OVERVIEW ON PSYCHIATRIC NURSING
NCM 117 Psychiatric Nursing LEC
MENTAL HEALTH
• Is a successful performance of mental activities
leading to:
✓ Productive activities
✓ Fulfilling relationships
✓ Ability to adopt to change
✓ Cope with diversity
❖ A mentally healthy person is capable of . . .
➢ Rational thinking
➢ Communication skills
➢ Learning
➢ Emotional growth
➢ Resilience
➢ Self-esteem
❖ Factors Influencing Mental Health
➢ Inherited characteristics
➢ Nurturing during childhood
➢ Positive and negative life circumstances
➢ Ego defense mechanisms
➢ Significant others or support role
➢ Interpersonal communication
MENTAL ILLNESS
• A health condition marked by alterations in
thinking, mood, and behavior that cause distress,
impair ability to function or both.
* Mood VS Behavior
* Mood VS Feelings
❖ Myth
➢ Myth #1: People are at fault and
responsible for their mental illness and can
just snap out of it.
➢ Myth #2: Mental illness can’t or won’t
happen to me.
➢ Myth #3: Mental illnesses are brought on
by a weakness of character.
➢ Myth #4: People with mental illnesses
cannot tolerate the stress of holding down
a job.
➢ Myth #5: Therapy and self-help are a waste
of time. Why bother when you can just take
a pill?
➢ Myth #6: Mentally ill people are violent.
Psychiatric Nursing VS Mental Health Nursing
PSYCHIATRIC NURSING
• Focuses on the care and rehabilitation of people
with identifiable mental illnesses or disorders.
MENTAL HEALTH NURSING
• Focuses on well and at-risk populations to prevent
mental illness or provide immediate treatment for
those with early signs of disorder.
A Psychiatric Mental Health Nurse . . .
• Is someone who can attempt to satisfy the needs of
other by selflessly using her personality to give
some meaning to the client’s life.
o Through . . .
▪ Listening with understanding
▪ Responding with care and respect
▪ Supporting with trust and
confidence
▪ Reassuring with explanation and
honesty
▪ Physically nursing the helpless
with compassion and skill
▪ Carrying out procedures essential
to maintain or improve the client’s
quality of life
Essential Qualities of a Mental Health Nurse
✓ Ability to adapt
✓ Sensitive to the client’s needs
✓ Shows interest and motivation to understand
✓ Self-aware
✓ Uses empathy
✓ Genuine and trustworthy
✓ Warmth and unconditional positive regard
✓ Good listening and communication skills
Guiding Principles of Psychiatric Mental Health
Nursing
➢ Every person is worth of dignity and respect.
➢ Every person has the potential to change and grow.
➢ Al people share basic human needs.
➢ All behavior is meaningful and can be understood
from the person’s perspective.
➢ People have the right to participate in decisions
affecting their health and treatment.
➢ Through the therapeutic use of self via therapeutic
relationships and communication, nurses help
people adapt, change and grow.
LEVELS OF PRACTICE
❖ Basic Level
o Health promotion and disease prevention
o Serve as case managers
o Design therapeutic environment
o Use psychobiologic intervention
o Client education
❖ Advanced Practice Level
o Health teaching and screening
o Perform preventive interventions
o Formulate diagnoses
o Order and manage psychopharmacologic
medications
o Conduct individual, group, family
therapies
o Facilitate psychiatric rehabilitation
Mental Health Nurse’s Role
❖ Socializing agent
❖ Teacher
❖ Model
❖ Advocate
❖ Counselor
❖ Role player
❖ Milieu manager
Chrisyll Anne Dominguez BSN 3A
CONTINUUM OF CARE
• Provides consumers with wide-ranges of treatment
modalities
• From intense treatment (hospitalization) to
supportive intervention (outpatient therapy)
• GOAL of Continuum of Care
o To provide treatment that allows the
patient to achieve the highest level of
functioning in the least restrictive
environment.
COORDINATION OF CARE
• To provide individualized care
• To address client’s strengths and weaknesses,
cultural context, preferences, and recovery goals
including referral to community resources and
liaisons with others
• Achieved thru CASE MANAGEMENT
❖ Case Management in Mental Health
Service
▪ Fundamental Elements:
✓ Comprehensive needs
assessment
✓ Development of a plan of
care
✓ Method of ensuring the
individual has access to
care
✓ Method of monitoring the
care provided
Mental Health Services in the CONTINUUM OF CARE
❖ Crisis Intervention
• Focuses on
✓ Stabilization
✓ Symptom reduction
✓ Prevention of relapse requiring
inpatient services
• Patient in crisis:
✓ Has severe symptoms of acute mental
illness
✓ Requires medication for symptom
management
✓ Organized mechanism of rapid access
to care (within 24 hours), referral for
hospitalization or access to outpatient
services
• Key Nursing Intervention
✓ Assessment for interventions and
medications
✓ Facilitate proper referral
❖ 23-Hour Observation
• A short-term treatment that serves the patient
in immediate but short-term crisis
• Inpatient admission for 23 hours, services are
provided at a less-than-acute care level
• Clinical problem: Transient disruption of
baseline function which will resolve quickly
• Threat to self- others
• Indications:
✓ Acute trauma/rape
✓ Alcohol and narcotic detoxification
✓ Those with Axis II Personality
Disorders with self-injurious
behaviors
❖ Crisis Stabilization
• When immediate crisis doesn’t resolve quickly
• Lasts fewer than 7 days
• Has major focus on symptom management
(indication for hospital admission)
Acute inpatient care
o Involves most intensive treatment
o Most restrictive setting in the continuum
o For the acutely ill have one or more of the
following:
✓ High risk for harming oneself
✓ High risk for harming others
✓ Unable to care for their basic
needs
o From 24 hours to several days
Partial hospitalization
o Also known as DAY HOSPITAL
o Indications:
✓ Has a decline in social or
occupational functioning
✓ Unable to function independently
in a daily basis
✓ Those who do not pose imminent
danger to themselves or others
o Qualities:
✓ Time-limited
✓ Ambulatory
✓ Active treatment program
✓ Offers therapeutically intensive,
coordinated, and structured
clinical services in a stable milieu
✓ Offers full day or half-day
programs
✓ Doesn’t include overnight hospital
stay
Chrisyll Anne Dominguez BSN 3A
 Residential services
• To provide a place for people to reside
during a 24-hour period or any portion of
the day on an ongoing basis.
• INTENSIVE RESIDENTIAL SERVICES:
o Provide short term treatment for
stays from 24 hours to 3-6 months
to long term treatment for several
months to years

Respite residential care

• Can provide short-term necessary housing
for the patient and periodic relief for
caregivers.

In-home mental health care

• Emphasizes personal autonomy and the
need to collaborative relationship between
client and the nurse
• Provide direct patient care and case
management skills
• To decrease hospital stays and increase
functionality of the patient within the
home
• Indications:
✓ Chronic, persistent mental illness
✓ Patients with mental illness and
co-morbid medical conditions that
require on-going monitoring

❖ Outpatient Care
• Level of care that occurs outside a hospital
or institution
• Less intensive
• Upon discharge from inpatient setting
▪ Ongoing medication management
▪ Skills training
▪ Supportive group therapy
▪ Substance abuse counseling
▪ Social support services
▪ Case management

❖ Intensive outpatient programs

• PRIMARY FOCUS: Stabilization and
relapse prevention
• Indicated for highly vulnerable individuals
who can function independently on a daily
basis
• Treatment duration: 3-4 hours per day, 2-
3 days per week
• Teach stress management, illness
medication, and relapse prevention

Chrisyll Anne Dominguez BSN 3A

THERAPEUTIC MODEL AND RELEVANCE TO o Id
o Ego
NURSING PRACTICE
o Superego

A. Psychoanalytic Theories and Therapies
B. Interpersonal Theories and Therapies
C. Behavioral Theories and Therapies
D. Cognitive Theories and Therapies
E. Humanistic Theories and Therapies
F. Biological Theories and Therapies
G. Additional theories

Psychoanalytic Theories and Therapies

Sigmund Freud
• Believed that an individual’s drivers,
instincts, and defenses are formed early
in life and are crucial to an
understanding of the personality.
• Argues that human behavior is the
result of the interactions among three
component parts of the mind: id, ego,
superego.
• Places great emphasis on the role of Conflicts among these three structures, and out
unconscious psychological conflicts in efforts to find balance among what each of
shaping behavior and personality. them “desires”, determines how we behave and
approach the world.
Levels of Consciousness
ID
- The most primitive of the three
structure, is concerned with instant
gratification of basic physical needs and
urges. It operates entirely unconsciously
(outside of conscious thoughts).

SUPEREGO
- Concerned with social rules and morals
– like what many people call their
“conscience” or their “moral compass.”
It develops as a child learns what their
culture considers right and wrong.

EGO
- Is the rational, pragmatic part of our
personality. It is less primitive than the
id and is partly conscious and partly
• Consciousness – material within an unconscious. It is what Freud
individual’s awareness is only small part considered to be the “self”, and its job
of the mind is to balance the demands of the id and
• Preconscious – refers to memories that superego in the practical context of
can be recalled to consciousness with reality.
some effort
• Unconsciousness – larger area consists Example:
of memories, conflicts, experiences and You walked past a stranger eating ice cream, ID
material that have been repressed and would most likely take the ice cream for itself.
cannot be recalled at will ID doesn’t know, or care, that it is rude to take
something belonging to someone else; it would
According to freud, our personality develops care only that you wanted the ice cream.
from the interactions among what he proposed
as the three fundamental structures of the If your SUPEREGO walked past the same
human mind: stranger, it would not take their ice cream
because it would know that that would be rude.

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 However, if both your ID and your SUPEREGO • Compensation – consciously covering
were involved, and your ID was strong enough up for a weakness by overemphasizing
to override your SUPEREGO’s concern, you or making up a desirable trait
would still take the ice cream, but afterwards • Reaction formation – a conscious
you would most likely feel guilt and shame over behavior that is the exact opposite of an
your actions unconscious feeling
• Undoing – consciously doing something
If you walked past the stranger with ice cream to counteract or make up for a
one more time, your EGO would mediate the transgression or wrongdoing
conflict between your ID (“I want that ice cream • Displacement – unconsciously
right now”) and SUPEREGO (“It’s wrong to take discharging pent-up feelings to a less
someone else’s ice cream”) and decide to go threatening object
buy your own ice cream. • Projection – unconsciously or
consciously blaming someone else for
While this may mean you have to wait 10 more one’e difficulties or placing one’s
minutes, which would frustrate your ID, your unethical desires in someone else
EGO decides to make that sacrifice as part of • Conversion – unconscious expression of
the compromise – satisfying your desire for ice intrapsychic conflict symbolically
cream while also avoiding an unpleasant social through physical symptoms
situation and potential feelings of shame. • Regression – unconscious return to an
earlier and more comfortable
DEFENSE MECHANISM developmental level
- When anxiety is too painful, the
individual copes by using defense Erik Erikson
mechanisms to protect the ego and • Psychosocial Theory
diminishes anxiety. • Erikson’s was built from Freud’s
- When these mechanisms are used psychoanalytical model however it
excessively, individuals are unable to included the impact of environmental
face reality and do not solve their factors, parents, and society on
problems.
personality development from
- These are primarily unconscious childhood to adulthood.
behaviors, however some are within
• He believed every person must pass
voluntary control.
through a series of 8 interrelated stages

over the life cycle from birth to death.
• Denial – unconscious refusal to admit
an unacceptable idea or behavior Stages of Psychosocial Development
• Repression – unconscious and
involuntary forgetting of painful ideas, a. Trust vs. Mistrust
events, and conflicts o Infant
• Suppression – conscious exclusion from o 0 – 18 months old
awareness – anxiety producing feelings, b. Autonomy vs. Shame & Doubt
ideas, and situations o Toddler
• Rationalization – conscious and o 18 months – 3 years old
unconscious attempts to make or prove c. Initiative vs. Guilt
that one’s feelings or behaviors are o Pre-schooler
justifiable o 3 - 5 years old
• Intellectualization – consciously or d. Industry vs. Inferiority
unconsciously using only logical o Grade-schooler
explanations without feelings or an o 6 - 12 years old
affective component e. Identity vs. Role Confusion
• Dissociation – unconscious separation o Teenager
of painful feelings and emotions from o 12 – 20 years old
an unacceptable idea, situation or f. Intimacy vs. Isolation
object o Young adult
• Introjection – unconsciously o 18 – 30 years old
incorporating values and attitudes of g. Generativity vs. Stagnation
others as if they were your own o Middle-age adult
• Sublimation – consciously or o 39 – 65 years old
unconsciously channeling instinctual h. Integrity vs. Despair
drives into acceptable activities o Older adult
• Identifications – conscious or o 65 – death
unconscious attempt to model oneself
after a respected person

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 Interpersonal Theories and Therapies • Starts when the client meets
nurse as a stranger
Harry Stack Sullivan • Defining problem and deciding
• Believed that the interactional was the type of service needed
more important than the intrapsychic. • Client seeks assistance, conveys
• Viewed mental illness as any degree of needs, asks questions, shares
lack of mental awareness or skill in preconceptions and
interpersonal relations. expectations of past
• Viewed relationships as source of experiences
anxiety, maladaptive behaviors and
negative personality formation. 2. Identification Phase. The identification
• Developed the Interpersonal phase begins when the client works
Psychotherapy (IPPT) used for interdependently with the nurse,
treatment of depression and other express feelings, and begins to feel
mood disorder. stronger.
• Selection of appropriate
Interpersonal Psychotherapy (IPT) professional assistance
- GOAL: To improve social functioning by • Patient begins to have a feeling
examining interpersonal disputes, role of belonging and a capability of
transitions, grief and interpersonal dealing with the problem which
deficits. decreases the feeling of
- FOCUS: Is on the patient’s interpersonal helplessness and hopelessness
issues and distortions created by past
experiences. 3. Exploitation Phase. In the exploitation
- NURSE’S ROLE: Helps correct these phase, the client makes full use of the
distortions with clear communication, services offered.
consensual validation, and a warm and • Use of professional assistance
collaborative relationship for problem-solving alternatives
• Advantages of services are used
Hildegard Peplau is based on the needs and
• Defined nursing as “an interpersonal interests of the patients
process of therapeutic interactions • The individual feels like an
between an individual who is sick or in integral part of the helping
need of health services and a nurse environment
especially educated to recognize, • They may make minor requests
respond to the need for help.” or attention-getting techniques
• She saw a major goal in nursing as • Nurse aids the patient in
helping patients reduce their anxiety exploiting all avenues of help
and convert it to constructive action. and progress is made towards
the final step
The assumptions of Hildegard Peplau’s
Interpersonal Relations Theory are: 4. Resolution Phase. In the resolution
1. Nurse and the patient can interact. phase, the client no longer needs
2. Peplau emphasized that both the professional services and gives up
patient and nurse mature as the result dependent behavior. The relationship
of the therapeutic interaction. ends.
3. Communication and interviewing skills • Termination of professional
remain fundamental nursing tools. relationship
4. Peplau believed that nurses must • The patients needs have
clearly understand themselves to already been met by the
promote their client’s growth and to collaborative effect of patient
avoid limiting the client’s choices to and nurse
those that nurse’s value. • Now they needs to terminate
their therapeutic relationship
FOUR PHASES OF THE THERAPEUTIC NURSE- and dissolve the links between
PATIENT RELATIONSHIP them
• Sometimes may be difficult for
1. Orientation Phase. The orientation both as psychological
phase is directed by the nurse and dependence persists
involves engaging the client in
treatment, providing explanations and
information, and answering questions.
• Problem defining phase

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 Behavioral Theories and Therapies unpleasant consequences is less likely to be
repeated.
Ivan Pavlov • Neutral operants: responses from
• Classical Conditioning Theory the environment than neither
increase nor decrease the
Basic Principles of Classical Conditioning probability of a behavior followed
- It is a form of learning whereby a by unpleasant consequences is less
conditioned stimulus (CS) becomes likely to be repeated.
associated with an unrelated • Reinforcers: responses from the
unconditioned stimulus (US) in order to environment that increase the
produce a behavioral response known probability of a behavior being
as a conditioned response (CR) repeated. Reinforcers can be either
- The conditioned response is the learned positive or negative.
response to the previously neutral • Punishers: responses form the
stimulus. environment that decrease the
- The unconditioned stimulus is usually a likelihood of a behavior being
biologically significant stimulus such as repeated. Punishment weakens
food or pain that elicits an behavior.
unconditioned response (UR) from the
start. Cognitive Theories and Therapies
- The conditioned stimulus is usually
neutral and produces no particular Aaron Beck & Albert Ellis
response at first, but after conditioning • Beck’s Cognitive Therapy and Ellis’
it elicits the conditioned response. Rational Emotive Therapy on cognitive
approach based on an individual’s
abilities to think, analyze, judge, decide
and do.
• View individual’s present perceptions,
thoughts, assumptions, beliefs, values,
attitudes, and philosophies as needing
modifications or change.
• Even distorted can be unlearned.

Rational Emotive Therapy
- Using A-B-C theory of personality
o A – Activating event
o B – Belief about A
o C – Emotional reaction
- A (event) does not cause C (emotion);
Unconditioned response: the dog’s natural rather B (irrational beliefs about A)
salvation in response to seeing or smelling their causes C.
food. - Intervention is aimed at B (irrational
beliefs) and is called D (disputing and
Unconditioned stimulus: the sight or snell of changing irrational beliefs). The
the food itself. outcome is E (the end result or
profound effective new philosophies.
Conditioned stimulus: ringing of the bell, which
previously had no association with food. Jean Piaget
• Cognitive Development
Conditioned response: salvation of the dog in • His theory focuses not only on
response to the ringing of the bell, even when understanding how children acquire
no food was present.
knowledge, but also on understanding
the nature of intelligence.
John B. Watson
• As kids interact with the world around
• Behaviorism Theory them, they continually add new
• In the early 1900’s, he carried out a knowledge, build upon existing
controversial classical conditioning knowledge, and adapt previously held
experiment on an infant boy called ideas to accommodate new
“Little Albert.” information.

B.F Skinner’s Operant Conditioning Theory Stages of Cognitive Development
- According to this principle, behavior that is
• Sensori-motor (Birth – 2 yrs old)
followed by pleasant consequences is likely to
o Differentiates self from objects
be repeated, and behavior followed by

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 Recognizes self as agent of
o unconscious motive or someone else’s
action and begins to act interpretation of the situation.
intentionally: e.g. pulls a string
to set mobile in motion or
shakes a rattle to make a noise
o Achieves object permanence:
realizes that things continue to
exist even when no longer
present to the sense (Pace
Bishop Barkeley)
• Pre-operational (2 – 7 yrs old)
o Learns to use language and to
represent objects by images
and words.
o Thinking is still egocentric: has
difficulty taking the viewpoint
of others.
o Classifies objects by a single
feature: e.g. groups together all
the red blocks regardless of Biological Theories and Therapies
shape or all the square blocks
regardless of color. 1. Advent of Pharmacology
• Concrete Operational (7 – 11 yrs old) 2. Stress Diathesis Model – posits that
o Can think logically about objects psychological disorders result from an
and events. interaction between inherent
o Achieves conservation of vulnerability and environment stressors
numbers (age 6), mass (age 7), 3. Biological Model – involves such things
and weight (age 9). as studying the brain, immune system,
o Classifies objects according to nervous system, and genetics
several features and can order
them in series along a single Additional Theories and Therapies
dimension such as size.
• Formal Operational ( 11 yrs old and up) 1. Milieu Therapy – manipulate the
o Can think logically about environment so that all aspects of the
abstract and test hypotheses client’s hospital experience are
systematically. considered therapeutic.
o Becomes concerned with the 2. Albert Bandura’s Social Learning
hypothetical, the future, and Theory – emphasizes the importance of
ideological problems. observing, modeling, and imitating the
behaviors, attitudes, and emotional
Humanistic Theories and Therapies reactions of others. 4 steps: Attention,
Retention, Reproduction, and
Abraham Maslow’s Hierarchy of Needs Motivation.

Carl Roger
• Client-Centered Theory
• He suggested that clients would be
better helped if they were encouraged
to focus on their current subjective
understanding rather on some

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 PSYCHOBIOLOGIC BASIS OF BEHAVIOR
NCM 117 Psychiatric Nursing LEC

Objectives: ✓ Temporal Lobe (T)

✓ Biological basis for understanding psychiatric o Upper anterior part:
disorders and treatments. Auditory functions
o Lower part: Short-Term
✓ Locate brain structures primarily involved in memory
psychiatric disorders and describe the primary o Olfactory sense
functions of these structures. o Expression of emotion
✓ Describe basic mechanisms of neuronal o Left temporal lobe:
transmission. Language interpretation
✓ Identify the location and function of
neurotransmitters significant to hypotheses
regarding major mental disorders.
✓ Discuss the role of genetics in the development of
psychiatric disorders.
✓ Discuss the basic utilization of new knowledge
gained from fields of study, including
psychoneuroimmunology and chronobiology.

The BRAIN
❖ Functions and Activities of the Brain
✓ Monitor changes in the external world • Diencephalon
✓ Monitor the composition of body fluids - Connects the cerebrum
✓ Regulate the contractions of the skeletal with the lower brain
muscles structures
✓ Regulate the internal organs
- Parts of the
✓ Initiate and regulate the basic drives: hunger,
Diencephalon:
thirst, sex, aggressive self-protection
✓ Thalamus
✓ Mediate conscious sensation o Integrates all sensory
✓ Store and retrieve memories input towards the cortex
✓ Regulate mood (affect) and emotions except for smell
✓ Think and perform intellectual functions o Some involvement with
✓ Regulate the sleep cycle emotions and mood
✓ Produce and interpret language
✓ Hypothalamus
✓ Process visual and auditory data o Regulates anterior and
posterior parts of the
❖ Your BRAIN & NERVOUS SYSTEM pituitary gland
The nervous system is composed of two (2) major o Controls autonomic
divisions: nervous system actions
➢ Central Nervous System (CNS) o Appetite and
▪ Brain Temperature
o Is composed of three (3) main ✓ Limbic System
divisions o A.k.a the “emotional
1. Forebrain brain”
• Cerebrum o Fear and anxiety; anger
✓ Frontal Lobe (F) and aggression, love,
o Voluntary body joy, and hope; sexuality
movement and social behavior
▪ Speaking o Hippocampus,
▪ Thinking mammillary body,
▪ Judgment amygdala, olfactory
o Emotional experience tract, hypothalamus,
▪ Has limbic system cingulate gyrus, septum
connection pellucidum, thalamus
and fornix
✓ Parietal Lobe (P) o Functions
o Perception and ▪ Olfactory functions
interpretation of most  Smell relates to
sensory information emotion
▪ Touch, pain, taste,
and body position ▪ Feeding functions
o Language interpretation  Hypothalamic
of left hemisphere of this feeding and
lobe satiety centers

✓ Occipital Lobe (O) ▪ Fight or flight

o Visual reception and limbic function
interpretation  Amygdala,
o Visual perception hypothalamus,
▪ Judge spatial and midbrain
relationships  Bilateral
▪ See in 3 dimensions destruction of
o Language interpretation amygdala =
thru association of the calming effect
visual experience
Chrisyll Anne Dominguez and Alexi Gabrielle Ravanes BSN 3A
 ▪ Memory limbic 3. Hindbrain
function • Pons
 Amygdala and o Lies between the midbrain
hippocampus and medulla
 Transfer of o Connects cerebellum and
information from brain stem
short-term to o Contains central connections
long-term
memory
of CN V – CN VIII
o Respiration and skeletal
 Amnestic states,
amnestic muscle tone
dementias,
punch-drunk • Medulla
syndrome, o Pathway for all ascending
herpes and descending fiber tracts
encephalitis, o Regulate heart rate, blood
Alzheimer’s pressure, respiration
disease involve o Reflex centers for
dysfunction of swallowing, sneezing,
the hippocampi
coughing, and vomiting
and other limbic
structures o Contains nuclei for CN IX –
 Pleasure – CN XII
reward • Cerebellum
pathway: o Located below the occipital
Dopaminergic
lobes
neurons from
ventral o Involuntary movement:
tegmental area muscular tone and
projects to coordination
nucleus o Maintenance of posture and
accumbens (r/t balance
cocaine use)
 Sexual arousal ▪ Spinal cord
when septal
area is
stimulated  NERVE TISSUE
 Emotions and ✓ Neurons
Motivation
functions

• Afferent neuron
- Carry impulses from the
periphery to the CNS
- A.k.a. Sensory neurons
• Efferent neuron
- Carry impulses from the
CNS to the muscles and
glands in the periphery
- A.k.a. Motor neurons

✓ Synapses
o The junction between 2
neurons
o Synaptic cleft
o Presynaptic neurons
o Postsynaptic neurons

✓ Neurotransmitters
2. Midbrain o Are stored in the axon
: Mesencephalon terminals of the presynaptic
• Mainly composed of nuclei neuron
and fiber tracts o An electrical impulse through
• Extends from the pons to the the neuron stimulates the
hypothalamus release of the
• Integration of various reflexes neurotransmitter into the
✓ Visual reflex synaptic cleft
✓ Auditory reflex o RECEPTORS – molecules
✓ Righting reflex situated on the cell membrane
that are binding sites for
neurotransmitters
Chrisyll Anne Dominguez and Alexi Gabrielle Ravanes BSN 3A
 o Functions o Mesolimbic dopamine
 Affect human emotion and pathway is involved in such
behavior things as pleasurable
 Target for the mechanism of sensations, the euphoria that
action for most psychotropic results from drugs of abuse,
drugs and delusions and
o Major Categories of hallucinations that result from
Neurotransmitters psychosis.
Cholinergics o Mesocortical dopamine
Monoamines pathway mediates positive
Amino Acids and negative psychotic
Neuropeptides symptoms as well as the
cognitive side effects of
CHOLINERGICS antipsychotic medications.
 Acetylcholine o Tuberoinfundibular
• First chemical to be identified and (endocrine) dopamine
proven as a neurotransmitter pathway controls the release
• Major effector chemical within ANS of prolactin.
affecting all sympathetic and  Serotonin
parasympathetic presynaptic nerve • Derived from the dietary amino acid,
terminals and all parasympathetic tryptophan
postsynaptic nerve terminals • Location: Raphe nuclei
• Affects neurotransmission at junctions • Function: Sleep, arousal, libido,
of nerve and muscles appetite, mood, aggression, and pain
• Mostly dense in basal ganglia perception
• Function: Sleep, arousal, pain • Implication:
perception, modulation and ✓ Increased levels: Schizophrenia
coordination of movement, memory and anxiety states
acquisition and retention ✓ Decreased levels: Depression
• Implications: Disorders of motor  Histamine
behavior and memory
• Location: various regions of
o Parkinson’s, Huntington’s, hypothalamus
Alzheimer’s Disease
• Function: unclear
o Depression at increased levels
• Implication: May play a role in
depressive illness
MONOAMINES
 Norepinephrine AMINO ACIDS
• Fight-flight syndrome  Gamma-amino butyric acid (GABA)
• ANS: Sympathetic postsynaptic nerve • Major inhibitory neurotransmitter
terminals
• Location: High concentration in CNS
• CNS: pathways from pons, medulla,
thalamus, dorsal hypothalamus, limbic • Functions: interrupts the progression
system, hippocampus, cerebellum, of the electrical impulse at synaptic
cerebral cortex junction; producing slowdown of body
activity
• Functions: Mood regulation, cognition,
perception, cardiovascular functioning, • Implication:
sleep and arousal ✓ Decreased levels: anxiety
disorders, movement disorders:
• Implication: Decreased in depression;
Huntington’s and epilepsy
Increased in mania, schizophrenia, anxiety
states  Glycine
 Dopamine • Inhibitory amino acid
• Derived from the amino acid, tyrosine • Highly concentrated in the brain stem
• Physical activation of the body and spinal cord
• Location: substantia nigra, ventral • Function: inhibition of motor neurons
tegmental area, hypothalamus; Pathways: in the spinal cord; regulation of spinal and
frontal cortex, limbic system, basal ganglia, brain stem reflexes
and thalamus • Implications:
• Functions: ✓ Decreased levels: spastic
✓ Regulation of movement and disorders
coordination ✓ Increased levels in CNS and
✓ Emotions brain: glycine encephalopathy
✓ Voluntary decision-making  Glutamate
ability • Excitatory neurotransmitter
✓ Inhibits release of prolactin • Located in various areas of the nervous
• Implication: system
✓ Decrease levels: Parkinson’s • Function: relay sensory information
disease and depression and regulate motor and spinal reflexes
✓ Increased levels: Mania and
• Implication:
schizophrenia
✓ Increased levels:
• Pathways: neurodegenerative d/o:
o Nigrostriatal dopamine Parkinson’s
pathway controls movements. ✓ Decreased levels: Psychotic
behavior

Chrisyll Anne Dominguez and Alexi Gabrielle Ravanes BSN 3A

NEUROPEPTIDES ❖ Common BRAIN Imaging Techniques
 Endorphins and Enkephalin  Electrical: Recording electrical signals
• A.k.a. Opioid peptides from the brain
• Found in hypothalamus, thalamus, ➢ Electroencephalograph (EEG)
limbic system, midbrain, and brain • A recording of electrical
stem signals from the brain made
• Enkephalins are also found in GI tract by hooking up electrodes to
• Function: Pain modulation; natural the subject’s scalp.
pain killers • Use: Show the state a person is
• Implication: Some link with in: asleep, awake,
schizophrenia anesthetized
• Provides support from a wide
 Substance P range of sources that brain
• First neuropeptide discovered abnormalities exist; may lead
• Found in most parts of the brain to further testing
• Function: Role in sensory transmission
particularly pain regulation  Structural: Show gross anatomical details
• Implication: of brain structures
✓ Decreased levels: Huntington’s ➢ Computerized Axial Tomography
Disease Scan (CT Scan)
• A series of Xray images is
 Somatostatin taken of the brain and a
• A.k.a. Growth hormone inhibiting computer analysis produces
hormone “slices” providing a precise
• Found in cerebral cortex, 3D-like reconstruction of each
hippocampus, thalamus, basal ganglia, segment.
brain stem, spinal cord • Can detect: Lesions,
• Functions: Both excitatory and abrasions, areas of infarct,
inhibitory aneurysm
• Implications: • Psychiatric relevance:
✓ Increased levels: Huntington’s Schizophrenia [cortical
disease atrophy, 3rd ventricle
✓ Decreased levels: Alzheimer’s enlargement, cognitive
disease disorders, abnormalities
➢ Magnetic Resonance Imaging
➢ Peripheral Nervous System (PNS) (MRI)
▪ Afferent System • A magnetic field is applied to
o Sensory neurons (somatic and the brain. The nuclei of
visceral) hydrogen atoms absorb and
emit radio waves that are
▪ Efferent System
analyzed by computer, which
o Somatic nervous system (somatic
provide 3D images of brain
motor neurons)
structure
o Autonomic nervous system
• Can detect: brain edema,
• Sympathetic Nervous
ischemia, infection, neoplasm,
System
trauma
✓ Visceral motor
neurons • Schizophrenia: enlarged
• Parasympathetic Nervous ventricles, reduction of
System temporal lobe and prefrontal
✓ Visceral motor lobe
neurons
 Functional: Show some activity of the
brain
➢ Functional Magnetic Resonance
Imaging (fMRI)
• Measures brain activity
indirectly by changes in blood
oxygen in different parts of the
brain as subjects participate in
various activities
➢ Positron Emission Tomography
(PET) Scan
• Radioactive substance
(Tracer) is injected, travels to
the brain and shows up as
bright spots on the scan
• Data collected by detectors are
relayed to a computer, which
produces images of the
activity and 3D visualization
of the CNS
• Can detect: oxygen utilization,
glucose metabolism, blood
Chrisyll Anne Dominguez and Alexi Gabrielle Ravanes BSN 3A
 flow, neurotransmitter-  Superior Brain Surface
receptor interaction ✓ Interhemispheric fissure
• Schizophrenia: Increased D2, ✓ Central sulcus
D3 receptors in caudate
➢ Medial and Ventral Surfaces
nucleus
 Medial Brain Surface
• Abnormalities in limbi system
✓ Parietooccipital fissure
• Mood disorders ✓ Corpus callosum
• Abnormalities and temporal ✓ Paracentral lobule
lobes
• Adult ADHD  Ventral Brain Surface
• Decreased utilization of ✓ Interhemispheric fissure
glucose ✓ Cranial nerves
✓ Brainstem
➢ Single Photon Emission
Computed Tomography (SPECT)
• Similar to PET but uses
radionuclides that emit
gamma radiation (Photons).
• Measures various aspects of
brain functioning and
provides images of multiple
layers of the CNS

❖ Organization of the BRAIN

 Neuroanatomy of the Human Brain (1st video)
• Embryonic Development

o Brodmann Areas
 Korbinian Brodmann (1868 –
1918)
 German neurologist
• Brain Regions
 Died of pneumonia at age 50
 One of the first to look at these
subregions and looked at them
histologically, the cell types in
those areas, and began to
divide the brain into regions
 52 cortical areas that differ
histologically

• Major Parts of the Brain

1. Cerebral Hemispheres
o 83% of total brain mass
o Cover the diencephalon and upper
brainstem
o Bumps (gyri) and grooves (sulci)
o Characteristic ‘pattern’ of
sulci/fissures over surface
➢ Dorsolateral Brain Surface
 Lateral Brain Surface
✓ Central sulcus
✓ Sylvian fissure
✓ Preoccipital notch

Chrisyll Anne Dominguez and Alexi Gabrielle Ravanes BSN 3A

o Functional Anatomy of the Brain cortex -> evaluates sounds
(Wernicke’s area on left side)
➢ Gustatory (taste) cortex
- Roof of lateral sulcus
➢ Vestibular (equilibrium)
cortex
- Posterior insula, deep to
lateral sulcus
➢ Olfactory (smell) cortex
- Medial temporal lobe at
uncus, connects to limbic
system (emotions)

 Prefrontal Cortex  Visual Areas

➢ Complex cognitive behavior, ➢ Primary visual cortex (striate)
- Buried in calcarine sulcus
decision making, social - Map of visual space
behavior, personality ➢ Visual association area
expression - Color, form, movement
➢ Executive functions ➢ Temporal and parietal areas
- Differentiate conflicting - Dorsal “where” stream
thoughts - Ventral “what” stream
✓ Good vs bad, better vs
best, same vs different  Association Areas
- Consequences of actions ➢ Prefrontal Cortex
✓ Outcome prediction - Anterior to motor areas,
- Task management involved in cognition and
✓ Working towards a goal personality/mood
- Social “control” ➢ General Interpretation Area
- Personality - Posterolateral cortex,
➢ Working memory interface among visual,
➢ Object-recall tasks auditory, and somatosensory
areas
 Motor Areas ➢ Language Areas
➢ Primary motor cortex - Broca’s (motor) and
- Precentral gyrus, Brodmann Wernicke’s (sensory)
area 4 ➢ Insula
- Large pyramidal cells - ???language, balance,
project to contralateral viscera, heart???
motor neurons, controlling
opposite side of body
- Somtotopic organization -> o Cerebral White Matter
motor homunculus ▪ Commissures
➢ Premotor cortex - Connect hemispheres
- Anterior to primary motor - Corpus callosum
cortex ▪ Association fibers
- Receives highly processed - Within one hemisphere
sensory info ▪ Projection fibers
- Involved in planning - Cortex <-> caudal areas
movements - Internal capsule
➢ Frontal eye field - Corona radiata
- Anterior to premotor cortex o Deep Gray Matter
- Controls voluntary eye
▪ Basal Forebrain Nuclei
movements
- Cholinergic system located
➢ Broca’s area anterior and dorsal to
- Anterior to inferior premotor hypothalamus
cortex - Function in arousal,
- Manages speech production learning, memory
(motor speech) - Involved in Alzheimer’s
 Sensory Areas Disease
➢ Primary somatosensory ▪ Claustrum (poorly understood)
- Postcentral gyrus, Brodmann ▪ Basal Ganglia
areas 1-3 - “corpus striatum” = caudate
- Conscious awareness of + lentiform (putamen and
general somatic sensation globus pallidus)
from opposite side of body - Start, stop, regulate intensity
- Spatial discrimination of voluntary movements
- Sensory homunculus 2. Diencephalon
➢ Somatosensory association o Thalamus
cortex ▪ Thalamus = ‘inner room”
- Posterior to primary sensory ▪ Egg-shaped structures
cortex ▪ Form superolateral wall of 3rd
- Integrates different sensory ventricle
inputs -> sensory recognition ▪ “gateway” to the cortex
➢ Auditory areas ▪ Different nuclei receive different
- Primary auditory cortex: sensory input
superior temporal lobe,
inside lateral sulcus o Hypothalamus
- Auditory association area: ▪ Lies below thalamus, forming
posterior to primary auditory inferolateral walls of 3rd ventricle
▪ Visceral control functions:
Chrisyll Anne Dominguez and Alexi Gabrielle Ravanes BSN 3A
 ✓ Autonomic nervous system  Neuroanatomy: The Human Brain (2nd video)
✓ Emotional responses • The human brain includes a forebrain –
✓ Body temperature
made of 2 hemispheres almost
✓ Hunger and thirst areas
✓ Sexual behavior symmetrical: left and right,
✓ Sleep-wake cycle diencephalon – a medial and single part
(suprachiasmatic nucleus) that includes the thalamus and the
✓ Pituitary gland function hypothalamus
✓ Memory (mammillary
• The 2 cerebral hemispheres are connected
bodies)
by commissural pathways
3. Brain Stem o The largest is the corpus
 Located in posterior cranial fossa callosum
 Functions: ▪ It contains more than 20
✓ Programmed, automatic behaviors million nerve fibers crossing
✓ Passageway between cord and from one side to the other
cerebrum
✓ Innervation of face and head (10/12 • Each cerebral hemisphere is divided into 2
cranial nerves) distinct regions
 Composed of 3 Parts: CEREBRAL CORTEX
➢ Midbrain ➢ A peripheral part: the cortex “gray
o Structure: matter” that contains the bodies of
✓ Superior colliculi nerve cells
✓ Inferior colliculi ➢ A central part, made of “white
✓ CN II matter” that contains the axonal
✓ CN IV extensions of neurons and their myelin
✓ Substantia nigra sheath
✓ Red nucleus
✓ Cerebral peduncles • Each hemisphere is cut by deep fissures
✓ Periaqueductal gray that define lobes
matter ➢ The first is the lateral sulcus or
✓ Superior cerebellar Sylvian fissure where lies the middle
peduncle cerebral artery. It separates the frontal
➢ Pons lobe of the temporal lobe.
o Structure: ➢ The second is the central sulcus or
✓ CN V: sensory input fissure of Rolando between the
from face, muscles of frontal lobe and the parietal lobe.
mastication ➢ The third sulcus is the parieto-
✓ CN VI: eye movements occipital sulcus separating the
(abduction) occipital lobe from the temporal and
✓ CN VII: muscles of facial
parietal lobes.
expression
✓ Pontine nuclei: relay for • Not to mention a fifth lobe, non-visible on
corticopontine tracts the surface, the lobe of the insula. It is
(motor input from found by removing the Sylvian fissure.
cortex -> pons ->
crbllm) • In each lobe, there are less deep sulci
✓ Middle cerebellar delimiting the ridges on the cerebral cortex
peduncles: axons from surface, each of these is called a gyrus.
pontine nuclei ->
cerebellum
(pontocerebellar tracts)  Neuroanatomy: Diencephalon, Thalamus, and
➢ Medulla Oblongata Hypothalamus (3rd video)
o Structure: • Covered by the two cerebral hemispheres,
✓ CN VIII – XII the diencephalon is the structure of the
✓ Pyramids central nervous system that is at the center
✓ Inferior cerebellar of the brain.
peduncles
o It contains masses of gray matter such
✓ Olive (inferior olivary
nuc) as the thalamus and the hypothalamus
✓ Cochlear nuclei that play tremendous roles in the
✓ Vestibular nuclei organism.
✓ Nucleus cuneatus • The thalamus is a nuclear complex that
✓ Nucleus gracilis
occupies the most part of the
✓ Retricular formation
diencephalon.
4. Cerebellum o It acts essentially as a relay to the vast
 Coordinated movements, maintains majority of sensory inputs that go up
posture and equilibrium to the cerebral cortex.
 11% of brain mass o It also plays a very important role in
movements and emotions.
 Regions:
✓ Outer cortex (gray matter)
o Made up of 2 masses of gray matter:
✓ Arbor vitae (white matter) right and left each taking an ovoid
✓ Deep cerebellar nuclei shape.
▪ These 2 parts are often joined
 Input to cerebellum:
together in the center by the
a. Equilibrium information
interthalamic adhesion
b. Proprioceptive information
o Consists of multiple nuclei, each of
(where limbs are in space)
c. Cerebral cortex input
those nuclei plays a very specific role.

Chrisyll Anne Dominguez and Alexi Gabrielle Ravanes BSN 3A

 o Thalamus marks the lateral side of the
third ventricle and it is surrounded on
top and front by the body and the head
of the 2 lateral ventricles.
• The hypothalamus is located directly
below and in front of the thalamus is much
smaller in size and volume. Nevertheless,
its role in the body is not the least.
o In fact, the hypothalamus contains
several distinct nuclei that provide
numerous functions including
thermoregulation, appetite, and
regulation of the sleep-wake cycle.
o It also plays a capital role in
modulating the autonomic nervous
system.
o The hypothalamus is the real
endocrine engine of the whole body.
▪ It controls the secretions of the
pituitary gland which produces the
most important hormones of the
body.
 Neuroanatomy: The Brainstem (4th video)
• The brainstem is the brain anatomical
structure that links different parts of the
central nervous system: the forebrain, the
cerebellum, and the spinal cord.
• The brainstem plays a vital role in the
many essential functions that its nuclei
regulate such as breathing and heart rate
and even consciousness.
• It is also a passageway to sensory and
motor pathways and a pain control center.
• The brainstem represents the emergence
area of most cranial nerves.
• 3 Parts of the Brainstem:
➢ Midbrain or “mesencephalon”
o Is the area of the brainstem that is
directly connected to the forebrain
through the cerebral peduncles.
o Behind these 2 peduncles, we find
the tegmentum with a hole in back
side, the cerebral aqueduct also
known as the aqueduct of Sylvius
it connects the 3rd to the 4th
ventricle.
o On the back of the midbrain is the
tectum with four colliculi where lie
the reflex centers involving
hearing and vision.
➢ Pons a.k.a. “pons varolii”
o The middle part of the brainstem.
o It plays an important role in motor
functions with its relay position
between the forebrain and the
cerebellum.
o It also contributes to autonomous
functions and facial sensitivity.
o It contains the core and the
emergence of the trigeminal nerve.
o The pons is connected to the
cerebellum by the middle
cerebellar peduncle.
o It delimits the front face of the 4th
ventricle.
➢ Medulla
o The medulla oblongata is the
portion of the brainstem between
the pons and the spinal cord.
Chrisyll Anne Dominguez and Alexi Gabrielle Ravanes BSN 3A
o The medulla contains the olivary
and a pair of pyramids that
contain the corticospinal fibers of
the pyramidal tract.
o The medulla contains vital
autonomic control centers for
functions such as breathing, heart
rate, and many reflex functions
such as vomiting, coughing,
sneezing, and swallowing.
o It ends at the bottom by the
pyramidal decussation, a crossing
region of the corticospinal fibers.
 Neuroanatomy: The Cerebellum (5th video)
• The cerebellum is a central nervous
system organ located directly behind the
brainstem.
• It occupies therewith the posterior cranial
fossa below the cerebellar tentorium.
• The cerebellum is attached to the
brainstem by 3 pairs of cerebellar
peduncles:
✓ Superior cerebellar peduncle
✓ Middle cerebellar peduncle
✓ Inferior cerebellar peduncle
• The cerebellum contributes primarily to
balance and motor coordination.
• The concentric grooves that marks the
surface of the cerebellum give it a mutli-
foliated appearance.
• The cerebellum is divided into 3 main
lobes:
➢ Anterior lobe
➢ Posterior lobe
➢ Flocculonodular lobe
• These lobes are subdivided into 10 lobules
by secondary grooves.
• The cerebellum contains a central region
“median” – cerebellar vermis, and 3 deep
cerebellar nuclei: dentate, interposed, and
fastigii.
• The cerebellum shares many similarities
with the brain/forebrain??.
o It has a peripheral cortex and deep
nuclei that contain the cell bodies of
neurons
o It has 2 hemispheres: right and left
o And several grooves delimiting lobes
• The fissures of the cerebellum are deeper
than those of the forebrain.
o This expands the surface of the
cerebellar cortex to almost 75% of the
cerebral cortex
❖ Cellular Composition of the BRAIN
 Brain and Neurotransmitters (6th video)
• Our brains are amazing – they think about
problems; tell body parts to move; tell the
stomach how to digest; figure out what we
see, taste, smell, and touch; they are the
boss of the body; they tell everything else
how to work; they even help us feel happy,
excited, scared, mad, and sad.
• Like all body parts, the brain can
sometimes have problems working
correctly and this can lead to mental
illness.
 o Sometimes brains make people feel
worried too much of the time. It is
called anxiety.
o Some brains make people feel too
much sadness. It is called depression.
o Other brains make people feel like they
need to repeat actions and that their
work is never good enough. It is called
OCD.
o Some brain make people feel very sad
at times and overly happy and excited
other times. It is called bipolar.
o Some brains do not communicate the
message to your body that it needs to
focus and stay on task. It is called DD
or ADHD.
o Some brains make people think they
hear, see, or touch things that aren’t
really there or think things that aren’t
true. It is called schizophrenia.
• Why does the brain the boss of the whole
body not work right sometimes?
- Doctors and scientists are still learning
but they know it often it has to do with
how the brain communicates.
• The brain is similar to a highly organized
collection of wires. It receives all the
signals that come in to the eyes, ear, and
nose and sends on messages to the mouth,
feet, and hands.
• Neurons are like the brain’s wires. They are
the connectors that move messages along
and there are 100 billion of them at work
in the brain all the time.
• But neurons must talk to other neurons to
move messages along and the way they talk
to each other is through chemical
messengers. These messengers called
neurotransmitters across the tiny gaps in
between neurons ferrying messages from
one neuron to the next. When a neuron
gets just the right neurotransmitter at just
the right time, it helps the brain
concentrate, relax, shift attention, and
create.
• But when neurotransmitters aren’t able to
do their job right when there are too many
messengers or too few, the messages are
not understood correctly. The brain loses
focus, gets tired, worried, or retreats from
reality.
o For example, when neurons called
smiley serotonin don’t make it across
the neuron yet the brain makes the
whole body feel sad and depressed.
o Doctors found that if they give a
depressed patient some medicine to
help smiley serotonin, it helps the
brain feel happier. Doctors have
discovered many medicines that help
correct neurotransmitter levels in the
brain. These other medicines influence
not only serotonin but other brain
messengers such as duit dopamine,
gregarious Gaba, and neardy
norepinephrine.
o Doctors are also learning that for some
brains – eating a healthier diet,
exercise, meditation, and enjoying
happy relationships can be very
helpful in getting neurotransmitter
levels back to working order.
Chrisyll Anne Dominguez and Alexi Gabrielle Ravanes BSN 3A
 Normal Brain Anatomy and Function (7th
video)
• The brain functions by transmitting
electrical signals between brain cells
(neurons).
• The neurons communicate through the
release of chemical neurotransmitters.
• Children have billions of neurons.
• Normal Neuronal Function: Synapse
o The junction between brain cells is
called the synapse.
o Brain cells communicate through
electrical signals travelling the axon of
one neuron to the other. The electrical
signal releases a neurotransmitter
(acetylcholine or Ach) into the space
between the neurons.
o Calcium is critical to the release of
Ach. The release of Ach occurs when
calcium contracts certain receptors on
the axon.
• Normal Neuronal Function:
Synaptogenesis
o As a child’s brain matures, neurons
develop additional and more complex
synapses. This process is called
synaptogenesis.
o Synaptogenesis is part of healthy brain
growth and function.
o This process requires the production
of the chemical Brain Derived
Neurotrophic Growth Factor (BDNF)
which promotes the growth of
additional synapses.
o Calcium and BDNF are critical for
neuron survival and growth. Working
together, calcium and BDNF allows
neurons to perform different functions
important to learning and memory.
• Normal Neuronal Function: Calcium
Modulation
o Normal, healthy neuron activity,
growth and function are highly
dependent on calcium.
o Calcium enters the neuron.
o Calcium is critical to healthy brain
development in every child.
• Normal Neuronal Function: Blood-
Brain Barrier
o The body has a natural barrier between
blood vessels and neurons that
prevents toxins and other harmful
chemicals from reaching the neurons
and inquiring them.
o This barrier is called the “blood brain
barrier”. The blood brain barrier acts
as a shield to protect the brain.
• Normal Neuronal Function: Neuronal
Pruning
o During normal brain development, a
child’s brain will decrease the number
of connections between neurons to
make signal transmission more
efficient.
o This process is called synaptic
pruning. It is normal part of healthy
brain function.
 ❖ Major Neurotransmitters in the BRAIN - Dopamine antagonist drugs are also some
 Dopaminergic Pathway of the most effective anti-nausea agents
o Tuberoinfundibular pathway and prolactin
release • Insufficient dopamine
- Blunting of affect/apathy
- Loss of motivation
Neurobiology: Understanding the Big 6 Neurotransmitters - Pain
(8th video) - Parkinson’s disease
Neurobiology: Dopamine, GABA, Serotonin, - Restless legs syndrome
Acetylcholine, Norepinephrine, & Glutamate - Attention deficit hyperactivity disorder
(ADHD)
What is Neurobiology?
- Neurological symptoms that increase in
➢ Is the study of brain and nervous system which frequency with age, such as decreased arm
generate sensation, perception, movement, swing and increased rigidity
learning, emotion, and many of the functions that - Changes in dopamine levels may also cause
make us human. age-related changes in cognitive flexibility
- Fatigue
- Apathy, inability to feel pressure
Think about - Procrastination
- Low libido
➢ A client who presents with apathy/ loss of pleasure, - Sleep problems
sleep disturbances, fatigue, and difficulty - Mood swings
concentrating - Hopelessness
• What would your diagnosis be? - Memory loss
• What medication would you expect the - Inability to concentrate
doctor to put him on? - (Looks like depression at a first glance)

A. Dopamine ➢ Nutritional Building block

➢ Mechanism of Action: • Eating a diet high in magnesium and
• Movement tyrosine rich foods will ensure you’ve got
• Memory the basic building block needed for
• Pleasurable Reward dopamine function
• Behavior and cognition • List of foods to increase dopamine:
• Attention - Chicken
• Inhibition of prolactin production - Almonds
• Sleep - Apples
• Mood - Avocado
• Altered dopamine neurotransmission is - Bananas
implicated in: - Beets
- Cognitive control (racing thoughts) - Chocolate
- Attention control - Green leafy vegetables
- Impulse control - Green tea
- Working memory - Lima beans
- Mood - Oatmeal
- Motivation sleep - Sesame & pumpkin Seeds
- Turmeric
➢ Where is it found - Watermelon
• Precursor, L-DOPA is synthesized in brain and - Wheat germ
kidneys
• Dopamine functions in several parts of the
peripheral nervous system ➢ Medications
- In blood vessels, it inhibits norepinephrine • Dopamine in blood is unable to cross the blood-
release and acts as a vasodilator brain barrier to reach the brain (which is why you
(relaxation) can’t just take in medication with dopamine but
- In the kidneys, it increases sodium and rather have the necessary building blocks to allow
urine excretion the body to make for itself)
- In the pancreas, it reduces insulin • Most common dopamine agonists (Parkinson’s,
production Restless legs, negative symptoms)
- In the digestive system, it reduces - Mirapex & Requip
gastrointestinal motility and protects - Levodopa – Cardidopa combination is
intestinal mucosa actually converted to dopamine in the
- In the immune system, it reduces brain
lymphocyte activity - Buspirone
• Most common dopamine antagonists (positive
➢ Symptoms of excess & insufficiency symptoms)
• Excess of dopamine - Risperdone, Haldol, Zyprexa
- Unnecessary movements, repetitive tics - Metoclopramide (Reglan) is an antiemetic
- Psychosis • Supplements which may increase dopamine
- Hypersexuality - L-theanine is an amino acid uniquely
- Nausea found in green tea that creates an alert
- Most antipsychotic drugs are dopamine state of relaxation without drowsiness
antagonists - Rhodiola rosea, or “golden root”
Chrisyll Anne Dominguez and Alexi Gabrielle Ravanes BSN 3A
 ✓ Improving depression, enhancing C. Glutamate
work performance, eliminating fatigue ➢ Is an amino acid (present in most high protein
and treating symptoms resulting from foods)
intense physical and psychological ➢ Most prevalent excitatory neurotransmitter
stress ➢ Used to make GABA (teeter-totter)
✓ Enhancing the stability of dopamine ➢ Facilitates learning and memory
and supporting its reuptake. This leads ➢ Excess glutamate is associated with
to notable decreases in depression, ✓ Panic attacks/anxiety
anxiety, and fatigue, as well as an ✓ Impulsivity
increased ability to handle stress. ✓ OCD
- Blood levels of antipsychotic medications ✓ Depression
and lithium are especially sensitive to ➢ Availability declines with age
hydration levels
- NMS
✓ Caused by a sudden, marked D. GABA (Gamma aminobutyric acid)
reduction in dopamine activity, ➢ Mechanism of action/ purpose
either from withdrawal of - Anti-anxiety, anti-convulsant
dopaminergic agents or from - Made from glutamate
blockade of dopamine receptors - Functions as an inhibitory
✓ Symptoms include high fever, neurotransmitter
confusion, rigid muscles, variable - Does the opposite and tells the adjoining
blood pressure, sweating, and fast cells not to “fire”
heart rate ➢ Where is it found
✓ Complications may include - Close to 40% of the synapses in the human
rhabdomyolysis, high blood brain work with GABA and therefore have
potassium, kidney failure or GABA receptors
seizures.
➢ Symptoms of Insufficiency
- Anxiety
➢ Age related changes - Depression
• Dopamine levels decline by around 10% per decade - Difficulty concentrating
from early adulthood and have been associated - Insomnia
with declines in cognitive and motor performance - Seizure disorders
• Dopamine levels are also impacted by availability
of estrogen ➢ Symptoms of excess
- Excess sleepiness
- Shallow breathing
B. Norepinephrine - Decreased blood pressure
➢ Function: - Memory problems
• Fight and flight excitatory neurotransmitter - Dizziness
• Implicated in motivation - Blurred vision
- Slurred speech
➢ Symptoms of Insufficiency - Weakness
• When faced with severe stress, the stress response
system activates raising norepinephrine and stress ➢ Nutritional building block
hormones - Fermented foods saurkraut, yogurt
• This increases arousal, increases insomnia, - Almonds & walnuts
anxiety, depression, irritability, or emotional - Cherry tomatoes
instability - Banana
• Prolonged stress leads to under activity of the - Brown rice
stress response system (desensitization) - Potato
• This lowers arousal and can result in low energy, - Oats
daytime fatigue, concentration/focus issues, and - Lentils
general apathy. - Vitamin b6, if deficient, may impair the
production of GABA as it is a cofactor
➢ Symptoms of excess nutrient
• ADHD or problems with concentration - Inositol (vitamin b-8) – wheat germ,
• Depression brown rice, green leafy vegetables, nuts,
• Anxiety navy and lima beans
• Poor sleep
➢ Medications
➢ Nutrition - Drugs that increase the available amount
• Tyrosine rich foods of GABA typically have relaxing, anti-
- Bananas anxiety, and anti-convulsive effect
- Beans and legumes - Gabapentin (neurontin) is a GABA
- Chicken analogue used to treat epilepsy and
- Cheese neurotic pain
- Chocolate
- Benzodiazepines and barbiturates
- Eggs
- Fish and seafood
including GHB, Valium, Xanax
- Meat - Baclofen (muscle relaxant)
- Oatmeal - Klonapin
• A daytime nap can also double your levels
of norepinephrine

Chrisyll Anne Dominguez and Alexi Gabrielle Ravanes BSN 3A

 E. Serotonin ➢ Increase serotonin release
➢ Mechanism of action/ purpose: - Amphetamines (ADHD medication,
• Helps regulate: MDMA)
- Mood - Anorectics (appetite suppressants
- Sleep patterns (dexadrine))
- Appetite - Anti-migraine medications as triptans
- Pain (axert, Amerge, Imitrex), carbamazepine
(tegratol) and valproic acid (depakene)
➢ Where is it found.
• Brain ➢ Stimulation of post synaptic receptors
• Gut/intestines - Buspirone
- Lithium
➢ Symptoms of excess (serotonin syndrome) - Pain medications such as opioid pain
- Shivering medications including codeine (Tylenol
- Diarrhea with codeine), fentanyl (duragesic),
- Muscle rigidity hyrdrocodone meperidine (demerol),
- Fever oxycodone (oxycontin, percocet,
- Seizures Percodan) and tramadol (ultram)
- Irregular heartbeat
- Agitation ➢ Serotonin Reuptake inhibitor
- High blood pressure - SSRI antidepressant (paxil, prozax, Zoloft)
- Ultram (SSRI + mu - receptor activation)
➢ Insufficiency - Trazadone (SARI: Serotonin Agonist and
- Depression Reuptake inhibitor)
- Anxiety - Tricyclic antidepressant (i.e. Elavil
- Pain sensitivity (amitriptyline), Tofranil (imipramine),
- Poor sleep and Pamelor (nortriptyline))
- Difficulty concentrating - Serotonin and norepinephrine reuptake
inhibitors (SNRIs), antidepressants such
- Carb cravings
as duloxetine (Cymbalta) and venlafaxine
- Constipation
(Effexor)
- Foods rich in tryptophan, an amino acid
- Bupropion (Wellbutrin, zyban)
that converts to serotonin in the brain.
antidepressant and tobacco addiction
(whole wheat, potatoes, brown rice, lentils,
oats, beans)
➢ Other drugs that act to raise serotonin
- Illicit drugs, including LSD, Ecstasy,
➢ Medications & supplements
cocaine and amphetamines
- SSRIs
- Herbal supplements, including St. John’s
- SNRIs
wort, ginseng and nutmeg, 5-HTP
- 5-HTP
- Over-the-counter cough and cold
- SAM-e
medications containing
- St. John’s Wort
dextromethorphan (delsym, mucinex DM,
- Atypical antipsychotics others)
- Anti-nausea medications such as
➢ Understanding some of the serotonin receptors
granisetron, metoclopramide (reglan),
droperidol (inapsine) and ondansetron
(zofran)
- Linezolid (Zyvox), an antibiotic
- Ritonavir (Norvir), an anti-retroviral
medication used to treat HIV/AIDS

➢ Serotonin Age Related Changes

- Serotonin goes down when estrogen or
testosterone go down (Dr. Jacques
Lorrain. (1994) Comprehensive
CAN identify (serotonin syndrome) Management of Menopause)
- Melatonin doesn’t decline as we age, unless
- medical emergency
serotonin declines significantly
• C = cognitive changes including agitation,
confusion, euphoria, insomnia, hypomania, and
hallucinations F. Acetylcholine
• A = autonomic changes including tachycardia, ➢ Mechanism of action/purpose
fever, arrhythmias, sweating, dilated pupils - In lower amounts, ACh can act like a
• N = neuromuscular changes including tremor, stimulant by releasing norepinephrine
rigidity, incoordination , seizures (NE) and dopamine (DA).
- Memory
- Motivation
Ways serotonin is increased - Higher-order thought processes
➢ Increase in serotonin synthesis - Sexual desire and activity
- L-tryptophan (esp. supplementation) - Sleep
➢ Reduction in serotonin breakdown
- MAOIs: Isocarboxazid (marplan) and ➢ Symptom of excess
phenelzine (nardil) - Depression (all symptoms)
- Nightmares
Chrisyll Anne Dominguez and Alexi Gabrielle Ravanes BSN 3A
 - Mental fatigue SUMMARY
- Anxiety
- ✓ There are a variety of different neurotransmitters
➢ Inverse relationship between serotonin and involved in addiction and mental health disorders
acetylcholine ✓ It is not always about increasing a
neurotransmitter. Sometimes you need to decrease
➢ Insufficiency it.
- Alzheimers/dementia ✓ Human brains try to maintain homeostasis and too
- Parkinsons much or too little can be bad.
- Impaired cognition, attention and arousal ✓ A balanced diet will provide the brain the necessary
› Cholinergic and GABAergic nutrients in synergistic combinations.
pathways are intimately
connected in the hippocampus
and basal forebrain complex.
Think About
➢ Nutritional building blocks
- Foods high in choline A client who presents with apathy/ loss of pleasure,
› Meats sleep disturbances, fatigue, and difficulty
› Dairy concentrating
› Poultry
› Chocolate
› Peanut butter
› Wheat germ
› Brussels sprouts and broccoli

➢ Medications
- Cholinergics (increase)
› Used for glaucoma, bladder
control and sevre muscle
weakness
- Anticholinergics
› May worsen GERD
› Used for extrapyramidal
symptoms is treating
schizophrenia
o Muscular spasms
o Akathisia: a feeling of
internal motor
restlessness, tension,
nervousness, or anxiety
o Tardive dyskinesia:
involuntary muscle
movements in the lower
face and distal
extremities
- Anticholinergics
› Atropine
› Benzatropine (congentin)
› Chlorpheniramine (chlor-
trimeton)
› Dimenhydrinate (Dramamine)
› Diphenhydramine (Benadryl,
sominex, advil pm, unisom)
› Hydroxyzine (atarax, vistaril)
› Bupropion (zyban, Wellbutrin)
› Dextromethorphan – cough
suppressant

• Anticholinergic drugs are used to treat a

variety of conditions:
› GI disorders (e.g. gastritis,
diarrhea, diverticulitis, ulcerative
colitis, nausea and vomiting)
› Respiratory Disorders (e.g
asthma, chronic bronchitis, and
chronic obstructive pulmonary
disease (COPD))
› Insomnia, although usually only
on a short-term basis.

Chrisyll Anne Dominguez and Alexi Gabrielle Ravanes BSN 3A

COMMON CNS TRANSMITTERS

TRANSMITTERS ACTIVITY DISTRIBUTION EFFECTS/COMMENTS ASSOCIATION WITH MENTAL HEALTH

MONOAMINES
Dopamine Excitatory Basal nuclei Involved in fine muscle movement Decrease:
Limbic system Involved in integration of emotions and thoughts 1. Parkinson’s disease
Involved in decision making 2. Depression
Stimulates hypothalamus to release hormones (sex, Increase:
thyroid, adrenal) 1. Schizophrenia
2. Mania
Norepinephrine Excitatory Pons Level in brain affects mood Decrease:
(noradrenaline) Medulla Attention and arousal 1. Depression
Stimulates sympathetic branch of autonomic nervous Increase:
system for “fight or flight” in response to stress 1. Mania
2. Anxiety states
3. Schizophrenia
Serotonin Excitatory Brainstem Plays a role, sleep regulation, hunger, mood states and Decrease:
Pons pain perception 1. Depression
Medulla Hormonal activity Increase:
Plays a role in aggression and sexual behavior 1. Anxiety states

Histamine Excitatory Hypothalamus Involved in alertness Decrease:

Mast cells Involved in inflammatory response 1. Depression
Basophils in Stimulates gastric secretion Increase:
blood 1. Anxiety states
2. mania
AMINO ACIDS
Γ-aminobutyric acid Inhibitory Primary Plays a role in inhibition; reduces aggression, excitation, Decrease:
(GABA) inhibitor in and anxiety 1. Anxiety disorders
the CNS May play a role in pain perception 2. Schizophrenia
Has anticonvulsant and muscle-relaxing properties 3. Mania
May impair cognition and psychomotor functioning 4. Huntington’s disease
Increase:
1. Reduction of anxiety
Glutamate Excitatory Primary Is excitatory Decrease (NMDA):
Receptors: exciter in the AMPA plays a role in learning and memory 1. Psychosis
NMDA CNS Increase (NMDA):
AMPA 1. Prolonged increased state
can be neurotoxic
 2. Neurodegeneration in
Alzheimer’s disease
Increase (AMPA):
1. Improvement of cognitive
performance in behavioral
tasks
CHOLINERGICS
Acetylcholine Excitatory Motor Plays a role in learning, memory Decrease:
neurons Regulates mood: mania, sexual aggression 1. Alzheimer’s disease
Pons Affects sexual and aggressive behavior 2. Huntington’s disease
Forebrain Stimulates parasympathetic nervous system 3. Parkinson’s disease
Increase:
1. Depression
PEPTIDES (NEUROMODULATORS)
Substance P Excitatory CNS Centrally active SP antagonist has antidepressant and 1. Involved in regulation of
PNS anti-anxiety effects in depression mood and anxiety
Promotes and reinforces memory 2. Role in pain management
Enhances sensitivity to pain receptors to activity

Somatostatin Excitatory CNS Altered levels associated with cognitive disease Decrease:
PNS 1. Alzheimer’s disease
2. Decreased levels of
somatostatin found in spinal
fluid of some depressed
patients
Increase:
1. Huntington’s disease
Neurotensin Excitatory CNS Endogenous antipsychotic-like properties Decreased levels found in spinal fluid
PNS of patients with schizophrenia

Resources:
Halter, Margaret Jordan. (2014). Varcolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical Approach. 7th ed. Elsevier Inc.
Fortinash, Katherine M. And Patricia A. Holoday Worret. (2012). Psychiatric Mental Health Nursing. 5th ed. Elsevier, Mosby Inc.
 HORMONAL CASCADE FROM THE HYPOTHALAMUS TO BEHAVIORAL EFFECTS

HYPOTHALAMUS- PITUITARY GLAND TARGET GLAND OR HORMONE BEHAVIORAL EFFECT

MADE HORMONES

CRH (Corticotropin- Stimulates production of Adrenal gland – produces cortisol and 1. Stress causes the release of cortisol
releasing hormone) two hormones: cortisol related hormones 2. Depressed children have decreased diurnal cortisol
1. ACTH ACTH drives cortisol production secretory pattern
(adrenocorticotropic 3. Depressed adoscents have increased cortisol
hormone) around sleep onsent
2. B-Endorphin 4. CRH increases in patients with PTSD
5. Patients with PTSD have a blunted ACTH response
to CRH
6. B-endorphin is involved in the endorphin pleasure
pathway and thus feeling good
TRH (Thyrotropin- Stimulates production of Thyroid gland produces thyroxine and 1. Adding T3 to and antidepressant regimen may
releasing hormone) TSH T3 potentiate medication’s response

GH-IH (growth Inhibits GH GH stimulates body growth 1. Depressed children have blunted GH response to
hormone – some drugs
inhibiting hormone)
(somatostatin)

ADH (anti-diuretic Released in pituitary portal ADH affects renal tubules in kidneys 1. Involved in memory acquisition, storage, and
hormone) system in pituitary gland for water retention retrieval
(vasopressin) 2. May be linked to polydipsic behavior in patients
with schizophrenia.
 Oxytocin Released in pituitary portal Affects myoepithelial cells in Involved in memory consolidation and retrieval
system in pituitary mammary glands for milk release

PRF (prolactin Stimulates production of Mammary glands – produce milk No significant effects
releasing factor) prolactin

LH-RH Stimulates the production of LH: No significant effects

two hormones: 1. Stimulates corpus luteum
1. LH (female) to produce progesterone
2. FSH 2. Stimulates interstitial cells (male)
to produce testosterone
FSH:
1. Stimulates follicle (female) to
produce estrogen
2. Stimulates seminiferous
tubules (male) to produce
testosterone

Resources:
Keltner, Norman and Steele, Debbie (2012) Pyschiatric Nursing. 6th ed. Elsevier, Mosby Inc
 PSYCHOPHARMACOLOGY
NCM 117 Psychiatric Nursing LEC

*NOTE: Red fonts are side notes Special Areas for Patient Education
✓ Discussion of side effects
Facts ✓ Discussion of safety issues
• Psychotropic drugs are not always effective. ✓ Attitudes of patient and nurse about medications
• Not every patient needs psychotropic drugs. ✓ Drug interactions
• Even when psychotropic drugs are effective, best ✓ Age-specific special instructions
outcomes typically occur when other interventions ✓ Instructions for pregnant or breast-feeding women
are co-administered.
• Psychotropic agents can be used to avoid the hard Common Reasons for Poor Medication
work of getting better. Compliance
• Many psychotropic drugs have significant or even ✓ Sexual dysfunction
life-threatening side effects, drug interactions or ✓ Specific S/E – dry mouth, insomnia, sleepiness
both. ✓ Other side effects
• Unfortunately, finding the right drug regimen is ✓ Emotional dulling
often a trial-and-error exercise. ✓ Cognitive slowing
✓ Denial of need
Nursing Responsibilities ✓ Fear of becoming addicted
✓ Describe psychopharmacologic agents based on ✓ Religious reasons
similarities and differences ✓ Interference with work
✓ Discuss actions of psychopharmacologic agents ✓ Inability to use alcohol or other recreational drugs
from global responses to cellular responses ✓ Pregnancy
✓ Differentiate psychiatric symptoms from ✓ Illness (suspiciousness, delusions of conspiracy)
medication side effects
✓ Apply basic principles of pharmacokinetics and
pharmacodynamics
✓ Identify appropriate use of psychopharmacologic ANTIPSYCHOTICS
agents in special populations ❖ Classifications:
✓ Involve clients and their families Typical (First-generation) Antipsychotics
✓ Identify factors that might prevent the active • Developed from 1950 – 1990
involvement of clients in their care • Further classified based on potency
✓ Describe appropriate nonpsychopharmacologic ✓ High-Potency (H=E) Typical
interventions Antipsychotics
✓ Discuss the use of standardized rating scales o Cause more EPSEs
✓ Demonstrate the knowledge necessary to develop → Fluphenazine (Prolixin)
psychopharmacologic education and treatment → Haloperidol (Haldol)
plans → Thiothixene (Navane)
→ Trifluoperazine (Stelazine)
✓ Moderated-Potency Typical
PHARMACOKINETICS Antipsychotics
• Effects that the body has on a drug → Loxapine (Loxitane)
❖ Absorption – getting the drug into the
→ Molindone (Moban)
bloodstream
→ Perphenazine (Trilafon)
❖ Distribution – getting the drug from the
bloodstream to the tissues and organs ✓ Low-Potency (L=A) Typical
Antipsychotics
❖ Metabolism – breaking the drug down into an
o Cause more intense
inactive and typically water-soluble form
anticholinergic effects and
❖ Excretion – getting the drug out of the body anti-adrenergic side effects
 Usually, this is through urine, sweat, saliva, bile, → Chlorpromazine (Thorazine)
feces, etc.
→ Thioridazine (Mellaril)
PHARMACODYNAMICS • General Rule: Drugs with increased
anticholinergic side effects produce fewer
• The effect that a drug has on the body.
EPSEs
• Two global responses to drugs:
✓ Desired effects Atypical (Second-generation) Antipsychotics
✓ Side effects • Characteristics:
✓ Reduced or no risk for EPSEs
• Down-regulation of receptors
o Chronic exposure to certain psychotropic ✓ Increased effectiveness in treating
drugs causes receptors to change negative and cognitive symptoms
 E.g., Consistent use of antidepressant
✓ Minimal risk of tardive dyskinesia
which causes _____ receptors to decrease ✓ Absence of prolactin level elevation
in number because this down-regulation and associated side effects
occurs about the same time that the → Clozapine (Clozaril)
antidepressant effect develops. It is → Risperidone (Risperdal)
thought by some that reduction in ___ → Olanzapine (Zyprexa)
synaptic receptor, it provide a better
explanation for mood elevation than
→ Quetiapine (Seroquel)
increases in neurotransmitter. → Ziprasidone (Geodon)
• Pharmacodynamic tolerance Novel (Third-generation) Antipsychotic
o Reduction in receptor sensitivity → Aripiprazole (Abilify)

Chrisyll Anne Dominguez BSN 3A

❖ Positive Symptoms of Schizophrenia
✓ Caused by excessive DA in Mesolimbic
tract
o Abnormal thoughts
o Agitation
o Associational disturbances
o Bizarre behavior
o Conceptual disorganization
o Delusions
✓ Excitement
✓ Feeling of persecution
✓ Grandiosity
✓ Hallucinations
✓ Hostility
✓ Illusions
✓ Insomnia
✓ Suspiciousness
❖ Negative Symptoms of Schizophrenia
✓ Caused by too little DA in Mesolimbic
tract
o Alogia
o Anergia
o Asocial behavior
o Attention deficits
o Avolition
o Blunted affect
o Communication difficulties
o Difficulty with abstractions
o Passive social withdrawal
o Poor grooming and hygiene
o Poor rapport
o Poverty of speech
❖ Indications for Antipsychotics
✓ Manage psychosis
o Hallucinations
o Delusions
o Disordered thought
✓ Schizophrenia
✓ Bipolar disorder
✓ Other psychotic disorders
❖ To understand better the mechanism of action of
antipsychotics, you must learn first the . . .
Neurochemical Theory of Schizophrenia
states that . . .
• INCREASED levels of DOPAMINE in the
limbic area of the brain cause schizophrenia
and its psychotic symptoms
❖ Antipsychotic’s M.O.A. (Mechanism of Action)
• Blocks dopamine receptors
❖ Four Major Dopaminergic Tracts
 Tract 1: Nigrostriatal Tract
o Involved in movement
o Traditional AP blockade => EPSEs
 Tract 2: Tuberoinfundibular Tract
o Modulates pituitary function
o Traditional AP blockade => increased
prolactin levels (amenorrhea in women;
erectile dysfunction, infertility,
gynecomastia in men; loss of libido)
 Tract 3: Mesolimbic Tract
o Involved in sensory and emotional
processes
o Traditional AP blockade NORMALIZES
these processes thereby relieving or
eliminating psychotic symptoms
 Tract 4: Mesocortical Tract
o Involved in cognitive processes
o Traditional AP blockade can intensify
negative and cognitive problems
❖ Pharmacologic Effects of APs
✓ CNS effects: emotional quieting and sedation
✓ Reduces alterations of perception:
hallucinations and illusions
✓ Improve reasoning, decrease ambivalence,
decrease delusions
✓ Slow psychomotor activity
✓ Decrease confusion and clouding
✓ Reduce inner psychological turmoil, freeing
psychic energy for normal interpersonal
relationships
✓ Decreases alterations in affect
❖ Route of Administration for APs
▪ Oral route
o Preferred route
o Watch out for “cheeking”
▪ Parenteral route (IM injection)
o For acutely ill individuals
o Those with significant compliance
risks
o Long-acting injectables given every 2-
4 weeks
▪ Long Acting Parenteral Agents
→ Fluphenazine decanoate (Prolixin
decanoate) – oil based
→ Haloperidol decanoate (Haldol
decanoate) – oil based
→ Risperidone (Risperdal Consta) –
water based
❖ Nursing Considerations when giving Long-acting
Antipsychotic Injections
✓ Injection site may become sore and inflamed
✓ Rotate sites and document
✓ Use a large-gauge needle (G. 21)
✓ Needle should be dry
✓ Given deep IM via Z-track method
✓ Do not massage injection site
❖ Side Effects of Antipsychotics
• Anticholinergic Side Effects
✓ Blurred vision
✓ Mydriasis, impaired accommodation
✓ Photophobia
✓ Diminished lacrimation
✓ Dry mouth
✓ Tachycardia
✓ Urinary hesitancy
✓ Constipation
✓ Fever
• Antiadrenergic Effects
✓ Hypotension
✓ Reflex tachycardia
✓ Caused by blocking of alpha-1 receptors
• Cardiac Effects
✓ Lengthening of the QTc interval
✓ Fatal arrythmia Torsades de pointes
✓ ECG monitoring may be needed
Chrisyll Anne Dominguez BSN 3A
 • Endocrine Side Effects • Anticholinergics are ineffective
✓ Elevation of prolactin levels • Irreversible
✓ Metabolic syndrome or insulin resistance • Symptoms stop with sleep
syndrome => DM Type 2 (Atypical APs) • Symptoms:
• Sexual Side Effects ✓ Tongue writhing
✓ Decreased libido, impotency, impaired ✓ Tongue protrusion
ejaculation ✓ Teeth grinding
✓ Lip smacking
• Gastrointestinal Effects ✓ Excessive eye blinking
✓ Weight gain ✓ Involuntary jaw movements
✓ Carbohydrate craving
 EPSE: Pisa Syndrome
• Other side effects
• Common in older individuals
✓ Jaundice
• Susceptible to leaning to one side
✓ Rare but serious blood dyscrasias
✓ Susceptibility to hyperthermia • High doses of antiparkinsonian drug
✓ Sun-sensitive skin
✓ Nasal congestion
✓ Wheezing ❖ Anticholinergic Drugs
✓ Memory loss • Treat most EPSEs
✓ Agranulocytosis with clozapine use → Benztropine (Cogentin)
→ Biperiden (Akineton)
→ Trihexyphenidyl (Artane)
❖ Extrapyramidal Side Effects (EPSE) • Risk associated with Anticholinergic use
o Abnormal involuntary movement disorders ✓ Might be lethal in overdose
o Caused by drug-induced imbalances of ✓ Might induce dependence
dopamine and acetylcholine ✓ Might exacerbate tardive dyskinesia
✓ Might induce psychosis
 EPSE: Akathisia
• Most common EPSE
• Responds poorly to treatment ❖ Neuroleptic Malignant Syndrome
• Subjective feeling of restlessness • A lethal side effect
• Demonstrated by restless legs, jittery • Less than 1% of those who use APs develop
feeling, nervous energy NMS
• A.k.a. “ants in the pants” • But 5% to 20% of those who develop NMS, DIE
without treatment
 EPSE: Akinesia and Bradykinesia • Related with high-potency APs
• Weakness, fatigue, painful muscles, and • Not related to toxic drug levels
anergia • NMS Symptoms:
• Responds to anticholinergics ✓ High body temperature – cardinal sign
✓ Muscular rigidity
 EPSE: Dystonia ✓ Tremors
• Abnormal postures cause by involuntary ✓ Impaired ventilations
muscle spasm ✓ Muteness
• Tend to appear early in treatment ✓ Altered consciousness
• Types: ✓ Autonomic hyperactivity
➢ Torticollis – contracted • NMS Treatment:
positioning of the neck → Dantrolene (Dantrium)
➢ Oculogyric crisis – contracted → Bromocriptine (Parlodel)
positioning of the eyes upward o APs should not be given for at least 2 weeks
➢ Writer’s cramp – fatigue spasms after complete resolution of NMS
affecting a hand symptoms
➢ Laryngeal – pharyngeal
constriction
➢ Opisthotonos
• Responds to anticholinergic drug ANTIDEPRESSANTS
• Treatment for Dystonia ❖ Neurochemical Theory of Depression
→ Benztropine (Cogentin) • Depressed individuals have lower levels of
→ Diphenhydramine (Benadryl) norepinephrine, serotonin, and dopamine.

 EPSE: Pseudoparkinsonism ❖ Goals of Antidepressant Therapy

• Parkinson-like symptoms ✓ Alleviate depressive symptoms
• Tremors ✓ Restore normal mood
• Bradykinesia ✓ Prevent recurrence of depression
• Rigidity ✓ Prevent a swing into mania for bipolar patients
• Mask-like face
❖ Four Main Classifications:
• Drooling
Selective Serotonin Reuptake Inhibitors
• Stoop posture (SSRI)
 EPSE: Tardive Dyskinesia → Citalopram (Celexa)
• Tends to develop after 6 months or more of → Escitalopram (Lexapro)
AP use → Fluoxetine (Prozac)
• Not caused by Ach-DA imbalance → Fluvoxamine (Luvox)

Chrisyll Anne Dominguez BSN 3A

 → Paroxetine (Paxil) ✓ Tryptophan: Serotonin
→ Sertraline (Zoloft) precursor
✓ St. John’s Wort
Tricyclic Antidepressants (TCA) - If this occurs, discontinue the
→ Amitriptyline (Elavil) drug. It usually resolves on its
→ Amoxapine (Asendin) own in 24 hours.
→ Desipramine (Norpramin) - Serotonin Syndrome Symptoms:
→ Doxepin (Sinequan) ✓ Mental status changes,
→ Imipramine (Tofranil) confusion or hypomania
→ Maprotiline (Ludiomil) ✓ Restlessness or agitation
✓ Myoclonus
→ Nortriptyline (Aventyl, Pamelor)
✓ Hyperreflexia
→ Protriptyline (Vivactil) ✓ Diaphoresis
→ Trimipramine (Surmontil) ✓ Shivering/shaking chills
✓ Tremor
Monoamine Oxidase Inhibitors (MAOIs)
✓ Diarrhea, abdominal cramps,
→ Phenelzine (Nardil)
nausea
→ Tranylcypromine (Parnate) ✓ Ataxia, or incoordination
→ Isocarboxacid (Marplan) ✓ Headaches
→ Moclobemide (Manerex)
o Novel antidepressants
Novel Antidepressants
→ Bupropion (Wellbutrin) • Second-line agents:
→ Duloxetine (Cymbalta) o TCAs (Tricyclic Antidepressants)
→ Mirtazapine (Remeron) ▪ MOA: Block the reuptake of
→ Venlafaxine (Effexor) norepinephrine and serotonin thereby
increasing the intrasynaptic levels and
❖ Most antidepressants require 2-4 weeks to have its alleviating the symptoms of
full therapeutic effect. depression
▪ Lag period of 2-4 weeks
❖ Antidepressant Treatment Strategies
• First-line agents: ▪ Therapeutic Effects of TCAs
o SSRIs ✓ Sedation to counteract insomnia
▪ MOA: inhibits serotonin reuptake into and agitation; Tolerance usually
neurons develops
✓ Alleviate lethargy: activating
▪ Has fewer anticholinergic, antidepressants
cardiovascular, and sedating SE ✓ Improve appetite: due to TCAs’
▪ Fluoxetine is associated with suicidal antihistaminic effect; may lead to
and homicidal behaviors weight gain
✓ Anxiety reduction
▪ Can induce high level of apathy: ✓ Urinary hesitancy
 Antidepressant Apathy
▪ TCAs’ PNS Side Effects
Syndrome (AAS)
➢ Anticholinergic Side Effects
✓ Lack of motivation
✓ Indifference ➢ Cardiac Effects
✓ Disinhibition ✓ Tachycardia and arrythmias
✓ Poor attention -> M.I.
✓ Heart block
▪ SSRIs Side Effects ✓ Amitryptiline – most
✓ Dry mouth, blurred vision, cardiotoxic antidepressant
sedation, cardiovascular
symptoms ➢ Antiadrenergic Effect
✓ GI symptoms: nausea, diarrhea, ✓ Orthostatic hypotension
loose stools, weight loss or gain ✓ Reflex tachycardia
✓ Hyponatremia mostly in older ▪ TCAs’ CNS Side Effects
clients ➢ Sedation
✓ CNS effects: headache, dizziness,
➢ Cognitive or psychiatric effects
tremors, anxiety, insomnia
✓ Confusion, disorientation,
✓ Sexual dysfunction: decreased
delusions, agitation, anxiety,
libido, impotence, ejaculatory
ataxia, insomnia, nightmares
delay
➢ High Risk for Suicide
▪ SSRIs most likely to cause Sexual
➢ Risk for TCA overdose
Dysfunction
→ Paroxetine ▪ TCA Overdose
→ Fluoxetine Symptoms:
→ Citalopram ✓ Sedation
→ Sertraline ✓ Ataxia
→ Escitalopram ✓ Agitation
✓ Stupor
▪ Serotonin Syndrome ✓ Coma
- Occurs when SSRIs interact with ✓ Respiratory depression
the following: ✓ Convulsion
✓ MAOIs ✓ Acute heat failure

Chrisyll Anne Dominguez BSN 3A

 ▪ Nursing Interventions for TCA ✓ Explosive occipital
Overdose headaches
✓ Monitor BP, HR, RR ✓ Head and face flushed and
✓ Maintain patent airway feel “full”
✓ ECG is recommended ✓ Palpations and chest pain
✓ Use cathartics or gastric lavage ✓ Sweating, fever, nausea,
with activated charcoal vomiting
✓ Antidote for severe TCA poisoning ✓ Dilated pupils,
→ Physostigmine (Antilirium) photophobia
▪ Drugs to avoid when taking TCAs  HYPERTENSIVE CRISIS Nursing
✓ Alcohol and benzodiazepines – Interventions
depress the CNS ✓ Discontinue MAOI and
✓ Drugs that have anticholinergic contact doctor
properties ✓ Reduce blood pressure (alpha-
✓ Drugs that stimulate the CNS 1 blocker)
✓ MAOIs ✓ Monitor vital signs
✓ Have the patient walk (which
• Third-line agents: lowers blood pressure slightly)
o MAOIs ✓ Manage fever by external
▪ Usually given to hospitalized clients cooling
✓ Institute supportive nursing
▪ Mechanism of Action: care
✓ Block monoamine oxidase
o Monoamine oxidase is a  HYPERTENSIVE CRISIS
major enzyme that Treatment
metabolizes and ➢ IM chlorpromazine 100 mg
inactivates NE, 5HT, and • MOA: blocks
DA norepinephrine
▪ Requires 2-4 weeks to achieve full ➢ IV phentolamine
therapeutic effect • Administered slowly
in 5 mg doses
▪ MAOI Side Effects • MOA: binds with NE
➢ CNS Effects: receptor sites,
✓ Hyperstimulation blocking NE
- Agitation, acute
anxiety attacks, o ECT
restlessness,
insomnia, euphoria
- Hypomania
ANTIMANIC or MOOD STABILIZING AGENTS
➢ CARDIOVASCULAR Effects: Lithium
✓ Hypotension but absence of
reflex tachycardia can lead to • MOA: remains unclear; alters Na transport in
heart failure nerves and muscle cells
• Well absorbed in GI tract, usually given PO
➢ ANTICHOLINERGIC Effects
• Excreted in the kidneys
➢ Hepatic and hematologic
• Requires 7-10 days to elicit a therapeutic effect
dysfunctions
✓ CBCs and liver function test • Blood Serum Lithium Levels
▪ Drug-to-Drug Interactions o Maintenance level
 Be cautious in using MAOIs with ✓ 0.6 to 1.2 mEq/L
✓ Drugs causing hypertension o Therapeutic serum level
✓ Drugs causing severe ✓ 0.5 – 1.2 meq/L
anticholinergic responses o Toxic
✓ Drugs that cause profound ✓ Mild to moderate: 1.5 to 2 meq/L
depression ✓ Moderate to severe: 2 – 2.5 meq/L
✓ Meperidine (Demerol) ✓ Needs dialysis: 3 meq and above
specifically contraindicated
• Expected SE (Side Effects) of Lithium
▪ Food-to-Drug Interactions
✓ Fine hand tremors
 MAOIs should not be taken with
tyramine rich foods ✓ Memory problems
 May lead to hypertensive crisis ✓ Goiter
 Tyramine rich foods ✓ Hypothyroidism
✓ All high protein foods that ✓ Mild diarrhea
have undergone protein ✓ Anorexia
breakdown by aging, ✓ Nausea
fermentation, pickling, or ✓ Edema
smoking ✓ Weight gain
✓ Aged cheese, bananas, salami, ✓ Polydipsia, polyuria
coffee
• Mild to Moderate Toxicity
 Signs of HYPERTENSIVE CRISIS ✓ Diarrhea
Symptoms: ✓ Vomiting
✓ Sudden elevation of BP ✓ Drowsiness
Chrisyll Anne Dominguez BSN 3A
 ✓ Dizziness ✓ Dysarthria
✓ Coarse hand tremors ✓ Diplopia
✓ Muscular weakness ✓ Nausea and GI upset
✓ Lack of coordination
• Nursing Considerations
✓ Dry mouth
✓ Assess drug levels every 3-4 days
• Moderate to Severe Li Toxicity o 6-12 ng/ml
✓ Previous symptoms o Taken 10 hours after last dose
✓ Ataxia ✓ Monitor salt and fluid intake
✓ Giddiness ✓ Avoid alcohol and non-prescription drugs
✓ Blurred vision ✓ Refer decrease in UO
✓ Large output of dilute urine ✓ Don’t stop abruptly
✓ Delirium ✓ C/I: pregnancy
✓ Nystagmus ✓ Take with meals
• Severe Toxicity
✓ Previous symptoms MEDICATION DOSE RANGE THERAPEUTIC
✓ Seizures LEVEL
✓ Organ failure Lithium 900 – 3600 0.5 – 1.5 mEq/L
✓ Renal failure mg/day
✓ Coma
✓ Death Carbamazepine 800 – 1200 6 – 12 ng/mL
mg/day
• Nursing Interventions
✓ Lithium levels should be checked every 2- Valproate acid 1000 – 1500 50 – 100 ug/mL
3 months mg/day
✓ Serum drawn in the AM, 12H after last
dose
✓ Common causes of increase levels Antipsychotics
o Decrease Na intake ❖ Antipsychotics that treat mania
o Diuretic therapy → Aripiprazole (Abilify)
o Decrease renal functioning → Clozapine (Clozaril)
o Medical illness → Olanzapine (Zyprexa)
o Overdose → Quetiapine (Seroquel)
o NSAIDS
→ Risperidone (Risperdal)
• Other Nursing Considerations → Ziprasidone (Geodon)
✓ Take Lithium with meals to reduce nausea
✓ Drink 10-12 glasses of water per day ❖ Antianxiety drugs
✓ Elevate feet to relieve ankle edema ➢ Anxiolytics
✓ Maintain consistent dietary sodium intake • A.k.a. minor tranquilizers
• Severe Toxicity Interventions • Subdivided into:
✓ NO ANTIDOTE! → Buspirone (BuSpar)
✓ Discontinue the drug o First nonsedating drug
✓ Gastric lavage specifically indicated for
✓ Parenteral normal saline generalized anxiety disorder.
✓ Forced diuresis o Lacks the anticonvulsant,
✓ Hemodialysis sedative, muscle relaxant
properties of benzodiazepines.
o A/E: headache, nausea,
Anticonvulsants dizziness, rarely insomnia
• Can be used as an adjunct or substitute for o C/I: renal or liver impairment,
lithium lactating women
→ Carbamazepine (Tegretol)
→ Benzodiazepines
→ Divalproex Na (Depakote)
o Indications
→ Valproic acid (Depakene) ✓ Anxiety
→ Lamotrigine (Lamictal) ✓ Sedation/sleep
→ Oxcarbazepine (Trileptal) ✓ Muscle spasm
→ Gabapentin (Neurontin) ✓ Seizure disorder
→ Topiramate (Topamax) ✓ Alcohol withdrawal
syndromes
• MOA: Increase levels of GABA; inhibits the
kindling process or “snowball”-like effect seen GENERIC NAME TRADE NAME
in mania and seizures
Alprazolam Xanax
• Side Effects
✓ Dizziness Chlordiazepoxide Librium
✓ Ataxia
✓ Clumsiness Clorazepate Tranxene
✓ Sedation
Chrisyll Anne Dominguez BSN 3A
Diazepam Valium

Lorazepam Ativan

Oxazepam Serax

Temazepam Restoril

• MOA: Depress the CNS, thereby

increasing the effects of GABA, which
produces relaxation and may depress
the limbic system
• Side Effects
✓ Daytime sedation
✓ Hypotension
✓ Ataxia
✓ Tremor
✓ Dizziness
✓ Amnesia
✓ Headache
✓ Slurred speech
✓ Blurred vision
✓ Urinary incontinence
✓ Constipation
✓ Paradoxical CNS excitement
• Nursing Considerations
✓ Monitor for:
o Motor response: agitation,
trembling, and tension
o Autonomic responses: cold
clammy hands and sweating
o Paradoxical CNS excitement
during early treatment
o Visual disturbances; may
worsen glaucoma
o Labs: liver and renal function
tests and CBCs
✓ Initiate Safety Precautions
o Risk for falls
o Assist with ambulation
o Avoid tasks that require
alertness especially driving
✓ Avoid Alcohol
✓ Do not take other medications
without consulting with physician
✓ Do not stop abruptly may cause
seizures

Chrisyll Anne Dominguez BSN 3A

 CULTURAL IMPLICATIONS FOR PSYCHIATRIC NURSING
NCM 117 Psychiatric Nursing LEC
*NOTE: Red fonts are side notes
What is the importance? Why do we have to study about the
different cultures and why do we need to adapt it within ourselves
as a mental health and psychiatric nurses? Why do we have to be
equipped with the different knowledge of the different cultures
around the world?
❖ It is important to know that culture is a critical
component of patients’ lives that affects their health care
attitude and actions as well as their ability to understand
and use the interventions that psychiatric nurses
develop.
❖ The main purpose of why we have to study this chapter
is to explain the role of the nurse and the connection
between culture and cultural competence as they relate
to psychiatric nursing.
• We, nurses, have to be culturally competent in
regard to our dealings with our patient.
CULTURE
• Is external and internal manifestation of learned
and shared values, beliefs, and norms of a person,
group or community used to help individuals
function in life and understand and interpret life
occurrences (Leininger & McFarland, 2006).
 Culture is the way of life; how the people from that
certain area/community is living their lives. We tend
to have different culture, tradition, and belief. So
whatever our belief, culture, attitudes are that alone
will affect how we view health care.
– IMPORTANCE OF CULTURAL COMPETENCE –
CULTURAL COMPETENCE
• Is the process whereby the nurse shows proficiency
in developing cultural awareness, knowledge, and
skills to promote effective health care.
 Different patients, different culture, whatever they
believe in might block or facilitate our care for them.
• A culturally competent nurse:
 Not only possesses knowledge about the
process of cultural competence but also
incorporates cultural competence into
interaction peers, students, patients, families
and communities
 It is useful for us if we have the complete
knowledge, the complete set of understanding
of what a culturally competent nurse is if we do
not use that as a backup towards dealing with
our patients. So knowledge and skill should go
hand-in-hand – not only in dealing with our
patient but also with the peers, students, or
anyone else inside our community or even
people from different areas of our lives,
different cultural background.
 Can enhance clinical excellence and promote
recovery of psychiatric patients.
 With those set of skills and knowledge, we can
help them recover.
CULTURE AND PSYCHIATRC NURSING
✓ Nurses provide services to multitude of patients
from diverse cultures.
 Especially Filipino nurses, we are everywhere
around the world so we are expected to encounter
different or diverse cultures.
✓ Cultural diversity might encompass areas such as
gender, age, socioeconomic status, religion, race,
ethnicity, mental illness and physically challenging
conditions (Andrew & Boyle, 2007).
The use of cultural competence in conjunction with the
psychotherapeutic management models serves as evidence-based
health care approach that can enhance clinical excellence and
promote recovery of psychiatric patients.
Different cultures, different beliefs, different traditions, different
way of life. Its important for us to be knowledgeable on how these
patients live and what are their attitudes in regard to dealing with
their health.
A growing knowledge on research-based indicated patients
adherence to treatment increases when cultural needs are
incorporated into health care planning so it is important to know
what the barriers are to culturally competent care.
BARRIERS TO CULTURALLY COMPETENT CARE
1. Miscommunication
▪ The nurse might not recognize the value
and importance of these beliefs to the
patient as they relate to health care
practices.
▪ Might lack knowledge and sensitivity
regarding patients cultural beliefs and
practices.
▪ Patients, similarly, might be unaware of
the nurse’s cultural perspectives and
misinterpret health recommendations
from the nurse (Diala et al., 2001).
 There may be a misinterpretation in the middle
of the therapeutic relationship so that
misinterpretation and/or miscommunication is
a vital role to address whenever we have
encountered patient with a different cultural
background.
2. Failure to assess patient’s cultural perspective
3. Differences in the nurse’s and the patient’s cultural
worldviews
Critical Thinking question:
How would a nurse use the best evidence
therapeutically and in a culturally competent
manner in his care of a patient who is refusing to
follow a nursing care plan because it does not align
with the patient’s cultural belief system?
CULTURAL ETIOLOGY OF ILLNESS AND
DISEASE
➢ Health care actions and beliefs are generally
formulated by three factors:
1. Definition of health
▪ Nurses and patients might define
health quite differently
2. Perception of how illness occurs
▪ The nurse or patient may believe that
illness and diseases are created by:
✓ Natural
o Believes everything and
everyone in this world is
interrelated and that a
disruption of this
connectedness causes illness
or disease
 E.g., Tornado – a natural
catastrophe that occurs mostly in
the Savannah, USA; So certain
group of people believe that the
Chrisyll Anne Dominguez BSN 3A
 occurrence of tornado or any CULTURE-BOUND MENTAL HEALTH ISSUES
natural catastrophe will disrupt ❖ Culture-bound syndrome
the connectedness of the people, o These are recurring pattern of behavior
the biologic, the ecosystem, the that create disturbing experiences for
equilibrium inside the
community so that for them is a
individuals (American Psychiatric
cause of illness and/or disease. Association, 2013)
o The nurse must be aware of the symptoms
✓ Unnatural
to assess patients who are from racially
o Outside forces may create
and ethnically diverse cultures accurately
illness and diseases (e.g.,
o People from diverse culture often use
magician, witch, or ghost)
culturally specific language to describe
✓ Scientific mental distress that they may experience
o Specific, concrete o E.g.,
explanations that exist for ✓ Native Americans:
every illness and disease (i.e., ▪ Depressive symptoms = “heart
entrance of pathogens such as burn” or “heart problems”
virus and bacteria) ✓ Hispanic:
o Typical model taught in most ▪ Lethargic, appetite and sleep
Western culture schools in changes, and multiple physical
nursing complains = “soul was lost” (susto)
3. Cultural worldview or place an “evil eye (mal ojo)”
✓ Analytic
o Values detail to time (e.g., being Different description of psychotic symptoms:
on time, starting on time, ending ➢ Malaya and Laos = running amok
on time) ➢ Native-American nations = ghost sickness
o Learning style: written, hands-on, ➢ African-American = spell
and visual resources
✓ Relational A more inclusive description of culture-bound
o Grounded in a belief in spirituality syndrome can be found in DSM-5 (Diagnostic and
and the significance of Statistical Manual of Mental Disorder 5th Edition).
relationships and interactions
between and among individuals
o Learning style: verbal
communication
ALTERNATIVE THERAPIES
✓ Community
o Believes that community needs
and concerns are more important
than individual ones
o Learning style: quiet, respectful
communication, meditation and
reading
✓ Ecologic
o Believes there is a form of
interconnectedness between
human beings and the earth and
that individuals have
responsibility to take care of the
earth
o Learning style: quiet observation
and contemplation and verbal
communication is minimized ➢ Acupuncture
➢ Nutritional Therapy
Critical Thinking question:  Herbal therapy and the likes
A 33-year old who is from Appalachian culture is ➢ Moxibustion
worried because she is sure her illness is due to a  There is a cotton ball containing a substance known
hex placed on her by another woman in the as moxa that is ignited with a match in a small
community. How would you, as a nurse, provide glass/cup which is then place on the skin above
care for her? Do you attempt to convince her that meridian (most often placed on the level of the
her ideas are wrong and there is no such thing as a spine).
hex?  The belief is that the illness or evil is release from a
 Remember that your culture is different from your persons body when heat is generated within the
patient. So you can explore the reason behind why meridian
your patient thinks that a certain woman from their ➢ Skin scraping
culture/tribe is the one that cause her the illness.
Maybe they have preexisting conflict between them ➢ Acupressure
or anything else that might influence your patient to  Triggering the pressure points of the body
think that.
 Never contradict your patient with regards to her ➢ Cupping
belief. Let the patient explore or verbalize why she
think that it was a hex, why she think that the illness
is placed on her by another woman. From the
exploration inside your conversation, we can notice
and recognize the reasons behind why she believes
or do not believe in a certain thing.
Chrisyll Anne Dominguez BSN 3A
 ETHNOPHARMACOLOGY
• Study of pharmacogenetic, pharmacodynamic, and
pharmacokinetic influences based on different
ethnic, racial and cultural groups.
 Culturally competent care is enhanced when these
type of cultural knowledge is incorporated into
patient care.
 There are times that some drugs that might
accumulate in a patient’s body when medications
are metabolized too slowly.
• Individuals react to pharmacologic interventions
based on their normal biologic makeup,
environmental influences, and cultural influences
 So the medication will react to a patient body
according to these 3 factors: normal biologic
makeup, environmental influences, and cultural
influences.
• Variation in metabolism is most often cited as the
cause of cross-ethnic differences in response to
medications.
 Some are fast, some are slow metabolizers.
• Individuals from certain racial/ethnic groups have
a genetically based pharmacokinetic variation that
causes them to be fast or slow metabolizers.
 The natural biologic makeup is affecting how certain
group of people metabolized their food or drinks.
• Example: Asian and Native American are more
sensitive to alcohol than any groups and may be
related to their deficiency in aldehyde
dehydrogenase (evidenced-based)

CULTURAL ASSESSMENT ISSUE

• Questions and observations relative to cultural
issues must be smoothly and sensitively
incorporated into the nursing assessment process
to ensure that the nurse does not appear rude or
intrusive.
 There are certain culture belief that for example,
when you look at them for quite a while and then
they interpret that as a staring then equates staring
to being rude or being unprofessional (usually from
Eastern side of the world).

❖ Cultural preservation
o Is the nurse’s ability to acknowledge, value
and accept a patient’s cultural beliefs.
 All nurses, ideally, should have this ability
 We should not be rude or arrogant enough
to inject our culture towards theirs
❖ Cultural negotiation
o Is the nurse’s ability to work within a
patient’s cultural belief system to develop
culturally appropriate interventions.
 Work in the grounds of the patient
 Where she/he comfortable, how she/he
should be treated – nurses should be able
to negotiate
❖ Cultural repatterning
o Is the nurse’s ability to incorporate cultural
preservation and negotiation to identify
patient needs, develop expected outcomes
and evaluate outcome plans (Leininger &
McFarland, 2006).
 Culture is a manifestation of beliefs, values,
and norms of an individual, group, or
community used for daily life functioning.
So us nurses should be able to incorporate
our ability to preserve or negotiate the
different and diverse culture that our
patients are in.
Chrisyll Anne Dominguez BSN 3A
 LEGAL AND ETHICAL GUIDELINES FOR SAFE PRACTICE
NCM 117 Psychiatric Nursing LEC
*NOTE: Red fonts are side notes
ETHICS
• The body of knowledge that explores the moral
problems surrounding specific issues
ETHICAL DILEMMA
• Situation which conflict between or among more
than one course of action in which each option has
advantages and disadvantages
• Conflict arise due to differences in values or
judgements
Nursing Implication:
1. Nurses working with mental health need to be
prepared to confront ethical dilemmas and analyze
issues that may conflict with personal beliefs as
thoroughly as possible
ETHICAL PRINCIPLES
Terminology
➢ Autonomy (self-determination)
➢ Beneficence (promotion of or bringing about
good)
➢ Nonmaleficence (avoidance of harm)
➢ Justice (fairness)
➢ Veracity (truthfulness) and Fidelity
(faithfulness)
➢ Accountability (answerable for one’s own
questions) and Responsibility (dependable role
performance)
➢ Confidentiality (maintaining privacy)
MAKING ETHICAL DECISIONS
• Ethical issues become legal issues through court
case decisions or by legislative enactment
• Code of Ethics is broader and more universal than
laws but cannot override laws
STEP in Ethical Decision Making
1. Gathering background information – finding
information to understand and clarify issues
2. Identifying ethical component – determining the
ethical dilemma
3. Clarification of the rights of agents – understanding
and clarifying of the rights of all parties involved
4. Exploring of options – considering every possible
choice in the situation
5. Applying principles – can be approached in different
manners:
• Utilitarianism (best choice for all)
 Is a theory of morality, which advocates
actions that foster happiness or pleasure
and opposes actions that cause
unhappiness or harm.
 Utilitarianism would say that an action is
right if it results in the happiness of the
greatest number of people in a society or a
group.
• Egoism (best choice for oneself)
 Is a theory, in ethics, that human beings act
or should act in their own interests and
desires
• Formalism (formal rule)
 (psychological) Formalism is defined as
the science of mind and corresponds to the
behavior of animal objects.
• Fairness based on justice
6. Resolution into action – executing of the chosen plan
ETHICAL ISSUES
in Psychiatric Mental Health Nursing
✓ Potential irreversible side effects of medications
✓ Effects of treatment such as ECT
 Electroconvulsive Therapy (ECT) treatment: some
people experience nausea, headache, jaw pain or
muscle pain
✓ Health care cost constraints
✓ Whether physical health care should be prioritized
over mental health care
✓ Role of the nurse as a client advocate
✓ Are all treatment sites equal
LEGAL CONSIDERATION
Sources of Law
➢ Main sources:
1. Common Law
• Applied to the body of legal principles that has
evolved and continues to evolve and expand
from actual court cases
2. Statutory Law
• Written law developed from a legislative body,
such as state legislature
3. Administrative Law
• Public law issued by administrative agencies
authorized by statute to administer the enacted
laws of federal and state governments
➢ Other sources:
4. Contracts
• Legal binding agreements between both parties
5. Criminal Law
• Law of crimes and their punishments
6. Civil Law
• Concerns relationships of individuals
• These laws regulate private matters and deal
with people’s rights instead of crimes
❖ Torts – are acts (that are not contract breaches) that
hurt someone but are not crimes; these are handled
by civil courts
UNINTENTIONAL TORTS (CIVIL LAW)
A. Negligence
• It is a personal wrongdoing that is
distinguished from a criminal law violation
• Described as a failure to do or not to do what a
reasonably careful person would do under the
circumstance
• Carelessness
• Departure of the standard of conduct
• Malpractice
→ Type of negligence during professional
practice
→ Any unreasonable lack of skill in
professional duties or illegal or immoral
Chrisyll Anne Dominguez BSN 3A
 conduct that results in injury to or death of PATIENT’S RIGHTS
a client 1. Right to be treated in a least-restrictive
 E.g., environment
• A nurse fails to implement safety ✓ Must be provided to patient with the use of
measures for a client who has been least-restrictive treatment
identified as at risk for falls. ✓ Involves consideration of all alternatives:
• Malpractice (Professional negligence) inpatient treatment, partial hospitalization,
– a nurse administers a large dose of foster or respite care
medication due to a calculation error.
The client has a cardiac arrest and 2. Right to confidentiality of records
dies. ✓ Information regarding all clients, voluntary
and involuntary, should be treated
• 4 ELEMENTS of Negligence
confidentially
1. Duty of Care
▪ Legal obligation of care and performance,
✓ The nurse should document all confidential
or an observance imposed on a person who information that is released in the nursing
is in a position to safeguard the rights of notes including:
others a. Date and circumstance under which
disclosure was made
2. An obligation of reasonable care / b. Names of the individuals or agencies
Reasonable Care (Standard of Care) receiving the disclosure
▪ The degree of skill, care and knowledge
ordinarily possessed and exercised by
c. Relationship to the patient
other nurses in the care and treatment of d. Specific information disclosed
patients 3. Right to freedom from restrain and
▪ “Did the nurse meet the standard of care?” seclusion
3. Breach of Duty • Restrain: any form of limiting a person’s
▪ Is the failure to conform to or the departure movement or access to his/her own body
from a required duty of care owed to a • Seclusion: the process of isolating a person in
person room in which he is physically prevented from
4. Injury proximately caused by a breach of leaving
duty / Proximate cause of causation ✓ Nurses who are aware of the potential negative
▪ The defendant’s negligence must be a
consequences, are more apt to look for
substantial factor causing the injury
alternative strategies
✓ Most valuable intervention are aimed at
INTENTIONAL TORTS (CIVIL LAW) preventing a patient’s escalation of behaviour
 When a person does damage to another person in a
and loss of control
willful way and without just cause or excuse ✓ General Guidelines in Documentation
A. Assault (Restrain and Seclusion):
 A mental or physical threat knowingly threatening a. Staff members must receive special
or attempting to do violence to another without training in applying/removing
touching the person restraints
B. Battery b. Alternatives must be considered
 There’s already touching or wounding a person in an before the use of restraint and
offensive manner with or without intend to do harm seclusion
C. Fraud c. A physician’s order must be required
 A purposeful false presentation of facts to create within an hour
deception d. Least restrictive method/device
 It includes presenting false credentials (for licensure possible must be chosen
or employment) e. Orders must contain a type of
D. Invasion of privacy restraint, rationale for use, and time
 It involves privilege communication and limitations
unreasonable intrusion f. As needed orders (PRN) are not
permitted
 Encroachment or trespass to another person’s  Need dapat case-to-case basis ang
body order sa restriction
 It includes any unwarranted operation, g. Should be used for the shortest
unauthorized touching, and unnecessary possible time. Reevaluation is needed
exposure or discussion of client’s case unless
every 2 hours for continued need of
authorized
restraint and seclusion
 False imprisonment
h. Patient must be observed constantly
 Even without force or malicious intent, includes
intentional confinement without authorization during the intervention with
as well as threat of force or confining structures documentation of safety and comfort
and/or clothing at least every 15 minutes
 It is not false imprisonment especially when it i. Patient must be debriefed after
is necessary to protect an emotionally disturbed restrictive interventions
person from harming herself/himself from j. Patient have the right to request
others notification of a family member/other
 Defamation person in the event that
 It involves communications, even if its true, restraints/seclusion are implemented
that causes of lowering the opinion of the k. Death of any patient while in restraint
person is required to report to the FDA
 It includes: (both of which are dependent on
communication to a third party) 4. Right to give or refuse consent to treatment
a. Slander (Oral) ✓ Voluntary patient: has the right to receive or
b. Libel (Written, Pictured, Telecast) refuse treatment
Chrisyll Anne Dominguez BSN 3A
 ✓ Involuntary patient: have not always been
understood to have the same right to refuse
treatment however, through the years many
has been forced to take medications against
their will
✓ After the court decides that a person is
incompetent, medications can be imposed to
that person
5. Informed consent
✓ In emergency situation, two (2) health care
providers may sign consent client
✓ Explanation of the treatment done including
risks, benefits, and alternatives
✓ The health care provider must determine
whether the client’s knowledge level is
sufficient to give consent before asking it
DUTY TO WARN
→ Mental health professionals have a duty to notify an
intended and identifiable victim
→ Many mental health care facilities have duty-to-
warn policies (known as “Tarasoff” policies after
the court case) and procedures for reference
→ Failure to warn exposes the nurse to civil damages
for malpractice
→ Balance between duty to protect confidentiality
with a responsibility to warn society of possible
danger
SUSPENSION OF PATIENT’S RIGHTS
→ Happens when it is believed that the patient might
attempt to harm himself given that specific right
COMMITMENT ISSUES
COMMITMENT
• Is a term that refers to the various ways that an
individual enters mental health treatment
• Types:
➢ Voluntary Patient
▪ Seek help voluntarily and sign necessary
documents including consent
▪ When ready to leave, they sign themselves
out
▪ Mostly facilities have 24-72 hours grace
period to allow professional staff time to
properly assess the patient before they
leave voluntarily
➢ Involuntary Patients (Commitment)
▪ When an individual has the legal capacity
to consent mental health treatment refuses
to do so
▪ Mental illness is not equivalent to
incompetence
▪ Criteria: dangerous to self, dangerous to
others and gravely disabled
▪ 3 Categories of Involuntary Commitment
1. Emergency Care
❖ 48-72 hours is required to
determine whether more long-
term commitment is needed of the
client may be discharged to
outpatient treatment
❖ Nursing Implications:
✓ The nurse must be absolutely
aware of the point at which the
emergency treatment is over and
prepare the patient for discharge
at that time
✓ Patients might be asked to remain
voluntarily in the facility, and if
they refuse, they might be asked
to sign out against medical advice
2. Short-term Observation and
Treatment
❖ To determine whether a patient
has a treatable mental disorder
❖ A treatable mental disorder means
that the problem is amenable to
and can improve with treatment
❖ Court-ordered observational
admission: used to assess a
person’s mental status in relation
to legal activities (e.g., competency
to stand trial)
❖ Nursing Implications:
✓ Patients must be released when
no legal basis exists for continued
confinement in the hospital
✓ The staff cannot hold someone
simply because they believe that
the individual needs to be
protected from him/herself
3. Long-term Commitment
❖ This is reserved for persons who
need prolonged psychiatric care
but refuse to seek such help
voluntarily
❖ Last from 90 days to longer
➢ Commitment of Incapacitated Persons
▪ A person who is identified as being gravely
disabled is viewed by the legal system as
incompetent
▪ Once judged incompetent, the
individual loses rights such as right to
marry, vote, drive a car, and sign contracts
▪ Gravely disabled means the inability to
provide food, clothing, and shelter for
oneself because of mental illness
▪ NOTE: Not all people in the street are
gravely disabled thus should be
hospitalized for their own good. However,
people with money in their pockets who
cannot negotiate arrangements for food
or shelter are gravely disabled
• Conservators and Guardians
o An appointed conservator or guardian can be
given broad powers, including the right to
order the conservatee to receive psychiatric
treatment
o There is a legal distinction between this type of
commitment and an involuntary commitment
o Based on the premise: the conservator now
speaks for the patient; hence the treatment is
not voluntary
o Conservators are legally obliged to act in the
best interest of conservatees
• Nursing Implications:
✓ The nurse must obtain consent from the
conservators for decisions that are otherwise
made by patient
Chrisyll Anne Dominguez BSN 3A
 PSYCHIATRIC ADVANCE DIRECTIVE
• A client with a recurrent or severe persistent
psychiatric disorder may establish an advance care
directive to guide treatment during a future
episode of mental illness when judgement is
impaired
• This directive is similar to medical care advance
directives in many ways, but they have additional
challenges particularly with patients having
fluctuating mental disorder
• Individuals in the mental health care setting may
issue the following but not limited to:
✓ Use of specific medication including dose and
route
✓ Use of specific treatment options: ECT
✓ Use of behavior management including
restraint, sedation, seclusion
✓ A list of individuals who are to be notified and
allowed to visit
✓ Consent to contact health care provider and
obtain health treatment record
PHILIPPINE MENTAL HEALTH LAW
(RA 11036)
A. Mental Health
• Mental health includes our emotional,
psychological, and social well-being. It affects
how we think, feel, and act. It also helps
determine how we handle stress, relate to
others, and make choices.
B. Mental Health Law
• An Act establishing a national mental health
policy for the purpose of enhancing the
delivery of Integrated Mental Health Services,
Promoting and Protecting the rights of Persons
utilizing psychiatric, neurologic and
psychosocial health services, appropriating
funds therefor, and for other purposes.
C. Who signed the Mental Health Bill into Law?
• Philippine President Rodrigo Roa Duterte
signed the Mental Health Bill and officially
acknowledged it as the Mental Health Law or
Republic Act 11036 on June 20, 2018, a day
before the bill finally lapsed into law.
D. What changes can the RA 11036 bring to the
country?
• Mental Health Law will provide patients and
sufferers access to the benefits of government
medical insurance like PhilHealth. These
benefits include payment coverage for the
mental health patient’s medical check-up,
medicine, and hospital confinement.
• Most importantly, the RA 11036 mandates the
government to provide specific health sectors,
units and health workforce that are primarily
dedicated to attending to mental health
sufferers.
E. Is RA 11036 the first law of its kind?
• According to the Mental Health Law’s
proponents and its supporting coalition, RA
11036 is actually the very first legislation that
was written to protect the rights as well as the
welfare of Filipinos with mental health
conditions.
• Most importantly, the law is the first to
acknowledge measures that directly shifts the
focus of care, primarily to the community,
emphasizing the importance of access to
services and integration of mental health in
both the national school curricula and
countrywide workplace regulations.
F. How was RA 11036 received by the Filipinos?
• Mental health advocates, lawmakers, health
workers, and millions of Filipinos have
supported and commended the move to finally
recognize the need for measures to support,
assist and provide the necessary help to mental
health sufferers.
Situation:
 Bai, a pharmacy student. And like you, Bai also
have problems sometimes (self, grades, family, love
life). And its makes her depressed at school.
 With RA 11036: Bai started to consult right away
before it will lead to chronic mental illness.
 After, Bai is facing life with positivity (trust
yourself, etc.)
How did the law improved her life?
• She was able to share her problems without
being judged by others.
• She was able to gain advices which she could
use to make wiser decisions.
• She was able to share her problems to others
and make them inspired that no matter how
though life is, a person should be tougher.
STATUS OF MENTAL HEALTH LAW IN THE
PHILIPPINES
❖ Mga Pangunahing Punto ng Bagong Mental Health
Law (Main Points of the Mental Health Law)
1. Access sa Mental Health Services
(Access to Mental Health Services)
2. Proteksiyon laban sa Diskriminasyon
(Protection against Discrimination)
3. Pagpapalaganap ng Kaalaman sa
Mental Health (Widespread
information about Mental Health)
4. Maayos na Pagtugon sa Problema sa
Droga (Right action against Drug
Problems)
❖ Philippine Mental Health Law, pinirmahan na ni
Pangulong Duterte (June 20, 2018)
❖ Senator Hontiveros:
✓ Gustong burahin ng mental health law ang
stigma sa mga taong may mental health needs
✓ Layunin ng mental health law na magbigay ng
mental health services hanggang sa barangay
level
✓ Sa ilalim ng mental health law, maglalaan ng
pondo ang gobyerno para sa mental health
services
✓ Magkakaroon na rin ng PhilHealth coverage
ang mga taong may mental health disorder
✓ 1-2% lang ng mga may mental health disorder
ang kailangang i-confine
✓ Dapat tugunan sa isang public health
perspective ang problema sa droga sa bansa
✓ Hindi epektibo ang law enforcement approach
lang sa problema sa droga base sa karanasan
ng ibang bansa
✓ Palalakasin ang help line para sa mga taong
nangangailangan ng mental health service
Chrisyll Anne Dominguez BSN 3A
 NURSING PROCESS AND STANDARDS OF CARE IN PSYCHIATRIC MENTAL HEALTH NURSING
NCM 117 Psychiatric Nursing LEC

*NOTE: Red fonts are side notes

(1) Assessment, (2) Nursing diagnosis, (3) Outcome  Behaviors during interview
identification, (4) Planning, (5) Implementation, (6)  Degree of cooperation, resistance
Evaluation, (7) Documentation and engagement

NURSING PROCESS  Social skills

• Is defined as an organized problem-solving method  Friendliness, shyness or
that is unique to nursing and is designed to meet withdrawal
the needs of the patient, the family, the community,
and the environment.  Amount and type of motor activity
• Its universal language acts as a common thread  Psychomotor agitation or
retardation, restlessness, tics,
that unites nurses in delivering quality care to
tremors, hypervigilance or lack of
patients in all settings.
activity
• STEPS of the Nursing Process
❖ Assessment  Speech patterns
→ The nurse assesses the patient’s mental  Amount, rate, volume, tone,
pressured speech, mutism,
status, psychosocial state, physical health,
slurring or stuttering
pain level, and nonverbal behaviors with
the use of various methods of data  Degree of concentration and
collection. attention span
→ This phase begins on admission to a unit or
program with a nurse.  Orientation
 To time, place, person, situation,
→ Steps: and level of consciousness
✓ Assess for behaviors or risk factors
that threaten the safety of the patient  Memory
or others.  Immediate recall, recent, remote,
✓ Assess for physical pain on a scale of 1 amnesia, and confabulation
to 10 and for medical problems that
 Intellectual functioning
may affect patient functioning, mood
state or overall well-being.  Educational level, use of language
✓ Establish trust, rapport, and respect and knowledge, abstract versus
concrete thinking (proverbs), and
throughout patient contact.
calculations (serial sevens)
✓ Maintain a calm, empathetic and
nonjudgmental attitude.  Affect
✓ Identify current problem and explain  Labile, blunted, flat, incongruent,
it clearly to the patient and his or her or inappropriate
family with the use of language that is
basic but not condescending.  Mood
✓ Determine the patient’s current level  Specific moods expressed or
of mental, emotional, and psychosocial observed –euphoria, depression,
functioning; include cognition, mood, anxiety, anger, guilt, or fear
affect, coping, relatedness, recent
stress or trauma, hygiene and posture.  Thought content
✓ Recognize aspects of the patient’s  Is what the client actually says
behaviors, vulnerabilities, beliefs or  Helplessness, hopelessness,
other areas that require attention to worthlessness, suicidal thoughts
affect a positive outcome. or plans, suspiciousness, phobias,
✓ Ask the patient and his or her family obsessions, compulsions,
what outcomes they expect to obtain preoccupations, poverty of
from treatment content, denial, hallucinations
✓ Develop a patient-centered treatment (auditory, visual, olfactory,
plan and prioritize problems to be gustatory, tactile), or delusions
addressed to meet the patient’s needs. (of reference, influence,
persecution, grandeur, religious,
→ Mental Status Examination nihilistic, somatic)
▪ Is a very important component of
patient assessment in psychiatric  Thought processes reflected in
settings. speech
▪ It focuses on the patient’s current state  Thought process –> refers to how
in terms of thoughts, feelings, and the client thinks
behaviors.  Ambivalence
▪ COMPONENTS:  state of mixed feelings
 General appearance  Circumstantiality
 Type, condition and  A client eventually answers a
appropriateness of clothing (for question but only after giving
age, season, setting), grooming, excessive unnecessary detail
cleanliness, physical condition
and posture.

Chrisyll Anne Dominguez BSN 3A

  Tangentiality ✓ Personal psychiatric treatment,
 Wandering off the topic and including medications and
never providing the complementary therapies
information requested ✓ Stressors and coping methods
✓ Quality of activities of daily living
 Thought blocking
✓ Personal background
 Stopping abruptly in the ✓ Social background, including support
middle of a sentence of train systems
of thought; sometimes ✓ Weaknesses, strengths, and goals for
unable to continue the data treatment
 Loose associations ✓ Racial, ethnic and cultural beliefs and
 Disorganized thinking that practices
jumps from one idea to ✓ Spiritual beliefs or religious practices
another with little or no  It is most often the SUBJECTIVE part
evident relation between the of the assessment.
thoughts
 Focuses on the patient’s perceptions
 Flight of ideas and recollections of current lifestyle
 Excessive amount and rate of and life in general.
speech composed of
fragmented or unrelated
ideas Spiritual/Religious Assessment
 Perseveration  Importance of spirituality and
 Repetition of particular religious beliefs is an often overlooked
response (word, phrase, or element of patient care although
gesture) regardless of numerous empirical studies have
absence of stimulus suggested that being part of a spiritual
 Neologisms community is helpful to people coping
 Made up words that have with illness and recovering from
meaning for the patient surgery.
 Word salad  RELIGION
 Flow of unconnected words → Is an external system that includes
that convey no meaning to beliefs, patterns of worship and
the listener. symbols. An individual connects
 Insight personal spiritual beliefs with a
 Degree of awareness of illness, larger organized group or
behaviors, problems, and their institution.
causes → Belonging to a religious
community can provide support
 Judgement during difficult times.
 Soundness of problem solving
and decisions  SPIRITUALITY
→ Is more of an internal
 Motivation phenomenon and is often
 Degree of motivation for understood as addressing
treatment universal human questions and
needs.
Ongoing Assessment → It can be expressed as having 3
 Even when the initial assessment is dimensions:
complete, each encounter with a ✓ Cognitive – beliefs, values,
ideals, purpose, truth, wisdom
patient involves a continuing
✓ Experiential – love, compassion,
assessment that might or might not be connection, forgiveness, altruism
congruent with the initial assessment. ✓ Behavioral – daily behavior,
 Explore the following that might be moral obligations, life choices and
valuable: medical choices
✓ Context or situation that precipitated → Is more about the believer’s faith
the behavior being more personal, less
✓ Patient’s thoughts at the time dogmatic, and more inclusive,
✓ Whether the behavior makes sense in considering the belief that there
that context are many spiritual paths and no
✓ Whether the behavior was adaptive or one “real path”.
dysfunctional  Commonly used questions in
✓ How this episode fits with the total spiritual/religious assessment
picture of the patient ✓ Do you have a religious affiliation?
✓ Whether a change is needed ✓ Who or what supplies you with
strength and hope?
Psychosocial Assessment ✓ Do you practice any spiritual activities
(yoga, tai chi, medication)?
 It provides additional information
✓ Do you participate in any religious
from which to develop a plan of care. activities?
 Includes the following: ✓ Do you pray or meditate?
✓ Central or chief complaint
✓ History of violent, suicidal, or self- Cultural and Social Assessment
mutilating behaviors
✓ Alcohol and or substance abuse  Since there is cultural diversity in most
✓ Family psychiatric therapy societies, there is a need for nursing
assessments, diagnoses, and

Chrisyll Anne Dominguez BSN 3A

 subsequent care to be planned around
the unique cultural health care beliefs,
values, and practices of each individual
patient.
 Sample questions include:
✓ What is your primary language?
✓ Who do you live with?
✓ Are there special foods that you eat?
✓ Are there special health care practices
within your culture that address your
particular mental or emotional health
problem?
❖ Nursing Diagnosis
→ Is the identification of patients’ problems
based on conclusions about the dynamics
evident in verbalizations and behaviors.
→ Emergency behaviors (e.g.,: suicidal or
homicidal ideas or attempts, aggression,
destructive behaviors, risk of arson or
escape) are given priority in establishing
nursing diagnoses and in negotiating no-
harm agreements with patients.
→ Suicidal intent should be regularly
assessed whether or not a patient agrees to
a no-harm contract.
→ 3 Components:
▪ NANDA International diagnoses
suggest a statement format that has
the following components:
1. Risk for actual problems
2. Contributing, causative or
etiologic factors
3. Defining characteristic or
behavioral outcome
→ Format:
✓ (Problem) related to (contributing factor)
as evidenced by (behavioral outcome)
✓ Sample: “Anxiety, moderate, related to
marital problems as evidenced by
ineffective problem solving.”
❖ Outcome Identification
→ A goal or outcome specifies an adaptive
behavior to replace one that is
dysfunctional.
→ Should be SMART.
→ In establishing goals and outcomes with a
patient (collaboration), the nurse must
understand the problems the patient wants
to address and the goals the patient wants
to achieve. PATIENT DESIRES AND
MOTIVATION play a major role in
attaining outcomes.
→ SHORT-TERM GOAL
o Achievable in perhaps 4-6 days for
hospitalized patients and perhaps
somewhat longer for patients in other
settings.
→ LONG-TERM GOAL
o Relate to issues that require follow-up
counseling after discharge to another type
of service within the continuum of care.
→ Example:
 Patient’s short-term goal is to identify
difficulties in intimate relationships.
 Patient’s long-term goal is to practice how
to respond to anxiety-provoking dating
situations; thus, by increasing awareness
of fears, the patient might be better in
addressing these types of situations.
❖ Planning and Intervention
→ Nursing Care Plans
▪ Nurse often develop standardized care
plans with expected outcomes for certain
types of patient problems.
▪ Focuses on psychiatric diagnoses (e.g.,:
major depression), or more specific
problems (e.g.,: self-mutilation).
→ Initial nursing care plan may be updated at
any time but begins with one or two
behavior-oriented problems to be
addressed immediately
✓ E.g.,: suicide, aggression, arson, escape,
withdrawal or isolation, delusions,
hallucinations, impulsive or compulsive
acts, suspiciousness, uncooperativeness, or
alter thought processes.
→ Goal of standardized care plans is to
expedite treatment activities to achieve
patient outcomes in a cost-effective
manner.
→ Nursing interventions should focus
particularly on safety, structure, support,
and symptom management.
→ However, nurse must remember that each
patient is an individual, and patient’s
unique problems and needs must not be
ignored when formulating the plan of care.
→ Sample:
✓ A patient who has suicidal ideation
(problem) would be expected to sign a no-
harm agreement (outcome) within 24
hours (time constraint) and to verbalize a
plan for dealing with suicidal ideation
(outcome) by day 3 of admission (time
constraint).
✓ Related nursing intervention would
include:
 An agreement with the patient for
safety
 Removal of dangerous objects from
the patient and the patient’s room
 Assessment for suicidal ideation
during every shift
→ Focus of psychiatric nursing. . .
▪ Is often on the verbal strategies that
are used to guide patients in solving
problems for themselves and
achieving outcomes.
▪ Psychiatric nurses are primarily
FACILITATORS and EDUCATORS.
→ Progress Notes and Shift Reports
▪ Is a tool used to communicate with
team members to ensure continuity of
care.
▪ These reports are also ways of
evaluating the effectiveness of
treatment plans and progress toward
patient short-term and long-term
outcomes.
▪ 4 COMPONENTS of Progress Notes
 Subjective Content
 The patient’s statements about
his or her own thoughts, feelings,
behaviors and problems
 Objective Data
 The nurse’s observations or
measurements, such as the
patient’s appearance, nonverbal
behaviors, and vital signs
Chrisyll Anne Dominguez BSN 3A
  Analysis or Conclusions
 The nurse’s impressions of what
the patient is..
✓ Experiencing or
demonstrating in behavioral
or descriptive terms (not
medical diagnoses);
✓ Defenses, mood, and issues
are identified;
✓ Depressed mood and
paranoid ideas can be
discussed, but “depression”
and “paranoia” are not listed
as illnesses;
✓ Conclusions about changes
(regression or progression)
in the patient and medication
responses are described.
 Plans
 Actions that nurses or other team
members can take to intervene
with the problems described in
the progress note.
→ Basic Level Intervention
➢ RN-PMH Registered Nurse - Psychiatric
Mental Health
➢ APRN-PMH Advanced Practice
Registered Nurse - Psychiatric Mental
Health
A. Coordination of Care
 The psychiatric mental health
nurse coordinates the
implementation of the plan and
provides documentation
B. Health Teaching and Health
Promotion
 Health teaching – includes
identifying the health education
needs of the patient and teaching
basic principles of physical and
mental health, such as giving
information about coping,
interpersonal relationships,
social skills, mental disorders, the
treatments for such illnesses and
their effects on daily living,
relapse prevention, problem-
solving skills, stress management,
crisis intervention, and self-care
activities.
 Self-care activities assists the
patient in assuming personal
responsibility for activities of
daily living and focuses on
improving the patient’s mental
and physical well-being.
C. Milieu** Therapy
 An extremely important
consideration in helping patients
feel comfortable and safe.
 Includes orienting patients to
their rights and responsibilities,
selecting specific activities that
meet patient’s physical and
mental health needs, and
ensuring that patients are
maintained in the least restrictive
environment safety permits.
D. Pharmacological, Biological,
and Integrative Therapies
 Nurse is expected to discuss and
provide medication teaching tools
to the patient and family
regarding drug action, adverse
side effects, dietary restrictions,
and drug interactions and to
provide time for questions.
➢ APRN-PMH Advanced Practice
Registered Nurse - Psychiatric Mental
Health
E. Prescriptive Authority and
Treatment
 The APRN-PMH is educated and
clinically prepared to prescribe
psychopharmacological agents
for patients with mental health or
psychiatric disorders in
accordance with state and federal
laws and regulations.
F. Psychotherapy
 The APRN-PMH is educationally
and clinically prepared to conduct
individual, couples, group and
family psychotherapy, using
evidenced0based
psychotherapeutic frameworks
and nurse-patient therapeutic
relationships.
G. Consultation
 APRN-PMH works with other
clinicians to provide consultation,
influence the identified plan,
enhance the ability of other
clinicians, provide services for
patients, and effect change.
❖ Evaluation
→ The nurse evaluates the patient’s
outcomes, which reflect the success of
nursing interventions.
→ Evaluation of the patient’s progress and
the nursing activities involved are critical
because nurses are accountable for the
standards of care in each discipline.
→ The evaluation of achieved outcomes
occurs at various times during treatment
as stated in the outcomes section, with the
patient’s health state and capabilities being
the primary consideration.
→ Steps in Evaluation Phase:
 The nurse compares the patient’s
current mental health state or
condition with the outcome statement.
o Is the patient’s anxiety reduced to
a tolerable level?
o Can he or she sit calmly for 10
minutes, attend to an activity for
15 minutes, or socialize with the
staff for 5 minutes without
distractions?
o Is there a significant reduction in
pacing, fidgeting, or scanning?
o The degree to which the patient
achieves outcomes is an
evaluation of the effectiveness of
nursing, although other factors
influence outcomes as well.
 The nurse considers all of the possible
reasons that the patient did not
achieve outcomes.
o Sometimes, it is too soon to
evaluate outcomes, and the plan of
action needs to continue for a
longer period of time.
Chrisyll Anne Dominguez BSN 3A
 o Occasionally, the interventions are
too strong and frequent, or they
may be too weak and infrequent.

❖ Documentation
→ Is considered the seventh (7th) step in the
nursing process.
→ Medical records are legal documents and
may be used in a court of law.
→ Includes the following:
✓ Informed consent
✓ Reaction to medication
✓ Documentation of symptoms
✓ Concerns of the patient
✓ Any untoward incident in the
health care setting
→ Documentation is the responsibility of the
entire mental health team.
→ Must consider the following when
choosing documentation system:
✓ Professional standards
✓ Legal issues
✓ Requirements for reimbursement
by insurers
✓ Accreditation by regulatory
agencies
→ Information also must be in a format that
is retrievable for quality improvement
monitoring, utilization management, peer
review and research.
→ Documentation must be focused,
organized, pertinent, and conform to
certain legal and other generally accepted
principles.

Chrisyll Anne Dominguez BSN 3A

 THERAPEUTIC RELATIONSHIPS AND COMMUNICATION
NCM 117 Psychiatric Nursing LEC

THERAPEUTIC RELATIONSHIP 6. THERAPEUTIC USE OF SELF

COMPONENTS of a Therapeutic Relationship • The use of the nurse’s aspects of his
personality, experiences, values, feelings,
1. TRUST intelligence, needs, coping skills and
• Builds when the client is confident in the nurse perceptions to establish relationship with
and the nurse’s presence convey is integrity clients
and reliability • Johari’s Window (Open, Blind, Hidden,
• Consistency and congruence Unknown)
• Trusting Behaviors:
✓ Friendliness
✓ Caring
✓ Interest TYPES of Relationship
✓ Active Listening
❖ Social Relationship
✓ Providing schedule of activities
✓ Understanding • Primarily initiated for the purpose of
✓ Consistency friendship, socialization, companionship, or
✓ Treating the client as a human-being accomplishment of a task
 No matter how senseless they say, you have • Communication is superficial; meets basic
to be able to treat them as human beings need for people to interact
still that they are patient with the disease
(they are not eaten by their disease but ❖ Intimate Relationship
human beings carrying the disease). Thus, • Two people emotionally committed to each
you have to help them become stronger other
than their symptoms • May include sexual/ emotional intimacy and
✓ Approachability sharing of mutual goals
✓ Keeping promises
• Has no place in nurse-patient relationship
✓ Honesty
❖ Therapeutic Relationship
2. GENUINE INTEREST
• Focuses on the needs, experience, feelings and
• Occurs when the nurse is comfortable with
ideas of the client only
himself, aware of his strengths and limitations
and clearly focused when dealing with the • Parameters are clear
client • Rooted from self-awareness
• The concept of self-disclosure on the nurse’s • Nurse and patient agree about the areas to
part (focus on the patient) work
• Empathy vs Sympathy
➢ Empathy – ability of the nurse to perceive the
meaning and feelings of the client and to PHASES of Therapeutic Relationship
communicate that understanding to the client 1) Preorientation
(Empathy is always the healthy and • Self-awareness activities
therapeutic) • Prepare the setting
3. ACCEPTANCE
2) Orientation
• When the nurse does not become upset or
• Begins when the nurse and client meet and
respond negatively to a client’s outburst, anger
ends when the client begins to identify
or acting out
problems to examine
• Avoiding judgement of the person, no matter
• Nurse establishes roles
what the behavior is
• State purpose
• Acceptance of the person as worthy
• Parameter/LAGDA of subsequent meetings
4. POSITIVE REGARD • Identify client’s problem
• Appreciating the client as a unique, worthwhile • Clarifies expectations (let the patient know the
human being can respect the client regardless objectives of interventions and relationship)
of the behavior, background or lifestyle • Nurse and patient contract
• Avoid communicating negative opinions or ✓ Time, place and lengths of sessions
value judgements about the client’s behavior ✓ When sessions will terminate
5. SELF-AWARENESS ✓ Clients responsibilities
• Process of developing an understanding one’s ✓ Confidentiality
values, beliefs, thoughts, feelings, attitudes, ✓ Duty to warn
motivation, prejudices, strengths, and • Self disclosure: the degree of information you tell
limitations and how these qualities affect your clients
others
➢ Values – are abstract standards that give a person a 3) Working Phase
sense of right and wrong and establish a code of • Maintain trust and support
conduct for living • Promote client’s insight (client’s awareness of
➢ Beliefs – are idea that one holds to be true his new condition) and perception of reality
➢ Attitude – general feelings or a frame of reference • Problem-Identification
around which a person organizes knowledge about - in depth but selective exploration of issues
the world

Chrisyll Anne Dominguez BSN 3A

 • Exploitation
- Overcome resistance behaviors
- Reality testing and cognitive
restructuring
- Writing and journaling
- Supportive confrontation
- Promoting change
- Teaching new skills
• SPECIFIC TASK for Working Phase
 Maintaining the relationship
 Gathering more data
 Exploring perception of reality
 Developing positive coping mechanisms
 Promoting positive self-concept
 Encouraging verbalization of feelings
 Facilitating behavior change
 Working through resistance
 Evaluating progress and redefining goals
as appropriate
 Providing new opportunities for the client
to practice new behaviors
 Promoting independence
 Identifying transference and
countertransference
➢ Transference – occurs when a client
unconsciously transfer to the nurse
feelings he/she has for significant others
➢ Countertransference – occurs when the
nurse responds to the client based on
personal unconscious needs and conflicts
4) Termination
• Therapeutic conclusion of the relationship
occurs when progress has been made toward
attainment of goals
• A plan of care for more adaptive coping with
future stressful situations has been established
• Feelings about termination of the relationship
are recognized and explored
 The nurse will say, “Okay we are about to
end our session or the entire
therapy/intervention, how are you feeling?
What do you think are the improvements
that you gain for yourself? What do you
think are the things that you learned that
might be helpful for you? Etc..”
• Evaluation and summary of progress
• Synthesizing the outcomes
• Proper referrals
• Discussion of termination
BEHAVIORS THAT DIMINISH the Therapeutic
Relationship
A. Inappropriate boundaries
✓ Maintain professional boundary
✓ Nurse must be self-aware
✓ Nonacceptance and avoidance
THERAPEUTIC COMMUNICATION
1. COMMUNICATION
• Two or more people that involves the exchange
of information between a sender and receiver
• Product: Message
• Channels: Words and behaviors
2. CATEGORIES
• Written: Primary means of acquiring and
sharing information
• Telephone
• Electronic
3. THEMES in Patient Communications
➢ Content – goes beyond the words that a patient is
saying & examine underlying message about the
patient’s perception with themselves & their
problem overtime
➢ Mood – relate to feelings conveyed while patients
discuss their concerns
➢ Interaction – involves examining the ways in which
patient relate to family, friends & other patients
4. CONSIDERATIONS
• Environmental considerations: noise levels,
privacy, type of furniture, space, temperature
• Illness & emotional factors: aggressiveness &
anxiety
• Physical considerations
✓ Sensory limitation
✓ Developmental disabilities
✓ Physical pain
✓ Physical deformities
• Kinesics consideration: study of body movement
• Paralanguage: any sound that is not a spoken word
(e.g., voice tone, inflection, emphasis, cough,
groaning, grunting, crying, and other audible
sounds)
• Proxemics: the study of distance zones between
people during communication
➢ 4 ZONES of Proxemics:
 Intimate (0 – 18 inches)
→ parents with young children, intimate
relationship
→ invasion is threatening and produces
anxiety
 Personal (18 – 36 inches)
→ between family and friends
 Social (4 – 12 feet)
→ acceptable for communication in
social, work & business settings
 Public (12 – 25 feet)
→ between a speaker and an audience
5. TOUCH
• As intimacy increases, the need for distance
decreases
• Knapp (1980) 5 TYPES of Touch:
➢ Functional – professional touch
➢ Social – polite touch
➢ Friendship – warm touch
➢ Love – intimacy touch
➢ Sexual – arousal touch
6. ACTIVE LISTENING
• Means refraining from other internal mental
activities and concentrating exclusively on what
the client says
7. ACTIVE OBSERVATION
• Means watching the speaker’s nonverbal
actions as he communicates
• ATTRIBUTES of Active/ Therapeutic Listening
✓ Being actively alert
✓ “Hearing” with all the senses
✓ Using eye contact
Chrisyll Anne Dominguez BSN 3A
 ✓ Assimilating verbal and nonverbal cues 4. MANIPULATION
✓ Exhibiting attending posture • Initially: address what is happening
✓ Ensuring concentration “I’m getting the impression that..”
✓ Being patient
“Would you like me to relieve it for you-let’s
✓ Offering empathy and support
✓ Openness talk about what you can do to..”
✓ Asking questions (therapeutic questions only) “I can see that you are.. what is it that you really
✓ Validating information want?”
✓ Summarizing important points • Limit setting
✓ Giving feedback • Help patient express their need
5. CRYING
• Assess meaning
AVOIDANCE OF NONTHERAPEUTIC • Provide privacy
COMMUNICATION • Be quiet and nonobtrusive
and • Discuss the circumstances that precipitates the
BARRIERS TO COMMUNICCAITON tears
 Direct personal questions are probing/invasive 6. SEXUAL INNUENDOS or INAPPROPRIATE
 Ridicule conveys a hostile attitude TOUCH
 Talking about one’s own problems (self-disclosure) and
• Ask them to stop
not listening
 Stereotyping • Limit setting
 Changing the subject • Maintain boundary setting
 False reassurance • Pair patient with same gender staff
 Minimizing concerns
7. DENIAL AND LACK OF COOPERATION
 Asking for explanations
 Using cliches
• Assess for probable cause
 Using terms of endearment • Listen, clarify and verbalize thoughts
 Defensive responses • Reality testing and supportive information
 Giving advice 8. DEPRESSED AFFECT, APATHY, and
 Challenging client to defend a position
PSYCHOMOTOR RETARDATION
 Lying/ being insincere
 Laughing or smiling inappropriately
• Patience, frequent contact & empathy
 Refusal to listen to others’ point of view • Nurse acknowledges feelings but discourages
 Problems in hearing and speech rumination
 Environmental considerations: noise, lack of privacy • Improvement in personal hygiene, proper
nutrition, and gradual increase in activity
• Major decisions are postpones until emotions
have subsided and thinking is illogical
INTERACTIONS WITH SELECTED BEHAVIORS 9. SUSCPICIOSNESS
1. VIOLENT BEHAVIOR • Communicate simply, clearly, and congruently
• Stay out of striking distance • Arguments over differences in opinion are
• Avoid touching the patient without approval avoided
• Change the topic temporarily if the patients • Simple rationales or explanations of rules,
behavior is escalating activities and occurrences noises and requests
• Suggest time out for the patient in a quiet are offered regularly
environment with fewer stimuli • Patient’s participation is encouraged but not
• Avoiding entering a room alone with a patient forced
who is out of control of his/her behavior 10. HYPERACTIVITY
• Leave temporarily if patient is agitated and • Place the patient in a quiet area, with minimal
asking to be left alone auditory and visual stimulation
• Call for staff assistance if patient is losing • Engage in physical activity
control • Nurses must remain calm
2. HALLUCINATION • Directions are given in a kind, simple but firm
• Initially: comment on their behavior manner
“You look like you are listening to something. What 11. TRANSFERENCE & COUNTERTRANSFERENCE
do you hear?”
• Recognize it
If the patient acknowledges hearing something,
“I don’t hear anything, tell me what you hear.” • Examine behaviors gently but directly
• Assessment of hallucination • Nurses must examine themselves
• Avoid focusing on the hallucination • Be open and clear
• Engage in productive activities • Nurses can state actions of what she can/can’t
• Exception: Command hallucination do
• Limit setting
3. SEVERE ANXIETY and INCOHERENT SPEECH • Redirections of needs to more appropriate
PATTERNS people that can help
• Clarify the meaning of the communication
12. DELUSIONS
• Key into their feeling & underlying themes
• Initially: clarifying meaning
• Medications
• Divert attention
• Spend frequent, brief time, offer support, build
trust • Determine whether this can harm self/others
• Ignore and distract for demented clients
Chrisyll Anne Dominguez BSN 3A
 THERAPEUTIC TECHNIQUE DESCRIPTION EXAMPLE

Silence Gives the person time to collect thoughts or think through a Encouraging a person to talk by waiting for the
point. answers.

Accepting Indicates that the person has been understood. An accepting “yes.”
statement does not necessarily indicate agreement but is “uh-huh.”
nonjudgmental. “I follow what you say.”

Giving recognition Indicates awareness of change and personal efforts. Does not “Good morning, Mr. James.”
imply good or bad, right or wrong. “You’ve combed your hair today.”
“I see you’ve eaten your whole lunch.”

Offering self Offers presence, interest, and a desire to understand. Is not “I would like to spend time with you.”
offered to get the person to talk or behave in a specific way. “I’ll stay here and sit with you awhile.”

Offering general leads Allows the other person to take direction in the discussion. “Go on.”
Indicates that the nurse is interested in what comes next. “And then?”
“Tell me about it.”

Giving broad openings Clarifies that the lead is to be taken by the patient. However, “Where would you like to begin?”
the nurse discourages pleasantries and small talk. “What are you thinking about?”
“What would you like to discuss?”

Placing the events in time or sequence Puts events and actions in better perspective. Notes cause-and- “What happened before?
effect relationships and identifies patterns of interpersonal “When did this happen?”
difficulties.
Making observations Calls attention to the person’s behavior (eg trembling, nail
biting, restless, mannerisms). Encourages patient to notice the
behavior and describe thoughts and feelings for mutual
understanding. Helpful with mute and withdrawn people.
Encouraging description of perception Increases the nurse’s understanding of the patient’s
perceptions. Talking about feelings and difficulties can lessen
the need to act them out inappropriately.
Encouraging compassion Brings out recurring themes in experiences or interpersonal
relationships. Helps the person clarify similarities and
differences.
Restating Repeats the main idea expressed. Gives the patient an idea of
what has been communicated. If the message has been
misunderstood, the patient can clarify it.
Reflecting Directs questions, feelings, and ideas back to the patient.
Encourages the patient to accept his or her own ideas and
feelings. Acknowledges the patient’s right to have opinions and
make decisions and encourages the patient to think of self as a
capable person.
Focusing Concentrates attention on a single point. It is especially useful
when the patient jumps from topic to topic. If a person is
experiencing a severe or panic level of anxiety, the nurse should
not persist until the anxiety lessens.
“You appear tense.”
“I notice you’re biting your lips.”
“You appear nervous whenever John enters
the room.”
“What do these voices seem to be saying?”
“What is happening now?”
“Tell me when you feel anxious.”
“Has this every happened before?”
“Is this how you felt when...?”
“Was it something like…?”
Patient: “I can’t sleep. I stay awake all night.”
Nurse: “You have difficulty sleeping?”
Or
Patient: “I don’t know…he always has some
excuse for not coming over or keeping our
appointments.”
Nurse: “You think he no longer wants to see
you?”
Patient: “What should I do about my husband’s
affair?”
Nurse: “What do you think you should do?”
Or
Patient: “My brother spends all of my money
and then has the nerve to ask for more.”
Nurse: “You feel angry when this happens?”
“This point you are making about leaving
school seems worth looking at more closely.”
“You’ve mentioned many things. Let’s go back
to your thinking of ‘ending it all.’”
Exploring
Giving information
Seeking clarification
Presenting reality
Voicing doubt
Seeking consensual validation
Verbalizing the implied
Examines certain ideas, experiences, or relationships more fully. “Tell me more about that.”
If the patient chooses not to elaborate by answering no, the “Would you describe it more fully?”
nurse does not probe or pry. In such a case, the nurse respects “Could you talk about how it was that you
the patient’s wishes. learned your mom was dying of cancer?”
Makes facts the person needs available. Supplies knowledge “My purpose for being here is…”
from which decisions can be made or conclusions drawn. For “This medication is for …”
example, the patient needs to know the role of the nurse, the “The test will determine…”
purpose of the nurse-patient relationship, and the time, place,
and duration of the meetings.
Helps patients clarify their own thoughts and maximize mutual “I am not sure I follow you.”
understanding between nurse and patient. “What would you say is the main point of what
you just said?”
“Give an example of a time you thought
everyone hated you.”
Indicates what is real. The nurse does not argue or try to “That was Dr. Todd, not a man from the
convince the patient, just describes person perceptions or facts Mafia.”
in the situation. “That was the sound of a car backfiring.”
“Your mother is not here. I am a nurse.”
Undermines the patient’s beliefs by not reinforcing the “Isn’t that unusual?”
exaggerated or false perceptions. “Really?”
“That’s hard to believe.”
Clarifies that both the nurse and patient share mutual “Tell me whether my understanding agrees
understanding of communications. Helps the patient become with yours.”
clearer about what he or she is thinking.
Puts into concrete terms what the patient implies, making the Patient: “I can’t talk to you or anyone else. It’s
patient’s communication more explicit. a waste of time.”
Nurse: “Do you feel that no one understands?”
 Encouraging evaluation Aids the patient in considering other persons and events from “How do you feel about…?”
the perspective of the patient’s own set of values. “What did it mean to you when he said he
couldn’t stay?”

Attempting to translate into feelings Responds to the feelings expressed, not just the content. Often Patient: “I am dead inside.”
termed decoding. Nurse: “Are you saying that you feel lifeless?
Does life seem meaningless to you?”

Suggesting collaboration Emphasizes working with the patient, not doing things for the “Perhaps you and I can discover what produces
patient. Encourages the view that change is possible through your anxiety.”
collaboration. “Perhaps by working together, we can come up
with some ideas that might improve your
communications with your spouse.”
Summarizing Brings together important points of discussion to enhance “Have I got this straight?”
understanding. Also allows the opportunity to clarify “You said that…”
communications so that both nurse and patient leave the “During the past hour, you and I have
interview with the same ideas in mind. discussed…”

Encouraging formulation of a plan of Allows the patient to identify alternative actions for “What could you do to let anger out
action interpersonal situations the patient finds disturbing (eg: when harmlessly?”
anger or anxiety is provoked). “The next time this comes up, what might you
do to handle it?”
“What are some other ways you can approach
your boss?”

Reference:
Halter, Margaret Jordan. (2014). Varcolis’ Foundations of Psychiatric Mental Health Nursing: A Clinical Approach. 7th ed. Elsevier Inc.
 INTRODUCTION TO MILIEU MANAGEMENT
NCM 117 Psychiatric Nursing LEC

MILIEU  Limit setting

• Comes from two much older French words: • Should be set on acting-out behaviors such as
➢ Mi – middle self-destructive acts, physical aggressiveness
➢ Lieu – place and sexual behaviors
• The physical or social setting in which something • It reinforces the norm on making rules and
occurs or develops: expectations clear and also encourages the
in medical use, it is referred as the – Environment milieu therapy concept on responsibility on self
• Firm yet kind, consistent
• Guidelines:
MILIEU THERAPY ✓ Advise patient on rules upon admission
• A scientific structuring of the environment in order ✓ Provide written copies of unit rules to each
to effect behavioral changes and to improve patient and post it
psychological health and functioning of the ✓ Consistency on implementation of rules
individual among staff members
• GOAL:
✓ To manipulate the environment so that all  Balance
aspects of the client’s hospital experience are • Involves the process of gradually allowing
considered therapeutic independent behaviors in dependent situation
✓ Psychiatric nursing is premised on the • Balance personal rights of patients to that of
therapeutic environment as a vital ingredient other patients
in facilitating the journey of recovery for
patients
✓ The therapeutic environment functions to GROUP THERAPY
protect the patient from potentially harmful • A form of psychosocial treatment in which a
effects, as well as maximizing opportunities for number of clients meet together with a therapist for
patients to learn something about themselves purposes of sharing, gaining, personal insight, and
and their difficulties in everyday living improving interpersonal coping skills
• GROUP
→ It is a collection of individuals whose
Elements of the Treatment Environment
association is founded on shared
 Safety
commonalities of interests, values, norms, and
• Is considered the primary aspect of the purpose
environment
→ May be by:
• In acute mental health units, safety is always ✓ Chance
the priority ✓ Choice
• 2 KINDS of Protections under Safety ✓ Circumstances
➢ Physical protection – refers to safety from → FUNCTIONS of Groups
physical harm through the management of risks ❖ 8 functions that groups serve for their
in the environment members:
➢ Psychological protection – involves the ✓ Socialization – the activity of mixing
nurse’s active intervention to prohibit verbal socially with others
abuse, ridicule or harassment of patients ✓ Support – getting assistant to
• Restrict visitors known to belittle patients ✓ Task completion – achieving goals
• Safety can’t be fully accomplished unless the ✓ Camaraderie – spirit of good
nurse are regularly out among the patients in friendship and loyalty among
the environment members of the group
• Nurses should create and adhere safety to the ✓ Informational – providing
information
nursing policies and procedures developed to
✓ Normative – the writing from a
control aggression
standardized norm especially of
 Structure behavior
• Consistency of ward routine ✓ Empowerment – process of
becoming stronger and more
• Refers to the physical environment, rules and
confident
daily schedules on treatment activities ✓ Governance – overseeing the control
• Physical design of the unit is considered and direction of something
• Adequate space/areas for socializing and
receiving visitors, telephones and areas for • Types
privacy 1. Task Groups
▪ Function:
 Norms ✓ To accomplish a specific outcome or
• Specific expectation of behaviors that task
permeate the treatment environment ▪ Focus:
• Are intended to promote safety and trust ✓ Problem solving and making decisions
through the sanctioning of socially acceptable to achieve this outcome
behaviors and consistency about what to ▪ Getting with deadlines
expect
2. Teaching / Educational Group
• Norms attempts to create an environment that ▪ Function:
is more predictable ✓ Convey knowledge and information to
a number of individuals

Chrisyll Anne Dominguez BSN 3A

 ✓ Set time frame and a number of
meetings
✓ Member learn from each other as well
as from the instructor
▪ Goal:
✓ Verbalization or demonstration by
which learner of the material
presented by the end of the designated
period
3. Supportive / Therapeutic Group
▪ Purpose:
✓ To prevent future upsets by teaching
participants effective ways of dealing
with emotional stress arising from
situational/developmental crises
4. Self-help Group
▪ Are led by people who are concerned about
coping with a specific problem or life crises
▪ Do not explore psychodynamic issues in
depth
▪ Professional usually do not attend these
groups or serve as consultants
• Physical Dimensions that affect Group Dynamics
 Seating
▪ No barrier between members
▪ Circle of chairs (arrangement)
▪ Members should be encouraged to sit in
different chairs each meeting
▪ No one should sit outside the group
▪ Session should be held in a quiet, pleasant
room with adequate space and privacy
 Size
▪ Varies but usually between 8 – 10
▪ Rationale: The larger the group, the lesser
time is available to devote to individual
members but provide more opportunities
for individuals to learn from other
members
 Membership
▪ 2 TYPES
➢ Open-ended groups are those in
which members leave and others join at
any time while the group is active; may
create discomfort
➢ Close-ended group
predetermined fixed time frame. It is often
composed of individuals with common
issues/problems they wish to address
• Why are Therapeutic Groups helpful?
1. Instillation of hope
▪ Hope is required to keep the patient in
treatment
2. Universality
▪ Finding out that others have similar
problems
3. Imparting information
▪ Didactic info about health and issues
4. Altruism
▪ Learning to give to others
5. Corrective recapitulation of the primary family
group
▪ Reliving and correcting early family
conflicts within the group
6. Development of socializing techniques
▪ Learning basic social skills
7. Imitative behavior
▪ Assuming some of the behaviors and
characteristics of the therapist
8. Interpersonal learning
9. Group cohesiveness
▪ Members develop a sense of belonging
10. Catharsis
▪ Open expression with affect to purge or
“cleanse” self
11. Existential factors
▪ Patient’s ultimate concern with existence;
death, isolation, freedom and
meaninglessness
• Group Learning Styles
➢ Direct leader
→ Leader controls the interaction by giving
directions and information and allowing
the discussion
→ Literally tells the members what to do
➢ Indirect leader
→ Primarily reflects with group members
discussion and offers little guidance and
information to the group
• Phases of Group Development
❖ Phase 1: INITIAL / ORIENTATION
→ Group activity:
✓ Leader and members work together to
establish rules that will govern the
group
✓ Goals of the group are established
✓ Introduction of members
→ Leader Expectations:
✓ Orient members to specific group
processes
✓ Encourage members to participate
without disclosing too much soon
✓ Promotes environment with trust
✓ Ensure that rules are established by
the group and don’t interfere with the
goals
→ Member behaviors:
✓ Maybe overly polite
✓ Have fear of not being accepted by the
have group
✓ May try to “get on the good side” of the
leader with compliments and
conforming behaviors
❖ Phase 2: MIDDLE / WORKING PHASE
→ Group activity:
✓ Ideally, cohesiveness has been
established in this stage
✓ Productive work toward completion of
the task is undertaken
✓ Cooperation prevails in the mature
group
✓ Differences and disagreements are
confronted and resolved
→ Leader Expectations:
✓ Leader becomes more of a facilitator
✓ Some leadership functions are shared
by certain members of the group as
they progress toward resolution
✓ Helps to resolve conflict and continue
to foster cohesiveness among
members
✓ Ensures that they do not deviate from
the intended task/purpose
Chrisyll Anne Dominguez BSN 3A
 → Member Behaviors:
✓ Trust has been established
✓ Turn more often to each other and less
often to the leader for guidance
✓ Accept criticism from each other
✓ Subgroups will form in which 2 or
more members conspire with each
other, with exclusion of the rest of the
group
✓ Conflict is managed by the group with
minimal assistance from the leader

❖ Phase 3: FINAL / TERMINATION PHASE

→ Group Activities:
✓ Termination should be mentioned
from the beginning
✓ Should be discussed in depth for
several meetings prior to the final
session
→ Leader expectations:
✓ Leader encourages members to
reminisce about what has occurred
within the group
✓ Review the goals and discuss actual
outcomes
✓ Encourages members to provide
feedback to each other about
individual progress within the group
✓ Encourages member to express
feelings associated with termination
phase
→ Member Behaviors:
✓ May express (actual) surprise over the
actual materialization of the end
✓ May have grief response of denial then
anger
✓ May reflect feelings of abandonment

• Nurse’s Role in Group Intervention

✓ Must know the various group process
✓ Select the most appropriate styles of the type of
group being led
✓ Gain continuing education

Chrisyll Anne Dominguez BSN 3A