PSYCHIATRIC NURSING

STATE OF MENTAL HEALTH IN THE PHILIPPINES

The Mental Health Act (RA 11036) and Universal Per 100,000 people
Health Care Law

 Established to enhance the delivery of mental

health services and to promote and protect
the rights of the Filipinos utilizing psychiatric,
neurologic, and psychosocial health services
In the Philippines,
THE STIGMA STILL EXISTS!
 Mental illness has become the third most
common disability in the Philippines
 Filipinos are generally unhappy not only
because of poor economic conditions
(unemployment, low salary, etc.), but also
because of pressures arising from high
expectations from family and society.

DISCRIMINATION IS STILL PREVALENT!

 Filipino culture has greatly embraced this

negativity and can affect people and
economy

In spite of the RA 11036,

 Only 5% of the healthcare expenditure is

directed toward mental health services

 Greater than or equal to 3.6 million Filipinos

suffer from at least one kind of mental,
neurological or substance use disorder

 The Philippines has the third largest rate of

mental disorders in the Western Pacific
region

 The increasing prevalence of mental illnesses

also made a huge impact in the country and
to the human, social, and economic capital.

 Mani Filipinos believe that depression and

anxiety are non-existent, and that the mental
illnesses are something to be ashamed of

 A study by Tanaka (2018), the stigma of the

Philippine public about mental disorder has
an effect which consists of three themes:

1. Familial problems – rejection by

family because they believe it can be
inherited

2. Unrealistic pessimism and

optimism – severity of disorder; wherein the
mentally ill either would certainly suffer from
severe functional impairment or would be
able to overcome any psychological suffering
by themselves

3. Oversimplified chronic course –

wherein people without mental
illnesses apply an acute illness
model to those ill, and expect full
recovery in the short term

Rate of psychiatric beds:

7.76 hospital beds

0.41 psychiatrists
PSYCHIATRIC NURSING
HISTORY OF PSYCHIATRIC NURSING

PRELITERATE TIMES
Sent on voyage ship of fools
ERA OF MAGICO-RELIGIOUS EXPLANATION

RENAISSANCE PERIOD
 SPIRITS OF TORMENT - acting outside the
body are responsible for ills. ERA OF CONFINEMENT

 Primitive healers Timeline of events:

 Healing methods:
 1656 - Hospital Generale in Paris,
o Magical rituals
threatening institution.
o Exorcism
o Incantation

 People with such conditions are denied

ordinary comforts:
o Heat
o Light
o Company
o Food and drink

ANCIENT GREECE

ERA OF ORGANIC EXPLANATION

 4 body humors
o Blood - bloodletting could remove the
excess.
o black bile- excesses causes
melancholy
o yellow bile
o phlegm

 4 ancient methods of psychotherapeutic

interventions:
o Interpretation of dreams
o Therapeutic milieu (environment)
o Ritual purification (use of offering)
o Catharsis (elimination from body)

MEDIEVAL PERIOD

ERA OF ALIENATION

 Madness means dramatic encounter with

secret powers

 Troubled minds are influenced by the mom.

 Fez, Morocco - where the 1st asylum was built

The
insane

shackled in prison
PSYCHIATRIC NURSING
HISTORY OF PSYCHIATRIC NURSING

 1547- St. Mary of Bethlehem in London;

BEDLAM (mad people beaten publicly)

 Johan Weyer

o First psychiatrist
o Claimed that illness are manifested
by the witches
o Importance of therapeutic
relationships.

LATE 18th & EARLY 19th CENTURIES

ERA OF MORAL TREATMENT

 Phillippe Pinel and William Tukes

developed ASYLUM.

 William Tukes focused moral treatment in a

humane millieu York Retreat

 Benjamin Rush - Father of American

Psychiatry, humanitarianism and moral
treatment
PSYCHIATRIC NURSING
HISTORY OF PSYCHIATRIC NURSING

(Mayer actually) - Swiss Psychiatrist staff

then director John Hopkins.

 Linda Richards - First American psyche

nurse (1873)

 Clifford Beers - created A MIND THAT

FOUND ITSELF, a book about intense
suffering a mental anguish

 Williamsburg, Virginia opened first

American psychiatric hospital (1773)

Period of scientific studies

ERA OF PSYCHOANALYSIS

 Emil Kraepelin - classified mental disorders

LATE 19th & EARLY 20th CENTURIES

ERA OF MENTAL PUBLIC HOSPITALS

 Dorothea Dix - leader in generating

public interest in building state mental
hospitals.

 Eugene (ACTUALLY EUGEN) Blueler –

termed the word SCHIZOPHRENIA

 Adolf
Mayor
PSYCHIATRIC NURSING
HISTORY OF PSYCHIATRIC NURSING

 Sigmund Freud - human behavior in

psychological terms.

20th CENTURY

 Drug treatment for mental illness was

developed

 Henry Stack Sullivan - Interpersonal theory

 Erik Erikson - Psychosocial theory

PSYCHIATRIC NURSING
HISTORY OF PSYCHIATRIC NURSING

 Prescriptive authority for drugs (in many

states)
 Consultation
 Evaluation

Psychiatric nursing

 Psyche - The mind, intellect including both

conscious and unconscious aspects.
 Maxwell Jones - Establish therapeutic
communities.
 Psychiatrist - One who specializes in the
diagnosis, prevention and treatment of
mental disorders

Johari window

 Used to enhance the individual’s perception

Areas of practice (basic level functions)

 Counseling
o Interventions and communication
techniques
on others.
o Problem solving
 This model is based on two ideas- trust can
o Crisis intervention
be acquired by revealing information about
o Stress management
you to others and learning yourselves from
their feedbacks.
 American psychologists Joseph Luft and
Harry Ingham developed this model in 1955.

 This model is also denoted as

feedback/disclosure model of self-awareness.

o o Behavior modification

 Milieu Therapy
o Maintain therapeutic environment
o Teach skills
o Encourage communication between
clients and others.
o Promote growth through modeling Mental health VS. Mental illness
Mental health - balance in a person's internal life
and adaptation to reality.
Areas of practice (advanced-level functions)

 Psychotherapy
PSYCHIATRIC NURSING
HISTORY OF PSYCHIATRIC NURSING

Mental illness - a state of imbalance  Reality orientation

characterized by a disturbance in a person's  Stress management
thoughts, feelings and behavior.
Criteria for positive mental health
Goal of Psychiatric Mental Health Nursing

 Aimed at assisting the client attain and  Physical health

maintain mental health, prevent mental  Meaningful work

illness, cope and find meaning in the
experience of mental illness and suffering.
Psychiatric mental nursing
 Enjoyment of life
 Satisfying relationship with others
 Ability to make sound judgments and decisions
 Accepts responsibilities for one's ability to give
and receive actions

 A specialty area of nursing practice employing  Express feelings appropriately

theories of human behavior as its science and
the purposeful use of the self as its art in the
diagnosis and treatment of human responses to
actual and/or potential health problems.
Influences of mental health

 Biological factors
Characteristics of a mentally healthy person
 Psychological factors
 Attitude of self-acceptance  Sociocultural factors

 Growth, development and self-actualization

 Integrative capacity

 Autonomous behavior

 Perception of reality

 Environmental mastery Ways to maintain mental health

 Interpersonal communication
 Ego defense mechanisms
Psychiatric nursing  Significant others or support people
 Personal strategies
 Psychiatric nursing is both science & art—
General criteria for mental health disorder
therapeutic use of self.
 The core of Psychiatric Nursing is the  Dissatisfaction with one's characteristics,
interpersonal process (human-to- human abilities, and accomplishments.
relationship).
 Ineffective or satisfying interpersonal
 Clients of the nurse in psychiatric settings: relationships.
family, community, mentally healthy, mentally ill.
 Dissatisfaction with one's place in the world.
 Mental hygiene - science that deals with
 Ineffective coping or adaptation to the events in
measures to promote mental health, prevent
one's life as well as the lack of personal growth.
mental illness and suffering, and facilitate
rehabilitation. Principles of psychiatric nursing

1) Patient should be accepted exactly as he is.

Components of mental health

2) Self-understanding should be used as a
 Self-governance therapeutic tool.
 Growth orientation
 Tolerance of uncertainty 3) Consistency is used to contribute patient

 Self-esteem security.

 Mastery of the moment

PSYCHIATRIC NURSING
HISTORY OF PSYCHIATRIC NURSING

4) Reassurance must be given in a suitable and  Member of the mental health team
acceptable manner  Socializing agent
 Parent surrogate
6) Patient behavior is changed through emotion
 Counselor
experience and not by use of reason.
 Teacher

6) Unnecessary increase of patient’s anxiety  Caregiver

should be avoided
Essential qualities

7) Maintain a professional nurse patient  Genuineness: sincerity; verted and behavioral

relationship
congruence; authenticity

8) Verbal and physical force must be  Respect: unconditional positive regard; non-
AVOIDED if possible
possessiveness warmth; consistency and active

9) Nursing care should be centered in the listening

patient as a person and not on the control of
 Empathy: nurse views world through client's
symptoms
eyes but remains objective
10) Routine and procedures should be
 Concreteness/Specificity: nurse speaks in
explained at the patient level of understanding.
realistic; literal terms vs. vague, theoretic

11) Many procedures are modified according concepts.

to the patient without alteration of basic
 Self-disclosure: appropriate disclosure of a
principles.
view of one's attitudes, feelings and beliefs
12) Observation of mentally ill patient is
 Confrontation: nurse approaches the client in a
directed toward the why of his behavior.
direct manner, usually because of perceived
13) Discussion of personal relationships and
discrepancies in the client's behavior
personal values should be initiated only by
 Self-exploration: nurse helps client vent and
the patient.
explore feelings during appropriate times
14) The vial structure of the institution and
throughout the interaction; serves as
the ward unit should be organized in promote
social participation of the patients. CATHARSIS.

 Role playing: nurse helps client act out a

Factors that contribute to mental illness
particular event, situation or problem to help the
 Individual factors
client gain understanding, may also be cathartic.
 Age
 Genetics
 Physical health and health practices
 Interpersonal factor
 Sense of belonging
 Social network and support
 Cultured factors

Roles of a psychiatric mental health nurse

 Skilled communicator
 Role model of adaptive behavior
 Director of therapeutic milieu
 Advocate of the client and family
PSYCHIATRIC NURSING
THE NERVOUS SYSTEM

THE NERVOUS SYSTEM

 LIMBIC SYSTEM
 communication system which occurs through
Regulates body temperature, appetite,
electrical signals (arrow) that spread over the
sensations and emotional arousal.
cell membrane of neurons and cause changes
at the synapse (the communication junction
between the neuron and its neighboring cell)
 involved in nearly every body function
 receive signals from and sending commands
to different areas of the body
 helps coordinate the body functions to
maintain homeostasis

Major functions of the nervous system

 Receiving sensory input

 Controlling muscles and glands
 Maintaining homeostasis
 Establishing and maintaining mental activity

Four brain lobes which is found within the left and

right hemisphere of the cerebellum

 frontal lobe
 parietal lobe
 temporal lobe
 occipital lobe

Three major parts of the brain

 CEREBRUM

Center of coordination and integration of all

information needed to interpret and respond to

the environment.

 CEREBELLUM

Center of coordination
of movements and
postural adjustments

 BRAIN STEM

Contains centers that

control cardiovascular and respiratory
functions, sleep, consciousness and impulses
PSYCHIATRIC NURSING
THE NERVOUS SYSTEM

 c o n t r o

regulation, pain control, sexual behavior and

regulation of emotions
 involved with delusion, hallucinations,
withdrawn behavior, mood, anxiety, sleep
Neurotransmitters induction
 levels of serotonin are elevated in
 Substances manufactured in the neuron that
schizophrenia (delusions, hallucinations, and
aid in the transmission of information
withdrawal)
throughout the body.
 drugs that block serotonin transporters, such as
 Can excitatory (excite the neuron and pass
messages to others) and/or inhibitory (block or Prozac, are used to treat depression and
prevent the chemical message from being anxiety disorders.
passed along any farther)
Acetylcholine
Norepinephrine & Epinephrine
 excitatory or inhibitory
 excitatory
 the chief neurotransmitter of the
 Fight & Flight response
parasympathetic nervous system, the part of
 most prevalent in Nervous System located in
the autonomic nervous system (a branch of the
the brainstem
peripheral nervous system)
 changes in attention, leaning and memory,
 affects sleep wake cycle and signals muscle
sleep and wakefulness and mood regulation
tone to become active
 excess cause memory loss, social withdraws,
 contracts smooth muscles, dilates blood
anxiety disorders & depression
vessels, increases bodily secretions, and slows
 limited in the brain; controls fight or flight heart rate
response in PNS.
Histamine
Dopamine
 It is a neuromodulator since it regulates the
 feel good hormone release of other neurotransmitters.
 can be excitatory or inhibitory control complex  peripheral allergic responses, control of gastric
movements, motivation, cognition and secretions & alertness
regulation of emotional response in the brain
 promotes wakefulness and orchestrates
stem
disparate behaviors and homeostatic functions
 implicates schizophrenia & other psychoses
as well as movement disorders - Parkinson Neuropeptides
disease (depression of voluntary motor control)
 Neuromodulator
results from destruction of dopamine-secreting
 auxiliary messenger molecules that always in
neurons.
nerve cells with one or
 more small molecule (classic) neurotransmitter
 enhance, prolong or limit the effects of principal
neurotransmitters
 play a role particularly when the nervous
system is challenged, as by injury, pain or
stress.
Serotonin

 inhibitory Glutamate
PSYCHIATRIC NURSING
THE NERVOUS SYSTEM

 the primary excitatory neurotransmitter of the

mammalian central nervous system
 essential for proper brain function
 excessive activation of glutamate receptors
may excite nerve cells to their death in a
process now referred to as "excitotoxicity"
 in the bram damage caused by stroke,
hypoglycemia, sustained hypoxia or ischemia,
Huntington's and Alzheimer's

GABAGamma-aminobutyric acid (GABA)

 major inhibitory
 modulates other neurotransmitters rather than
to provide direct stimulus
 reduce neuronal excitability by inhibiting nerve
transmission
 drugs that increase GABA function have been
used to treat Epilepsy (excessive discharge of
neurons).

Imaging brain techniques

TYPES:

 Computerized Tomography (CT) scan

 Computerized Axial Tomography (CAT) scan
 Magnetic Resonance Imaging (MRI)
 Positron Emission Tomography (PET) scan
 SPECT (Single Photon Emission CT) scan

LIMITATIONS:

 use of radioactive substances in PET and

SPECT.
 expensive to purchase and maintain.
 some can't tolerate it due to claustrophobia.
 cannot be detected (same changes in
disorders).

EUROBIOLOGIC CAUSES OF MENTAL ILLNESS

GENETICS & HEREDITARY

 Twin studies
 Adoption
 Family studies

STRESS & IMMUNE SYSTEM

(Psychoimmunology)

 compromised system could contribute to the

development of a variety of illness

INFECTION

 existence to a virus during critical fetal

development of the nervous system
PSYCHIATRIC NURSING
LEGAL AND ETHICAL CONSIDERATIONS

Concepts

 Ethics: The study of philosophical beliefs about

what is considered right or wrong in a society
 Involuntary commitment - without patient's
 Bioethics: Used in relation to ethical dilemmas
consent
surrounding health care
 Ethical dilemma: Conflict between two or more
courses of action, each with favorable and If….

unfavorable consequences
o Danger to self (DTS)
Six principles of bioethics
o Danger to others (DTO)
 AUTONOMY - respecting the rights of others to
o Gravely disabled (GD)
make their own decisions
o In need of treatment & illness prevents
 BENEFICENCE - the duty to promote good
voluntary help seeking
 NONMALEFICENCE - doing no harm to patient

 JUSTICE - distribute resources or care equally Discharge procedures

 FIDELITY - maintaining loyalty and  Unconditional release - Termination of the

commitment, doing no wrong to a patient legal patient-institution relationship

 VERACITY - one's duty to always communicate  Release against medical advice (AMA)

truthfully  Conditional release - Usually requires

outpatient treatment for a specified period of

Civil rights of persons with mental illness
time with follow-through evaluation
 Guaranteed same rights afforded to all under
 Assisted outpatient treatment - Similar to
federal and state laws
conditional release but court-ordered
 Right to vote

 Right to enter contracts

 Right to press charges

Patients' rights under the law
 Right to humane care and treatment
 Right to treatment
 Right to religious freedom
 Right to refuse treatment
 Right to social interaction
 Right to informed consent
 Right to exercise and participate in recreation
o Patient is informed of risks, benefits, and
alternatives
Due process in involuntary commitment o Person must voluntarily accept treatment
o Implied Consent
 Writ of habeas corpus o Capacity & competency

 Least restrictive alternative doctrine

Dementia Praecox – first term for

Hospital admission procedures schizophrenia

Res ipsa loquitor - the things speaks for itself

Force majeure - unforeseeable circumstances
 Voluntary admission - sought by patient or that prevent someone from fulfilling a contract
guardian Respondeat superior - a party is responsible
for acts of their agents
PSYCHIATRIC NURSING
LEGAL AND ETHICAL CONSIDERATIONS

Primum no nocere – first, do no harm

PSYCHIATRIC NURSING
MENTAL HEALTH AND MENTAL ILLNESS

MENTAL HEALTH o Developmental

o Biological
 A state of well-being o Physiological disturbances
 Able to recognize own potential
 Cope with normal stress  Culturally defined

 Work productively
 Mental illness versus physical illness
 Make contribution to community
o Root of most mental disorders lies in
Factors that impact mental health intercellular

 Early Childhood Experiences/ Conditioning Mental health continuum

 Genetics
 Mental Health versus Mental Illness
 Physical illness
 Social Systems Discrimination and Stigma o A real middle ground exists: Stress and
 Substance Use discomfort from everyday life
o Conceptualized as points along a
 Gut Health
mental health continuum
 Trauma
 Lack of sleep
 Long term, Chronic stress
 Exposure to Environmental Toxins
 Neurological conditions
 Hormonal Imbalance
 Socioeconomic status
 Vitamin Deficiency
 Support system

Attributes to Mental Health

Individual attributes and behaviors
 Rational thinking
 Resilience
 Effective coping
 Resiliency o Ability and capacity to secure resources
 Self-Control needed to support well-being
o Characterized by:
 Self-Awareness
 Developmentally on task
Ability to secure needed
 Spiritual satisfaction resources
 Happiness and joy Capacity for regulating one's own
emotions and overcoming
 Self-care negative, self-defeating thoughts.
 Positive self-concept Optimism

 Learning and productivity

o Essential to recovery
 Effective communication
 Meaningful relationships Risk and protective factors

MENTAL ILLNESS  Social and economic circumstances

 Psychiatric disorders with definable diagnoses o Family

o Schools and peer groups
o Socioeconomic status
o Use of Diagnostic o Educational advancement
and Statistical
Manual of Mental
Disorders, 5th ed.  Environmental factors
(DSM-5)
o Political climate & cultural
considerations
o Social & economic policies

 Significant dysfunction in mental functioning

related to:
PSYCHIATRIC NURSING
THEORIES, MODELS, & PHILOSPHIES

PSYCHOANALYTIC THEORY

SIGMUND FREUD THEORIES THREE LEVELS OF CONCIOUSNESS

 instincts (drives) produce energy they are

 Conscious
genetically determined, driver for sex and
aggression Contains all the material a person is
 human behavior is determined by part aware of at any one time
experiences and responses
 all behavior has meaning and can be  Preconscious
understood
Contains material that can be retrieve
 emotionally painful experiences / anxiety
rather easily through conscious effort
motivate
 client can change behavior and
responses when made aware of the  Unconscious
reasons for them
Includes all repressed memories,
passions, and unacceptable urges lying
THREE PERSONALITY COMPONENTS BY deep below the surface
FREUD:
Defense mechanisms and anxiety
1. ID
 Operate on unconscious level
o Unconscious
o Pleasure Principle  Deny, falsify, or distort reality to make it
o Has no sense of right and wrong less threatening
o Innate desires (e.g. pleasure-seeking
 Ward off anxiety by preventing
behavior, aggression, sexual
impulses) conscious awareness of threatening
o Present at birth feelings

2. EGO Classical Psychoanalysis

o Partly unconscious and conscious  Seldom used today

o Reality principle
o Integrator of personality
o Balances the id and superego
o Mature Adaptive behavior
3. SUPEREGO
 Intrapsychic conflict no longer considered
to be the cause of all mental illness
o Free association
o Dream analysis

o Unconscious  Valid tools and concepts

o Morality principle
o Controls behavior o Transference – development of
o Parental feelings, either positive or negative,
o Ethical values
by the client towards the nurse.
o Countertransference –

development of feelings by the nurse

towards the client

Psychodynamic therapy

 Newer psychoanalytic model

 Focuses more on here and now

 Uses many tools of psychoanalysis

 Best candidates are the "worried well"

o Have a clear area of difficulty

o Are Intelligent and well-motivated for
change
PSYCHIATRIC NURSING
THEORIES, MODELS, & PHILOSPHIES
 Increased back and forth between
therapist and patient
INTERPERSONAL THEORIES
 Purpose of all behavior is to get needs
met through interpersonal Interactions
and to reduce or avoid.
 Anxiety: painful feeding or emotion
that arises from social insecurity or
prevents biological needs from being
satisfied.
 Security operations: measures the
individual employs to reduce anxiety
and enhance security
 Self-system: all of the security
operations an individual uses to defend
against anxiety and ensure self-
esteem.
Interpersonal therapy
 Interpersonal therapy is most effective in
treating:
o Grief and loss
o Interpersonal disputes
o Role transition
Implications of interpersonal theory to nursing
 Foundations: Hildegard Peplau
 Nurse as both
participant & observer
o Self-awareness helps keep focus
on patient
 Application of Sullivan's theory of
anxiety to nursing practice.
o According to Sullivan, anxiety was
the experience of a threatened
loss of the sense of security of the
self.
SULLIVAN’S THEORY OF ANXIETY /
INTERPERSONAL THEORY
1. INFANCY (0-3)
o one secure person
o NEED FOR SECURITY: infant
o learns to rely on others to gratify
o needs and satisfy wishes,
o develops a sense of basic trust,
o security and self-worth
2. TODDLERHOOD / EARLY
CHILDHOOD
o child learns to communicate
o needs through use of words
o and acceptance of delayed
o gratification and interference of
wish fulfillment
3. PRESCHOOL
o develops body image and
self-perception
o organizes and uses
experiences in teams of
approval and disapproval
received
4. SCHOOL AGE
o The period of learning to form
satisfying relationships with
peers
o Uses competition,
compromises and cooperation
o The pre-adolescent learns to
relate to peers of the same
sex how to do things well
o chums (close friends) and
hobbies
o Needs to excel/accomplish
o Need for privacy and peer
interaction competence
o Begins using selective
inattention and dissociates
those that cause physical or
emotional discomfort and pain
5. ADOLESCENCE
o learns independence and how
to establish satisfactory
relationships with members of
the opposite sex
6. YOUNG ADULTHOOD
o becomes economically,
develops an acceptance
intellectually, and of
responsibility for emotionally
self-sufficient
7. SENESCENCE
o becomes economically
o develops an acceptance
intellectually, and of responsibility
for emotionally self-sufficient what
life is and was, and of its place in
the flow of history
 Lowering patients' anxiety improves
ability to think and function.
 PSYCHIATRIC NURSING
THEORIES, MODELS, & PHILOSPHIES

Hildegard Peplau's theory of interpersonal relationships

in nursing (1952)

 Major paradigm shift in nursing

 The art of nursing

o Provide care, compassion, and
advocacy
o Enhance comfort and well-being
o Focus is on the patient

 The science of nursing

o Application of knowledge
o Nursing is investigative and uses
theory
o To understand a broad range of
human problems and psychosocial
phenomena.
o To intervene in relieving patient's
suffering and promote growth.

Peplau and the Therapeutic Relationship

Levels of Anxiety

Communication

Aim to improve patient’s ability to think

and function

Personal growth