lack of follow-through on plans Little sense of guilt for actions Excessive expression of emotion Labile emotions Excessive competitiveness / showing off
Erikson’s Psychosocial Theory
Life Stage
Adult Behaviors Reflecting Mastery Adult Behaviors Reflecting Developmental Problems
IV. Industry vs. Sense of competence Inferiority Completion of projects (6 to 12 years) Pleasure in efforts and effectiveness Ability to cooperate and compromise Identification with admired others Joy of involvement in the world and with others Balance of work and play
Feeling unworthy and inadequate Poor work history (quitting, being fired, lack of promotions, absentism, lack of productivity) Inadequate problem solving skills Manipulating others / violating others’ rights Lack of friends of the same sex OR Overly high achieving / perfectionist Reluctance to try new things for fear of failing Feeling unable to gain love or affection unless totally successful Being a workaholic
Erikson’s Psychosocial Theory
Life Stage
Adult Behaviors Reflecting Mastery Adult Behaviors Reflecting Developmental Problems Lack of giving up of goals, beliefs, values, productive roles Feelings of confusion, indecision, & alienation Vacillation between dependence & independence Superficial, short-term relationships with the opposite sex OR Dramatic overconfidence Acting-out behaviors (including alcohol & drug use) Flamboyant display of sex role behaviors V. Identity vs. Confident sense of self Role Diffusion Emotional stability (12 to 18 or 20years) Commitment to career planning & realistic longterm goals Sense of having a place in society Establishing relationship w/ opposite sex Fidelity to friends Development of personal values Testing out adult roles
Erikson’s Psychosocial Theory
Life Stage VI. Intimacy vs. Isolation (18 to 25 or 30 years) Adult Behaviors Reflecting Mastery Ability to give and receive love Commitment and mutuality with others Collaboration in work and affiliation Sacrificing for others Responsible sexual behaviors Adult Behaviors Reflecting Developmental Problems Persistent aloneness / isolation Emotional distance in all relationships Prejudices against others Lack of established vocation; many career changes Seeking of intimacy thru’ casual sexual encounters OR Possessiveness and jealousy Dependency on parents and/or partner Abusiveness towards loved one Inability to try new things socially or vocationally (staying in routine / mundane job and activities)
Erikson’s Psychosocial Theory
Life Stage VII. Generative lifestyle vs. Stagnation or Self-absorption (30 to 65 years) Adult Behaviors Reflecting Mastery Productive, constructive, creative activity Personal and professional growth Parental and societal responsibilities Adult Behaviors Reflecting Developmental Problems Self-centeredness/selfindulgence Exaggerated concern for appearance and possessions Lack of interest in marriage and / or extramarital affairs OR Too many professional or community activities to the detriment of the family or self
Erikson’s Psychosocial Theory
Life Stage VIII. Integrity vs. Despair (65 years to death) Adult Behaviors Reflecting Mastery Feelings of selfacceptance Sense of dignity, worth and importance Adaptation to life according to limitations Valuing one’s life Sharing of wisdom Exploration of philosophy of life and death Adult Behaviors Reflecting Developmental Problems Sense of helplessness, uselessness, worthlessness, &/or meaninglessness Withdrawal and loneliness Regression Focusing on past mistakes, failures & dissatisfactions Feeling too old to start over Suicidal ideas or apathy Inability to occupy self with satisfying activities (hobbies, volunteer work, social events) OR Inability to reduce activities Overtaxing strength and abilities Feeling indispensable Denial of death as inevitable
Cognitive Theories
Jean Piaget
• Sensorimotor (birth to 2 years): – The child develops a sense of self as separate from the environment and the concept of object permanence. – Begins to form mental images. • Preoperational (2-6 years): – Child begins to express himself with language, understands the meaning of symbolic gestures, and begins to classify objects.
• Concrete operations (6-12 years): – Child begins to apply logical thinking, understands reversibility, is increasingly social and able to apply rules – Thinking is still concrete. • Formal operations (12 to 15 years and beyond): – Child learns to think and reason in abstract terms, further develops logical thinking and reasoning, and achieves cognitive maturity.
Application to Nursing
• Helps nurses recognize impaired development and prove a relationship that facilitates the person’s accomplishment of developmental tasks. • Enables early childhood interventions
Harry Stacks Sullivan:
Interpersonal Relationships and Milieu therapy
• The importance and significance of interpersonal relationships in one’s life • Personality is manifested only in a person’s interaction with another person or with a group • Developed the first therapeutic community or milieu with young men with schizophrenia in 1929.
Stages
• Infancy
– Development of self concept – Learn to trust others
• Childhood
– Accept influence of others
• Juvenile
– Peer relations
• Preadolescence
– Form friendships with same sex peers
• Early adolescence
– More independent – Establish relationship with opposite sex
• Late adolescence
– Develop enduring relationship with opposite sex
• Milieu therapy is used in the acute care setting; one of the nurses’ primary roles is to provide safety and protection while promoting social interaction
Application to Nursing
• Used to strengthen support systems • Foster interpersonal relationships • Strengthens clients belief systems • Facilitates faith, hope and life
Hildegard Peplau’s Theory
Hildegard Peplau’s Theory
Nursing is the significant therapeutic interpersonal process that makes health possible for individuals and groups. Influenced by: 1. Culture 4. Education 2. Religion 5. Past experiences 3. Ethnicity 6. Preconceived ideas
Defined anxiety as the initial response to a psychic threat!
Four levels of anxiety
• Acute anxiety
– Positive state of heightened awareness and sharpened senses – Learn new behaviors and solve problems. – Person can take in all available stimuli (perceptual field).
• Moderate anxiety
– Decreased perceptual field (focus on immediate task only) – Learn behavior only with assistance – Ideal anxiety state for teaching a client regarding health concerns such as diabetes
• Severe anxiety involves
– Feelings of dread or terror – CANNOT be redirected to a task; he focuses only on scattered details and has – Physiologic symptoms – Priority is to move the person away from all stimuli, and then attempt to talk with them to calm down.
• Panic anxiety can involve
– Loss of rational thought, delusions, hallucinations, and complete physical immobility and muteness.
Humanistic Theories
Maslow’s Hierarchy of needs
• • • • •
Physiologic needs, need to be met first. Safety and security needs Love and belonging needs Esteem needs Self-actualization,
– The need for beauty, truth, and justice. Few people actually become self-actualized.
• Remember, traumatic life experiences or compromised health can cause a person to regress to a lower level of motivation!
Application to Nursing
• Useful in organizing curricula and in assessing and giving care • Emphasis on physiologic needs as the priority when life and physical integrity are in jeopardy
Neurobiological Theories
• All behaviors are a reflection of brain function • All thought processes represent a range of functions mediated by nerve cells in the brain • Cognitive and emotional dysregulation result from multiple causes (trauma, genetics, nutrition etc) that cause neurotransmitter disturbances in the brain.
Application to Nursing
• Provide the basis of target sites for pharmacological and psychotherapeutic interventions that mitigate symptoms of various psychiatric disorders
PSYCHIATRIC NURSING
Interpersonal process whereby the professional nurse practitioner through the use of self, assist an individual, family, group or community to promote mental health, to prevent mental illness and suffering, to participate in the treatment and rehabilitation of the mentally ill and if necessary to find meaning in these experiences. It is both Science and an Art.
Science in Psychiatric Nursing. – The use of different theories in the practice of nursing, serves as the science of psychiatric nursing. Art in Psychiatric Nursing. – The therapeutic use of self is considered as the art of psychiatric nursing.
• Core of Psychiatric Nursing.
– The interpersonal process, that is, the human to human relationship, is the core of psychiatric nursing.
• Clientele in Psychiatric Nursing.
– The individual, family, and the community, both mentally healthy and mentally ill.
• Mental Hygiene.
– It is the science that deals with measures to promote mental health, prevent mental illness and suffering and facilitate rehabilitation.
ESSENTIAL QUALITIES OF A PSYCHIATRIC NURSE
• Therapeutic Use of Self
– The heart of psychiatric nursing – Forming a trusting relationship that provides comfort, safety and acceptance of the client
• Genuineness
– Sense of openness, realness and lack of defensiveness. It conveys congruence between verbal and non verbal behaviors
• Warmth
– Imparts consistency , kindness, patience, and caring for the client
• Empathy
– Experiencing clients feelings as though they were his own but the nurse does not totally lose her identity – Sympathy is feeling or sharing the identical concerns of another. It interferes with formation of therapeutic relationship
• Acceptance
– Tolerance and appreciation of the client as a human being regardless of race, gender, culture, religion
• Maturity and Self Awareness
– Ability to tolerate differences and be responsive to client needs
• Leadership
– Problem solving and decision making
ROLES OF THE NURSE IN PSYCHIATRIC SETTINGS
• Ward manager – creates a therapeutic environment • Socializing agent – assists the patient to feel comfortable with others • Counselor – listens to the patient’s verbalizations • Parent surrogate – assists the patient in the performance of activities of daily living
• Patient advocate – enables the patient and his relatives to know their rights and responsibilities • Teacher – assists the patient to learn more adaptive ways of coping • Technician – facilitates the performance of nursing procedures
• Therapist – explores the patient’s needs, problems and concerns through varied therapeutic means • Reality base – enables the patient to distinguish objective reality and subjective reality • Healthy role model – acts as a symbol of health by serving as an example of healthful livings
Mental health Team
• • • • • • Psychiatrist Clinical Psychologist Psychiatric Social Worker Occupational Therapist Mental Health Worker Internist
PRINCIPLES OF CARE IN PSYCHIATRIC SETTINGS
• The nurse views the patient as a Holistic human being with interdependent and interrelated needs • The nurse accepts the patient as a unique human being with inherent value and worth exactly as he is. • The nurse should focus on the patient’s behavior non-judgmentally, while assisting the patient to learn more adaptive ways of coping
• The nurse should explore the patient’s behavior for the need it is designed to meet and the message it is communicating • The nurse has the potential for establishing a nurse-patient relationship with most if not all patients • The quality of the nurse-patient relationship determines the degree of change that can occur in the patient’s behavior.
LEVELS OF INTERVENTIONS IN PSYCHIATRIC NURSING
Primary
• Interventions aimed at the promotion of mental health and lowering the rate of cases by altering the stressors – Examples: Health education • Information dissemination – Counseling
Secondary
• Intervention that limit the severity of a disorder • Two components
– Case finding – Prompt treatment – Examples: Crisis intervention, Administration of medications
Tertiary
• Interventions aimed at reducing the disability after a disorder • Two components
– Prevention of complication – Active program of rehabilitation – Examples: Alcoholic anonymous, Occupational therapy
Altered Genes Brain exposed to internal and external demands Brain attempts to cope Successful Unsuccessful
Mental Health
Mental Illness
Defense Mechanisms
They are psychological strategies used individuals (and by extension--groups of individuals and even entire nations at times) to cope with reality and to maintain his/her self -image intact.
A defense mechanism becomes pathological when it is used persistently and leads to maladaptive behavior that will eventually threaten the physical and/or mental health of the individual. There are psychological defenses that are: a. Almost always pathological b. Immature c. Neurotic d. Mature defense mechanisms
Level 1 Defense Mechanisms
• Always pathological or "psychotic" defenses • User - rearrange external reality (and therefore not have to cope with reality) • Beholder - appear crazy or insane. • Denial - a refusal to accept external reality because it is too threatening. There are examples of denial being adaptive (for example, it might be adaptive for a person who is dying to have some denial • Distortion - a gross reshaping of external reality to meet internal needs • Delusional Projection - frank delusions about external reality, usually of a persecutory nature
Level 2 Defense Mechanisms
• Frequently in adults and are common in adolescents. • User - alter distress and anxiety caused by reality or other people • Beholder - socially undesirable, immature, difficult and out of touch. They are considered “Immature" defenses and almost always lead to serious problems in a person's ability to cope with the world. These defenses are seen in severe depression, personality disorders, and
• Fantasy • Projection • Hypochondriasis • Passive Agressive Behavior • Acting Out Behavior
Level 3 Defense Mechanisms
• “Neurotic" but are fairly common in adults. • • • • • Intellectualization Repression Reaction Formation Displacement Dissociation
Level 4 Defense Mechanisms
• Common among most "healthy" adults and are considered the most "mature". • User – help to integrate many conflicting emotions and thoughts and still be effective • Beholder - viewed as a virtue • Sublimation • Altruism • Suppression • Anticipation • Humor
Principles and Techniques of Mental Health-Psychiatric Nursing Interview
• • • •
B ehavioral and General Appearance E motion: Mood and Affect S peech T though content and Process
• • • •
P erceptual Disturbances I mpulse Control C ognition and Sensorium K nowledge, Insight and Judgment
Composition of Mental Status Examination
Mini Mental Status Exam
Diagnostic Exams
Positron Emission Tomography
• Mapping via computer imaging for the following purpose
– Measuring physiological processes in the brain e.g. blood flow – Determining metabolic functions based on glucose utilization – Establishing density of neurotransmiters – Locating neuroreceptors – Determining intricate
Single Photon Emission Computerized Tomography (SPECT)
• Measures same physiological processes as PET • Costs less • Widely available • Monitoring effects of meds on brain functions
Neurometrics
• Measures the electrophysiology of the brain especially increased or decreased beta, alpha, theta and delta waves
Cerebral Blood Flow
• Measures the circulation of blood in a given brain region • Blood flow to both gray matter and white matter can be determined
Computer Electroencephalographic Tomography (CET)
• Converts electrical signals into electrical activity map of the brain • Less accurate than PET • Costs less • Can be repeated without risks
Magnetic Resonance Imaging • Distinguishes gray and white matter in 3 dimensions • Identifies structural abnormalities
Magnetic Resonance Spectroscopy (MRS)
• Expands MRI readings by adding radioactive tracers • Identifies structural abnormalities in 3 dimensions as well as physiological abnormalities
Mental Health
A state of emotional, psychological and social wellness evidenced by: a. Satisfying interpersonal relationships b. Effective behavior and coping c. Positive self concept d. Emotional stability
Factors that Influence Mental Behavior
Individual Factors Biologic makeup Autonomy, and independence Self-esteem Coping or stress management abilities Resilience or hardiness Interpersonal Factors Effective communication Helping others Intimacy Balance of separateness and connectedness Socio-cultural Factors Sense of community Intolerance of violence Diversity among people Mastery of the environment Positive yet realistic view of the world
Mental Illness
disharmony Is a sense of _____________ with the aspects of living that may be _________________ to the individual, distressing family, friends, and community.
APA (2000)
• “A clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom”.
Deviant behavior does not necessarily indicate a mental disorder!
6 Major Conceptual Approaches to Define Mental Health
1. Attitude toward the Individual Self Self-Concept: how a person views himself (4 Aspects): a. body image - physical b. personal identity – psychological aspect c. self-esteem - emotional d. role performance – expression of self-concept
6 Major Conceptual Approaches to Define Mental Health
Self-Acceptance: realistic concept of strengths and weaknesses Self-Awareness: noticing how self feels, thinks, behaves and senses at any given time (differs from introspection – evaluation of self)
6 Major Conceptual Approaches to Define Mental Health
2. Growth, Development and SelfActualization 3. Integrative Capacity
– Refers to balance of psychic forces: Id, Ego, Super Ego – Use of these attributes for good personal function – The ability to tolerate anxiety and frustration
6 Major Conceptual Approaches to Define Mental Health
4. Autonomous Behavior
– make own ____________ decisions regardless of pressure
5. Perceptions of Reality – how one perceives ________ & envt, people 6. Mastery of One’s Environment
– ability to _________, _________, adapt adjust and _________ appropriately according behave to culturally approved standards
& how he ________ to them reacts
Legal and Ethical Issues
Admissions of pts: a. Voluntary – pt willing b. involuntary inpatient – against own will c. involuntary outpatient Civil rights – right to consent to or refuse txt 1973 Patient’s Bill of Rights 1980 Mental Health Systems Act 1993 Social Security Act
Legal and Ethical Issues
Legal Issues 1. confidentiality 2. informed consent 3. right to refuse txt – emergencies, given meds, be secluded or restrained 4. seclusion 5. restraints – chemical or mechanical to control activity 6. incompetence – patient must have legal representation
Historical Review
Primitive: mentally ill possessed by demons as punishment for sin. Treatments: • trephine skull operations • starving • beating • abandoning in forests to be devoured by animals • burning at stake
Ancient to Middle Ages
• Sanatoriums – temples of Saturn for care of mentally sick in Egyptian civilization • Bible records of mentally ill • Golden Age of Greece – temple used as hospitals – plenty of fresh air, water and sunshine; riding walking, waterfalls as diversion for melancholic; starving, chains and flogging also done so those who refuse
• Romans – bleeding, purging, sulfur baths • Gheel in Belgium – start of Gheel colony by St. Dymphna
Reformation Era
• To almshouses, jails, dungeons – favorite therapeutic procedures: purging and bleedings • Bethlehem Royal Hospital in London (Bedlam: by King Henry VII) • Pinel, Phillippe and William Tukes– freed chained insane patients, started humane treatment
– Period of Enlightenment and Creation of Mental Institutions – Formulated the concept of asylum
• Esquirol – first regular teacher of psychiatry, followed Pinel
Development in the US
• • 1773 – Eastern Lunatic Asylum in Williamsburg, Virginia 1783 – Dr. Benjamin Rush: Father of American Psychiatry, organized first lectures
– Human treatment of the mentally ill – Invented the tranquilizer chair – Gyrator
Development in the US
• ________________________: Dr. Edward S. Cowles organized first course 1882, McLean Asylum, Waverly, Mass Dorothea Lynde Dix: aroused legislative action to establish & enlarge hospitals in US; d/t inhumane practices and filthy cells, jails & poorhouses
•
Other Developments
________________________: (French) Jean Martin Charcot Psychotherapy Emil Kraeplin ____________________: (German) Classification of mental disorders Sigmund Freud: Psychoanalysis, Psychosexual theory and neurosis
th 20
Century Developments
__________________: Psychobiology Dr. Adolf Meyer
A Mind that Found Clifford Beers: “______________________”
Itself Dr. Harry Sullivan: Interpersonal theory
20th Century Developments
1930’s: use of _______, __________ insulin Metrazol,
ECT
1946 US National Mental Health Act of ____: research and training, improvement, expansion of community health services Deinstitutionalization: shift from the community institution to the ___________
Development of Psychopharmacology
• In the 1950’s the development of psychotropic drugs were used to treat mental illness. • Chlorpromazine (Thorzine), an antipsychotic drug, and lithium, an anti-manic agent, were the first drugs to be developed. • 10 years later, monoamine oxidase inhibitors, haloperidol (Haldol), an antipsychotic; tricyclic antidepressants; and antianxiety agents (benzodiazepines), were introduced. • Because of these new drugs, hospital stays were shortened, and many people were well enough to go home.
Mental Illness in the 21st Century
• 56 million Americans have a diagnosable mental illness. • Many providers believe today’s clients are to be more aggressive than those in the past • 85% of the homeless population has a psychiatric illness and/or a substance abuse problem • The United States has the largest percentage of mentally ill citizens (29.1%) and provided care for only 1 in 3 people who needed it (Bijl et al., 2003). • Persons with minor or mild cases are most likely to receive treatment while those with severe and persistent mental illness were least likely to be treated.
History of Psychiatric Nursing Education
Linda Richards 1873 – __________________: first American psychiatric nurse 1882 – _______________________: first school McLean Hospital 1935 – ½ of Nursing schools in US required psych course Catholic Univ. of America Sch of Nsg Edu. 1943 – ___________________________________:
- start of specialization in Psych Nsg; 1950 _____ – National League for Nsg required Psych Nsg to be accredited
Major Contributors to Psychiatric Nursing
__________________ – wrote 1st textbook Harriet Bailey “Nrsg Mental Diseases” __________________– therapeutic nurse patient relationship w/ phases __________________– “Nursing Therapy”
Major Contributors to Psychiatric Nursing
__________________ – wrote 1st textbook Harriet Bailey “Nursing Mental Diseases” Hildegard Peplau __________________– therapeutic nurse patient relationship w/ phases June Mellow __________________– “Nursing Therapy” – Focused on psychosocial needs and strengths
Psychoanalysis
A form of psychodynamic psychotherapy therapist and client in which the ___________________ conscious explore the client’s ____________ unconscious and _______________ conflicts coping and ___________ patterns
Transference and Countertransference
• Transference occurs when the client displaces onto the therapist/nurse attitudes and feelings that the client previously felt in other relationships. • Counter-transference occurs when the therapist/nurse displaces onto the client attitudes or feelings from his or her past.
Founders of Psychoanalysis
Father of SIGMUND FREUD: ___________________ Psychoanalysis
Further explained the ANNA FREUD: ______________________ _______________________________ defense mechanisms
classified VAILLANT: ___________ the defense mechanisms in a hierarchy from _____________ to healthy psychotic
Primary Drives
• Eros
– Drive towards life – Instincts concerned with self preservation or survival of the fittest
• Thanatos
– Drive towards death – Aggression or hate which can be directed inward or outward
Theories of Personality Development
By Sigmund Freud
Personality
Personality – characteristic traits that are generally predictable in their influence on ____________, ____________, cognitive affective and behavioral patterns expressed through ______________ behavior Factors Influencing Personality:
1. hereditary 2. environment 3. training
A. Levels of Consciousness
1. Conscious
1. Functions when awake 2. Here and now 3. Easy recall of past experiences
A. Levels of Consciousness
2. Subconscious
1. Ideas and reactions are stored and partially forgotten 2. Prevents unacceptable disturbing memories from reaching conscious mind 3. “Tip of the tongue” experiences
A. Levels of Consciousness
3. Unconscious - greatest influence on personality - storehouse of memories, feelings throughout life - memories are not recalled - dreams, “slip of the tongue”, unexplained behavior
A. Levels of Consciousness
1. Conscious 2. Subconscious 3. Unconscious
B. Components of Personality or Drives
ID
• Primarily a sexual and aggressive drive • The first structure to develop in the personality
– Developed during infancy
• Pleasure principle to reduce tension
– Example a baby reflexively sucks to receive nourishment thus reducing her hunger. Also characterize by
• Primary process thinking which is imagery.
– Irrational and not based on reality. – Example, hallucinations of psychotic clients.
EGO
• CEO of the mind. • Toddler period • Mediates between the Id and Super Ego thus maintaining a reality orientation for the person.. • Reality principle. • Secondary process thinking which is
– logically oriented in time and distinguishes between reality and fantasy.
• Partially under conscious control. • What happens when ego cant mediate against the unconscious drives?
SUPER EGO
• Our conscience • 2 main functions- reward and punishment.
– Rewards good behavior and punishes bad behavior by creating guilt.. A residue of internalized values and moral training or early childhood..
• Pre-school age • Overly strict super ego may lead to extremes of guilt and anxiety
“Pleasure Principle”
“Reality Principle”
EGO
ID/
SUPEREGO
Resolving Conflicts
Stimulus Drive Response Resolution
Resolving Conflicts
Stimulus Drive Response Resolution
Hunger desire for ice cream
“I must have it now!”
Eats ice cream and feels satisfied momentarily. May become stimulus for guilt.
Resolving Conflicts
Stimulus Drive Response Resolution
Hunger, desire for ice cream
“I must NOT eat it.”
Does not eat. May become stimulus for sad or angry feelings.
Resolving Conflicts
Stimulus Drive Response Resolution
Hunger, desire for ice cream “I would like to have it
now, but I have just eaten a big meal. I will wait until later in the day and have a small portion.
Drive is reduced.
Pavlov
Classic conditioning (Behavior theory)
Application to Nursing
• Classic conditioning to initiate a behavior • Operant conditioning to ensure the behavior is repeated
Psychosexual Theory
By Sigmund Freud
Stages of Development
Oral Anal Phallic Latency Prepuberty & Adolescence Genital Birth – 18 mos. 18 mos – 3 years 3 – 5 years 6 – 12 years 12 – 15 years
15 years - adult
Fixation
Arrest of maturation at an earlier level of psychosocial development. It is behavior that should have been outgrown.
Oral Stage (0-18 mos.)
Critical Experiences Devt. Task Major Char: Weaning Establish Trust Autoeroticism, narcissism, omnipotence, pleasure principle, frustration, dependence
Other Possible Personality Traits
Fixation : passivity, gullibility, & dependence, the use of sarcasm, & the devt of orally focused habits (smoking and drinking)
Anal Stage (18 mos-3 yrs)
Critical Experiences Devt. Task Toilet training Developing sphincter control, Feeling of autonomy
Major Char:
Reality principle, fear of loss of object loved, approval & disapproval, Beginning superego development
Fixation: rel. to anal retentiveness (stinginess, rigid thought patterns, OCD) Or anal expulsiveness char (messiness, destructivenss, cruelty)
Other Possible Personality Traits
Toilet Training
Cues if Ready for Toilet Training:
1. 2. 3. 4. can stand alone can walk steadily can keep dry in interval of at least two hours can demonstrate awareness of defecating and voiding 5. are able to use words and gestures regarding TT and toilet needs 6. are desirous of pleasing the primary care giver
Toilet Training
Age in which Toilet Training is Achieved:
18 mos: 2 ½ yrs: 3 years: Bowel control Daytime bladder control Nighttime bladder control
Phallic Stage (3-5 yrs)
Critical Experiences Devt. Task Oedipal-Electra conflict (complex) Castration anxiety Establishing sexual identity Beginning socialization
Major Char:
Differentiation between the sexes, Superego more internalized
Unresolved outcomes may result in difficulties with sexual identity and with authority figures
Other Possible Personality Traits
Latency Stage (6-12 yrs)
Critical Experiences Devt. Task Peer growth experience Intellectual growth Group identification Identify with teacher and peers
Major Char:
Super ego influence in erotic interests, immense intellectual development
Fixations can result in difficulty in identifying with others and in developing social skills, resulting in a sense of inadequacy and inferiority
Other Possible Personality Traits
Adolescent Stage (12-15 yrs)
Critical Experiences Devt. Task Established heterosexual relationships Developing social control over instinct
Major Char:
Identity, turmoil, consideration of needs of others
Very modest, fear of exposing body parts for physical examination
Other Possible Personality Traits
Application to Nursing
• Anxiety has an important role in maladaptive behavior. • Nurses must understand the role of unconscious conflict in the motivation of behavior. • Nurses must be aware of the clients defense mechanisms.
Genital Stage (15 yrs-adult)
Critical Experiences Devt. Task Sexual maturity Resolving Dependence - Independence conflict
Major Char:
Other Possible Personality Traits
Heterosexual relationships
Inability to negotiate this stage could result in difficulties in becoming emotionally and financially independent, lack of strong personal identity and future goals, and inability to form satisfying intimate relationships
Psychosocial Theories
Erik Erikson
• Focused on personality development across the life span while focusing on social and psychological development in life stages. • Erikson believed that psychosocial growth occurs in sequential stages, and each stage is dependent on the completion of the previous stage/life task.
Application to Nursing
• Facilitate adaptive resolution of various developmental crises or tasks by using the nursing process to assess the client’s level of functioning and subsequent planning. • Provides basis for client centered nursing interventions.
• • • • • • • •
Trust vs. Mistrust (infant) Autonomy vs. Shame and Doubt (toddler) Initiative vs. Guilt (preschool) Industry vs. Inferiority (school age) Identity vs. Role confusion (adolescence) Intimacy vs. Isolation (young adult) Generativity vs. Stagnation (middle adult) Ego integrity vs. Despair (maturity)
Erikson’s Psychosocial Theory
Life Stage I. Trust vs. Mistrust (0 to 18 months) Adult Behaviors Reflecting Mastery Realistic trust of self & others Confidence in others Optimism and hope Shares openly with others Relates to others effectively Adult Behaviors Reflecting Developmental Problems Suspiciousness / testing of others Fear of criticism & affection Dissatisfaction & hostility Projection of blame & feelings Withdrawal from others OR Overly trusting of others Naïve and gullible Shares too quickly & easily
Erikson’s Psychosocial Theory
Life Stage II. Autonomy vs. Shame & Doubt (18 months to 3 yrs) Adult Behaviors Reflecting Mastery Self-control and willpower Realistic self-concept & self-esteem Pride and a sense of goodwill Simple cooperativeness Generosity tempered by withholding Delayed gratification when necessary Adult Behaviors Reflecting Developmental Problems Self-doubt / self-consciousness Dependence on others for approval Feeling of being exposed / attacked Sense of being out of control of the self and one’s life Obsessive-compulsive behaviors OR Excessive independence to defiance, Grandiosity Denial of problems Unwillingness to ask for help Impulsiveness – inability to wait Reckless disregard for safety for self & others
Erikson’s Psychosocial Theory
Life Stage III. Initiative vs. Guilt (3 to 5 years) Adult Behaviors Reflecting Mastery An adequate conscience Initiative balance w/ restraint Appropriate social behaviors Curiosity and exploration Healthy competitiveness Sense of direction Original and purposeful activities Adult Behaviors Reflecting Developmental Problems Excessive guilt / embarrassment Passivity and apathy Avoidance of activities / pleasures Rumination and self-pity Assuming a role as victim / selfpunishment Reluctance to show emotions Underachievement of potentials OR Lack of follow-through on plans Little sense of guilt for actions Excessive expression of emotion Labile emotions Excessive competitiveness / showing off
Erikson’s Psychosocial Theory
Life Stage
Adult Behaviors Reflecting Mastery Adult Behaviors Reflecting Developmental Problems
IV. Industry vs. Sense of competence Inferiority Completion of projects (6 to 12 years) Pleasure in efforts and effectiveness Ability to cooperate and compromise Identification with admired others Joy of involvement in the world and with others Balance of work and play
Feeling unworthy and inadequate Poor work history (quitting, being fired, lack of promotions, absentism, lack of productivity) Inadequate problem solving skills Manipulating others / violating others’ rights Lack of friends of the same sex OR Overly high achieving / perfectionist Reluctance to try new things for fear of failing Feeling unable to gain love or affection unless totally successful Being a workaholic
Erikson’s Psychosocial Theory
Life Stage
Adult Behaviors Reflecting Mastery Adult Behaviors Reflecting Developmental Problems Lack of giving up of goals, beliefs, values, productive roles Feelings of confusion, indecision, & alienation Vacillation between dependence & independence Superficial, short-term relationships with the opposite sex OR Dramatic overconfidence Acting-out behaviors (including alcohol & drug use) Flamboyant display of sex role behaviors V. Identity vs. Confident sense of self Role Diffusion Emotional stability (12 to 18 or 20years) Commitment to career planning & realistic longterm goals Sense of having a place in society Establishing relationship w/ opposite sex Fidelity to friends Development of personal values Testing out adult roles
Erikson’s Psychosocial Theory
Life Stage VI. Intimacy vs. Isolation (18 to 25 or 30 years) Adult Behaviors Reflecting Mastery Ability to give and receive love Commitment and mutuality with others Collaboration in work and affiliation Sacrificing for others Responsible sexual behaviors Adult Behaviors Reflecting Developmental Problems Persistent aloneness / isolation Emotional distance in all relationships Prejudices against others Lack of established vocation; many career changes Seeking of intimacy thru’ casual sexual encounters OR Possessiveness and jealousy Dependency on parents and/or partner Abusiveness towards loved one Inability to try new things socially or vocationally (staying in routine / mundane job and activities)
Erikson’s Psychosocial Theory
Life Stage VII. Generative lifestyle vs. Stagnation or Self-absorption (30 to 65 years) Adult Behaviors Reflecting Mastery Productive, constructive, creative activity Personal and professional growth Parental and societal responsibilities Adult Behaviors Reflecting Developmental Problems Self-centeredness/selfindulgence Exaggerated concern for appearance and possessions Lack of interest in marriage and / or extramarital affairs OR Too many professional or community activities to the detriment of the family or self
Erikson’s Psychosocial Theory
Life Stage VIII. Integrity vs. Despair (65 years to death) Adult Behaviors Reflecting Mastery Feelings of selfacceptance Sense of dignity, worth and importance Adaptation to life according to limitations Valuing one’s life Sharing of wisdom Exploration of philosophy of life and death Adult Behaviors Reflecting Developmental Problems Sense of helplessness, uselessness, worthlessness, &/or meaninglessness Withdrawal and loneliness Regression Focusing on past mistakes, failures & dissatisfactions Feeling too old to start over Suicidal ideas or apathy Inability to occupy self with satisfying activities (hobbies, volunteer work, social events) OR Inability to reduce activities Overtaxing strength and abilities Feeling indispensable Denial of death as inevitable
Cognitive Theories
Jean Piaget
• Sensorimotor (birth to 2 years): – The child develops a sense of self as separate from the environment and the concept of object permanence. – Begins to form mental images. • Preoperational (2-6 years): – Child begins to express himself with language, understands the meaning of symbolic gestures, and begins to classify objects.
• Concrete operations (6-12 years): – Child begins to apply logical thinking, understands reversibility, is increasingly social and able to apply rules – Thinking is still concrete. • Formal operations (12 to 15 years and beyond): – Child learns to think and reason in abstract terms, further develops logical thinking and reasoning, and achieves cognitive maturity.
Application to Nursing
• Helps nurses recognize impaired development and prove a relationship that facilitates the person’s accomplishment of developmental tasks. • Enables early childhood interventions
Harry Stacks Sullivan:
Interpersonal Relationships and Milieu therapy
• The importance and significance of interpersonal relationships in one’s life • Personality is manifested only in a person’s interaction with another person or with a group • Developed the first therapeutic community or milieu with young men with schizophrenia in 1929.
Stages
• Infancy
– Development of self concept – Learn to trust others
• Childhood
– Accept influence of others
• Juvenile
– Peer relations
• Preadolescence
– Form friendships with same sex peers
• Early adolescence
– More independent – Establish relationship with opposite sex
• Late adolescence
– Develop enduring relationship with opposite sex
• Milieu therapy is used in the acute care setting; one of the nurses’ primary roles is to provide safety and protection while promoting social interaction
Application to Nursing
• Used to strengthen support systems • Foster interpersonal relationships • Strengthens clients belief systems • Facilitates faith, hope and life
Hildegard Peplau’s Theory
Hildegard Peplau’s Theory
Nursing is the significant therapeutic interpersonal process that makes health possible for individuals and groups. Influenced by: 1. Culture 4. Education 2. Religion 5. Past experiences 3. Ethnicity 6. Preconceived ideas
Defined anxiety as the initial response to a psychic threat!
Four levels of anxiety
• Acute anxiety
– Positive state of heightened awareness and sharpened senses – Learn new behaviors and solve problems. – Person can take in all available stimuli (perceptual field).
• Moderate anxiety
– Decreased perceptual field (focus on immediate task only) – Learn behavior only with assistance – Ideal anxiety state for teaching a client regarding health concerns such as diabetes
• Severe anxiety involves
– Feelings of dread or terror – CANNOT be redirected to a task; he focuses only on scattered details and has – Physiologic symptoms – Priority is to move the person away from all stimuli, and then attempt to talk with them to calm down.
• Panic anxiety can involve
– Loss of rational thought, delusions, hallucinations, and complete physical immobility and muteness.
Humanistic Theories
Maslow’s Hierarchy of needs
• • • • •
Physiologic needs, need to be met first. Safety and security needs Love and belonging needs Esteem needs Self-actualization,
– The need for beauty, truth, and justice. Few people actually become self-actualized.
• Remember, traumatic life experiences or compromised health can cause a person to regress to a lower level of motivation!
Application to Nursing
• Useful in organizing curricula and in assessing and giving care • Emphasis on physiologic needs as the priority when life and physical integrity are in jeopardy
Neurobiological Theories
• All behaviors are a reflection of brain function • All thought processes represent a range of functions mediated by nerve cells in the brain • Cognitive and emotional dysregulation result from multiple causes (trauma, genetics, nutrition etc) that cause neurotransmitter disturbances in the brain.
Application to Nursing
• Provide the basis of target sites for pharmacological and psychotherapeutic interventions that mitigate symptoms of various psychiatric disorders
PSYCHIATRIC NURSING
Interpersonal process whereby the professional nurse practitioner through the use of self, assist an individual, family, group or community to promote mental health, to prevent mental illness and suffering, to participate in the treatment and rehabilitation of the mentally ill and if necessary to find meaning in these experiences. It is both Science and an Art.
Science in Psychiatric Nursing. – The use of different theories in the practice of nursing, serves as the science of psychiatric nursing. Art in Psychiatric Nursing. – The therapeutic use of self is considered as the art of psychiatric nursing.
• Core of Psychiatric Nursing.
– The interpersonal process, that is, the human to human relationship, is the core of psychiatric nursing.
• Clientele in Psychiatric Nursing.
– The individual, family, and the community, both mentally healthy and mentally ill.
• Mental Hygiene.
– It is the science that deals with measures to promote mental health, prevent mental illness and suffering and facilitate rehabilitation.
ESSENTIAL QUALITIES OF A PSYCHIATRIC NURSE
• Therapeutic Use of Self
– The heart of psychiatric nursing – Forming a trusting relationship that provides comfort, safety and acceptance of the client
• Genuineness
– Sense of openness, realness and lack of defensiveness. It conveys congruence between verbal and non verbal behaviors
• Warmth
– Imparts consistency , kindness, patience, and caring for the client
• Empathy
– Experiencing clients feelings as though they were his own but the nurse does not totally lose her identity – Sympathy is feeling or sharing the identical concerns of another. It interferes with formation of therapeutic relationship
• Acceptance
– Tolerance and appreciation of the client as a human being regardless of race, gender, culture, religion
• Maturity and Self Awareness
– Ability to tolerate differences and be responsive to client needs
• Leadership
– Problem solving and decision making
ROLES OF THE NURSE IN PSYCHIATRIC SETTINGS
• Ward manager – creates a therapeutic environment • Socializing agent – assists the patient to feel comfortable with others • Counselor – listens to the patient’s verbalizations • Parent surrogate – assists the patient in the performance of activities of daily living
• Patient advocate – enables the patient and his relatives to know their rights and responsibilities • Teacher – assists the patient to learn more adaptive ways of coping • Technician – facilitates the performance of nursing procedures
• Therapist – explores the patient’s needs, problems and concerns through varied therapeutic means • Reality base – enables the patient to distinguish objective reality and subjective reality • Healthy role model – acts as a symbol of health by serving as an example of healthful livings
Mental health Team
• • • • • • Psychiatrist Clinical Psychologist Psychiatric Social Worker Occupational Therapist Mental Health Worker Internist
PRINCIPLES OF CARE IN PSYCHIATRIC SETTINGS
• The nurse views the patient as a Holistic human being with interdependent and interrelated needs • The nurse accepts the patient as a unique human being with inherent value and worth exactly as he is. • The nurse should focus on the patient’s behavior non-judgmentally, while assisting the patient to learn more adaptive ways of coping
• The nurse should explore the patient’s behavior for the need it is designed to meet and the message it is communicating • The nurse has the potential for establishing a nurse-patient relationship with most if not all patients • The quality of the nurse-patient relationship determines the degree of change that can occur in the patient’s behavior.
LEVELS OF INTERVENTIONS IN PSYCHIATRIC NURSING
Primary
• Interventions aimed at the promotion of mental health and lowering the rate of cases by altering the stressors – Examples: Health education • Information dissemination – Counseling
Secondary
• Intervention that limit the severity of a disorder • Two components
– Case finding – Prompt treatment – Examples: Crisis intervention, Administration of medications
Tertiary
• Interventions aimed at reducing the disability after a disorder • Two components
– Prevention of complication – Active program of rehabilitation – Examples: Alcoholic anonymous, Occupational therapy
Altered Genes Brain exposed to internal and external demands Brain attempts to cope Successful Unsuccessful
Mental Health
Mental Illness
Defense Mechanisms
They are psychological strategies used individuals (and by extension--groups of individuals and even entire nations at times) to cope with reality and to maintain his/her self -image intact.
A defense mechanism becomes pathological when it is used persistently and leads to maladaptive behavior that will eventually threaten the physical and/or mental health of the individual. There are psychological defenses that are: a. Almost always pathological b. Immature c. Neurotic d. Mature defense mechanisms
Level 1 Defense Mechanisms
• Always pathological or "psychotic" defenses • User - rearrange external reality (and therefore not have to cope with reality) • Beholder - appear crazy or insane. • Denial - a refusal to accept external reality because it is too threatening. There are examples of denial being adaptive (for example, it might be adaptive for a person who is dying to have some denial • Distortion - a gross reshaping of external reality to meet internal needs • Delusional Projection - frank delusions about external reality, usually of a persecutory nature
Level 2 Defense Mechanisms
• Frequently in adults and are common in adolescents. • User - alter distress and anxiety caused by reality or other people • Beholder - socially undesirable, immature, difficult and out of touch. They are considered “Immature" defenses and almost always lead to serious problems in a person's ability to cope with the world. These defenses are seen in severe depression, personality disorders, and
• Fantasy • Projection • Hypochondriasis • Passive Agressive Behavior • Acting Out Behavior
Level 3 Defense Mechanisms
• “Neurotic" but are fairly common in adults. • • • • • Intellectualization Repression Reaction Formation Displacement Dissociation
Level 4 Defense Mechanisms
• Common among most "healthy" adults and are considered the most "mature". • User – help to integrate many conflicting emotions and thoughts and still be effective • Beholder - viewed as a virtue • Sublimation • Altruism • Suppression • Anticipation • Humor
Principles and Techniques of Mental Health-Psychiatric Nursing Interview
• • • •
B ehavioral and General Appearance E motion: Mood and Affect S peech T though content and Process
• • • •
P erceptual Disturbances I mpulse Control C ognition and Sensorium K nowledge, Insight and Judgment
Composition of Mental Status Examination
Mini Mental Status Exam
Diagnostic Exams
Positron Emission Tomography
• Mapping via computer imaging for the following purpose
– Measuring physiological processes in the brain e.g. blood flow – Determining metabolic functions based on glucose utilization – Establishing density of neurotransmiters – Locating neuroreceptors – Determining intricate
Single Photon Emission Computerized Tomography (SPECT)
• Measures same physiological processes as PET • Costs less • Widely available • Monitoring effects of meds on brain functions
Neurometrics
• Measures the electrophysiology of the brain especially increased or decreased beta, alpha, theta and delta waves
Cerebral Blood Flow
• Measures the circulation of blood in a given brain region • Blood flow to both gray matter and white matter can be determined
Computer Electroencephalographic Tomography (CET)
• Converts electrical signals into electrical activity map of the brain • Less accurate than PET • Costs less • Can be repeated without risks
Magnetic Resonance Imaging • Distinguishes gray and white matter in 3 dimensions • Identifies structural abnormalities
Magnetic Resonance Spectroscopy (MRS)
• Expands MRI readings by adding radioactive tracers • Identifies structural abnormalities in 3 dimensions as well as physiological abnormalities
