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