CHAPTER 1 Foundations of Psychiatric–Mental Health Nursing

A. Aristotle 382–322 BC - mental disorder is a PHYSICAL

MENTAL HEALTH AND MENTAL ILLNESS DISORDER. You need humor in order to be healthy.
Health – The complete state of physical, mental, and social Imbalance of the 4 can lead to mental disorder:
wellbeing.
• Calmness
1. Self-awareness
• Anger
2. Cope normal stressors
• Sadness
3. Work productively
• Happiness
4. Contributing to community

Mental Health - The World Health Organization defines health as a Treatment:

state of complete physical, mental, and social wellness, not merely • bloodletting, starving, and purging
the absence of disease or infirmity. This definition emphasizes health
as a positive state of well-being. People in a state of emotional, Renaissance period (1300 – 1600)
physical, and social well-being fulfill life responsibilities, function
effectively in daily life, and are satisfied with their interpersonal - Mental illness is distinguished from a criminal.
relationships and themselves. - Harmless mentally ill people can wander

Factors influencing a person’s mental health: A. St. Mary of Bethlehem

• 1st hospital for insane in the UK at 1547
• Individual - person’s biologic makeup, autonomy and • Method of Treatment
independence, self-esteem, capacity for growth, vitality, o Purging
ability to find meaning in life, emotional resilience or o Starving
hardiness, sense of belonging, reality orientation, and o Bleeding
coping or stress management abilities o Bathing
o Forced feeding
• Interpersonal - effective communication, ability to help
others, intimacy, and a balance of separateness and Affects mental health:
connectedness
• social/cultural - sense of community, access to adequate • Coping mechanism
resources, intolerance of violence, support of diversity • Support system
among people, mastery of the environment, and a positive,
Early Christian Times (1-1000 AD)
yet realistic, view of one’s world.
American Period
Mental Illness - includes disorders that affect mood, behavior, and
thinking, such as depression, schizophrenia, anxiety disorders, and A. Benjamin Franklin (1751)
addictive disorders. Mental disorders often cause significant distress • Pennsylvania hospital – 1st hospital to receive people with
or impaired functioning or both. Individuals experience mental disorder.
dissatisfaction with self, relationships, and ineffective coping. Daily B. Benjamin Rush (1745-1830)
life can seem overwhelming or unbearable. Individuals may believe • Father of American Psychiatry
that their situation is hopeless. • First to treat patient with moral
• Treats patient thru:
Factors contributing to mental illness: o bloodletting,
o cold and hot bath,
• Individual - biologic makeup, intolerable or unrealistic o purgative & emetics,
worries or fears, inability to distinguish reality from fantasy, o tranquilizing chair
intolerance of life’s uncertainties, a sense of disharmony in o Gyrator: rotates a mentally ill person for blood
life, and a loss of meaning in one’s life flow
• Interpersonal - ineffective communication, excessive
Period of Enlightenment and Creation of Mental Institutions
dependency on or withdrawal from relationships, no sense of
(1970s)
belonging, inadequate social support, and loss of emotional
control. - modern era of psychiatric care
• social/cultural - lack of resources, violence, homelessness,
poverty, an unwarranted negative view of the world, and Asylum (Sanctuary protection)
discrimination such as stigma, racism, classism, ageism, and
o safe space or heaven for people with problems or mental
sexism. disorders
DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL o Philippe Pinel in France and William Tuke in England
formulated the concept of asylum
DISORDERS
o Establishment of the first asylum, state hospitals were in
• Diagnostic and Statistical Manual of Mental Disorders, trouble. Attendants were accused of abusing the residents,
fifth edition (DSM-5) - a taxonomy published by the
1. Phillippe Pinel
American Psychiatric Association.
• unchained the mental ill; advocate of kindness and moral
treatment
The DSM-5 has three purposes:
o To provide a standardized nomenclature and language 2. William Tuke
for all mental health professionals • same with Pinel; advocate of kindness and moral treatment
o To present defining characteristics or symptoms that
differentiate specific diagnoses 3. Dorothea Lynde Dix (1802–1887)
o To assist in identifying the underlying causes of • established 32 state hospitals that offered asylum to the
disorders. suffering; she advocated adequate shelter, nutritious food, and
warm clothing.
HISTORICAL PERSPECTIVES OF THE TREATMENT OF
MENTAL ILLNESS Sigmund Freud and Treatment of Mental Disorders

Ancient Times A. Eugene Bleuler:

• Coined the term “Schizophrenia”
- Sickness is a punishment for sins and wrongdoing. 4 As of Schizophrenia:
o Apathy: absence of emotions • Lithium Carbonate
o Autism: poor social interactions
o Associative looseness: shifting from topic to another Move toward Community Mental Health
o Ambivalence: 2 opposing feelings at the same time
- The movement toward treating those with mental illness in
B. Emil Kraeplin: less restrictive environments gained momentum in 1963
with the enactment of the Community Mental Health
• classification of mental disorders according to sx.
Centers Construction Act.
C. Harriet Bailey: - Deinstitutionalization, a deliberate shift from institutional
care in state hospitals to community facilities, began.
• author of the psychiatric book “Nursing Mental Disease”
- Boarding
- Revolving door
D. Sigmund Freud:
• developed ‘psychoanalysis’ and ‘psychosexual theories’ PSYCHIATRIC NURSING PRACTICE

E. Harry Stack Sullivan: • Linda Richards – 1st American Psychiatric Nurse

• Interpersonal theory • John Hopkins Hospital – 1st school of nursing to include
psychiatric nursing in curriculum
F. Carl Gustav Jung: • Mclean Hospital – 1st school to train nurses to care for
• Swiss German mentally ill patient
• Introvert and extrovert personality • Hildegard Peplau – mother of psychiatric nursing. Published
• Different persona Interpersonal Relations in Nursing in 1952 and Interpersonal
Technique: The Crux of Psychiatric Nursing
• June Mellow - Mellow’s 1968 work, Nursing Therapy,
G. Karen Horney: described her approach of focusing on clients’ psychosocial
• neurosis- old term for psychiatric disorder, stemmed from needs and strengths
cultural and interpersonal relationship impairment • Harriet Bailey – 1st author of psychiatric nursing textbook
• culturally can affect mental health of person “Nursing Mental Disease”
• Mental Health: • Hospicio de San Jose – 1st mental health institution in the
o Ability to cope Philippines
o Support system • San Lazaro – 1st Hospital in the Philippines to have psych
ward
H. Hildegard Peplau: • Mental Health Act – R.A. 11036 (2018)
• mother of psychiatric nursing.
• Therapeutic use of self

Development of Psychopharmacology Self-awareness

• Development of psychotropic drugs: – is the process by which the nurse gains recognition of his or her
Benzodiazepines own feelings, beliefs, and attitudes. In nursing, being aware of one’s
o monoamine oxidase inhibitor antidepressants feelings, thoughts, and values is a primary focus.
o haloperidol (Haldol) - an antipsychotic
CHAPTER 2 Neurobiologic Theories and Psychopharmacology
o tricyclic antidepressants
o antianxiety agents Central Nervous System
1930s – “The Advent of Psychotherapies”
Cerebrum - is divided into two hemispheres; all lobes and structures
• Hypoglycemic shock therapy/insulin therapy
are found in both halves except for the pineal body, or gland, which
– treatment for schizophrenic
is located between the hemispheres
• Electro-shock therapy (electroconvulsive therapy)
• Psychosurgery therapy (lobotomy) Right: (Left Handed)
V: visual spatial
1949 – Lithium 1: Intuition
• (natural salt for manic episode/bipolar; has toxic effect) C: creative thinking
A: artistic ability
1950 - Chlorpromazine (Thorazine)
• 1st antipsychotic drug Left: (Right Handed)
• Psychosis (impairment); W: Writing ability
• Treat psychotic episodes of acute mania A: arithmetic
• For delusion (sensory); hallucinations R: Reading ability
Lo: Logical reasoning
1951 or 1952 – monoamine oxidase inhibitor (MAOI) Cerebral cortex
• Treats depression
• Caution: high level causes toxicity • outermost part of the bran
• convoluted > gray matter (gyrus)
1957 – Haloperidol (Anti-psychotic drug) • sulcus - groove between gyri
1958 – Tricyclic Antidepressants (TCA) – for depression Brain composes of fats. Fatty acids covers the brain (we need omega
1960 – Benzodiazepines (antianxiety) 3 ex. Fish salmon)

Classification of drugs: Lobes of the brain:

1. Anti-psychotic A. Frontal lobe

• Chlorpromazine • M: moral behavior
• Haloperidol • E: emotions
2. Anti-depressants
• judgement
• MAOI (Monoamine Oxidase Inhibitor) • speaking
• TCA (Tricyclic Antidepressants)
• thinking
• SSRI (Selective Serotonin Reuptake Inhibitor)
• memory recall
3. Anti-anxiety
• voluntary movements
• Benzodiazepines
4. Anti-manic if problems/ alteration:
➢ fear Reticular Formation
➢ aggressiveness • Central core of brainstem
➢ euphoria or depression • Controls sleep wake cycle
➢ irritability or apathy • Maintain consciousness, alertness, arousal, attention
➢ Schizophrenia
➢ ADHD Reticular Activating System
➢ Dementia • Times out other stimuli to focus
B. Parietal lobe
Cerebellum
• Touch, Taste, pain
• Little brain
• Perception
• Coordinates muscle synergy (coordinates movement)
• Interpretation of sensory information
• Posture
C. Temporal lobe • Equilibrium
• hearing & smelling
• control of sensation Peripheral Nervous System
• memory - From periphery to CNS
- Sensory neurons:
• emotions
• Somatic sensory neurons – ability to feel (external
• language interpretation
organs)
if problems/ alteration: Visual aphasia – cannot recognize words in • Visceral sensory neurons– internal organs
print
Efferent system
D. Occipital Lobe - Somatic system – CNS to skeletal muscles
• visual reception of interpretation - Autonomic nervous system – *involuntary*
• Language interpretation • Sympathetic nervous system: fight-or-flight
• Parasympathetic nervous system: to relax
if problems/ alteration:
➢ Loss of vision/blackout
➢ Visual hallucinations Neurotransmitter
- Chemical Substance
E. Limbic system (Limbic lobe) - Produced by neurons
• “center of emotions” - Transmit impulses (relay information)
• members: Cycle:
1. hippocampus 1. Sodium and potassium pump
- conversions of memory 2. Electrical Impulse
- Large amounts of neurotransmitters 3. Synapse
2. amygdala 4. Receptor Site
-generate emotions 5. Re-uptake
4 Fs: 6. Oxidize
•Feeding
• Figh or flight Circadian Rhythm:
•Fornication/pleasure • -internal clock
•Feelings • -24h cycle
3. Baral ganglia • -sleep I wake cycle
- motor functions
– EPS (Extrapyramidal System) When sleeping:
1am - Body temp lowest
Diencephalon-sensory
2am-cortisol ↑ rise
A. Thalamus 3am-5am↑ BP: pro-lactation
-strong emotions (Fear and Rage) 6am - insulin lowest
-major relay center
• S -Sensation Neuroimaging techniques:
• E - Emotions • EEG (Electroencephalogram)
• A - Activity -measures brain electrical activity
B. Hypothalamus -epilepsy, stroke, neoplasms, neurodegenerative disease
• T-temperature regulation • CT scan (Computed Tomography)
-measures brain structure
• E-endocrine function
-schizophrenia
• A-appetite
-bipolar
• R - rage and fear -mental disorders
• S - sexual behavior/ activity
C. Mesencephalon • MRI (Magnetic Resonance Imaging)
- substantia nigra is found
- measure anatomical & chemical status
- reflexes:
- schizophrenia
• Visual reflexes
• Auditory reflexes
• PET (Positron Emission Tomography)
• Righting reflexes
-measurer specific brain activity
• Keeping of head upright

Medulla Oblongata Chapter 3 Psychosocial, Interpersonal, Behavioral Theories &

- Center for heart rate regulation Therapies
-blood pressure Psychoanalytic theory – Sigmund Freud
-respiration
-reflexes (protective): • All human behavior is caused and can be explained.
• Coughing • Repressed (driven from conscious awareness) sexual
• Sneezing impulses and desire motivate much human behavior.
• Swallowing
• Vomiting Personality components
• Id- pleasure-seeking behavior, instant gratification (now and Humanistic Theory
want)
• Superego – person’s nature that reflects moral and ethical 1. Humanism – focuses on a person’s positive qualities
concepts (Good vs. bad) 2. Abraham Maslow: Hierarchy of needs – in which he used
• Ego- balancing or mediating force between Id and Superego a pyramid to arrange and illustrate the basic drives
3. Carl Rogers: Client-Centered Therapy
Behavior motivated by subconscious thoughts and feelings • Focuses on the role of client
• Therapies must promote the client’s self-esteem
• Conscious – perceptions, thoughts, and emotions that exist • Unconditional positive regards – a non-judgemental
in the person’s awareness positive care for the clients
• Preconscious – thoughts and emotions are currently in the • Genuineness – realness or congruence
person even though they are totally unaware • Empathetic understanding – therapist senses the
o Can be recalled/retrieved thru: feelings and personal meaning from the client.
▪ Dreams • Operant conditioning – manipulation of selected
▪ Free association reinforcers to elicit and strengthen desired behavioral
▪ Freudan Slip response
Ego defense mechanism • Positive reinforcement – giving client the attention and
Methods of attempting to protect the self and cope with basic drives or positive feedback
emotionally painful thoughts, feelings, or events • Negative reinforcement – removing a stimulus
1. Compensation – over achievement in one area to offset real immediately after a behavior occurs.
or perceived deficiencies in another area • Desensitization – form of behavior therapy whereby
2. Conversion – usually unconscious; expression of an exposure to increasing increments of a feared stimulus.
emotional conflict thru development of physical sx. (poop • Systematic desensitization – can be used to help client
during Board exam) overcome irrational fears.
3. Denial – failure to acknowledge unbearable conditions • Aversion therapy – negative reinforcement is used to
4. Displacement – ventilation of intense feelings towards less change behaviors
threatening • Modeling – behavioral therapy whereby therapist acts
5. Disassociation – dealing with emotional conflict by as a role model.
temporary alteration in consciousness or identity
6. Fixation – immobilization of a portion of the personality CHAPTER 5 Therapeutic Relationships
resulting from unsuccessful completion of tasks Phases of therapeutic Relationship:
7. Identification – modeling actors and opinions
8. Intellectualization – presenting facts Pre-interaction
9. Introjection – accepting another person’s attitude, belief, and
values of one’s own - obtain information about the client
10. Projection – unconscious blaming of unacceptable - self-awareness (transference & countertransference)
inclinations
11. Rationalization – excusing own behavior to avoid guilt 1. Orientation Phase
12. Reaction formation – acting the opposite of what one thinks goal: Establish therapeutic relationship
or feel nurse:
13. Regression – moving back to a previous developmental stage - responds to client
14. Repression – excluding emotionally painful or anxiety- - responds to client
provoking thoughts - gives boundaries
15. Resistance – overt or covert antagonism - gather data
16. Sublimation – substituting a socially acceptable activity for - establishes rapport
an impulse that is unacceptable
17. Substitution – replacing the desire gratification Nurses Responsibilities/Power:
18. Suppression – conscious exclusion of unacceptable thoughts ✓ Confidentiality- respecting the clients right to keep private
and feelings information
19. Undoing – exhibiting acceptable behavior ✓ Duty to warn- duty to warn identifiable third parties of threats.
✓ self-disclosure-revealing information to the client used to convey
Jean Piaget and Cognitive Stages of Development support.

1. Sensorimotor – birth to 2 years: object of permanence. Client

2. Preoperational – 2-6 years: symbolic gestures ✓ seeks assistance
3. . Sensorimotor – birth to 2 years: object permanence. ✓ asks question
4. Preoperational – 2-6 years: symbolic gestures ✓ convey needs
5. Concrete operations – 6-12; logical thingking; spatiality ✓ shares expectations
6. Formal operations – 12-15; Reasoning
Nurse - Client contract:
Harry Stack Sullivan: Interpersonal relationships and Milieu • Time, place, length of ressions
Therapy • when will sessions terminate
• who is involved in the treatment plan
• That one’s personality involves more than individual • clients responsibilities
characteristics • nurses responsibilities
• How one interacts with others.
• Inadequate or non-satisfying relationship produces anxiety 2. Working Phase
• The concept of Milieu therapy involves clients’ interaction - Problem identification *Subpart*
with one another, including practicing interpersonal skills - clients explore his problems

Hildegard Peplau developed the concept of Nurse-Patient nurse responsibilities:

Relationship ✓ unconditional acceptance
✓ help the client express needs "Therapeutic communication”
- Therapeutic nurse relationship ✓ provide information “Health Teaching”
1. Orientation phase: engaging the client in tx, providing Transference:
explanations and info, and answering questions • client to nurse
2. Identification phase: client may able to share his problems; • transfer of feeling of emotions
client works independently with the nurse • clingy patient
3. Exploitation phase: client makes full use of services offered
4. Resolution phase (termination phase): client no longer Counter transference:
need professional services; relationship ends
• nurse to divent Therapeutic Communication Techniques
• nurse concern
Initiative Interaction
clients: 1. Broad openings - allowing the client to take the initiative in
✓ begin to be aware of time introducing the topic
✓ respond to the help. 2. Giving information - making available the facts that the client
✓ explore feelings ex. Art (Specify or identify the art that is needs
applicable for you patient)
Altered thought contents/Perceptions
3. Exploitation phase 3. Encouraging description of perceptions - asking the client to
- meets his need and finds solution to the problem verbalize what he or she perceives
4. Exploring - delving further into a subject or an idea
4. Termination Phase (Resolution Phase) 5. Presenting reality - offering for consideration that which is real
- established during orientation phase 6. Reflecting - directing client actions, thoughts, and feelings back
- begins when the problems are resolved to client
7. Seeking information - seeking to make clear that which is not
nurse responsibilities:
meaningful or that which is vague
✓ promotes family interaction
8. Voicing doubt - expressing uncertainty about the reality of the
✓ health / psychoeducation
client's perceptions
✓ teach self-care
✓ terminate the relationship
Continuation of TCT
clients: 9. Accepting - indicating reception
✓ aspire new goals 10. Consensual validation - searching for mutual understanding,
✓ becomes independent for accord in the meaning of the words
✓ apply new coping skills 11. Encouraging comparison - asking that similarities and
✓ positive self-change ex. Good hygiene differences be noted
12. Encouraging expression- asking the client to appraise the
CHAPTER 6 Therapeutic Communication quality of his or her experiences
Communication 13. Focusing - concentrating on a single point
- exchange of information 14. Formulating a plan of action - asking the client to consider
- written or verbal kinds of behavior likely to be appropriate in future situations
15. General leads - giving encouragement to continue
Verbal communication-use of words and sounds 16. Giving recognition - acknowledging, indicating awareness
• Content - is the literal words that a person speaks. 17. Making observations - verbalizing what the nurse perceives
• Context – is the environment in which the communication 18. Offering self - making oneself available
occurs. 19. Placing event in time or sequence - clarifying the relationship
of events in time
Nonverbal 20. Restating - repeating the main idea expressed
- most effective communication 21. Silence - absence of verbal communication, which provides time
- is the behavior that accompanies verbal content such as body for the client to put thoughts or feelings into words, to regain
language, eye contact, facial expression, tone of voice, speed composure, or to continue talking
and hesitations in speech, grunts and groans, and distance from 22. Suggesting collaboration- offering to share, to strive, and to
the listeners. work with the client for his or her benefit
23. Summarizing - organizing and summing up that which has
Privacy and Respecting Boundaries
gone before
Proxemics is the study of distance zones between people during 24. Translating into feelings - seeking to verbalize client's feelings
communication. People feel more comfortable with smaller distances that he or she expresses only indirectly
when communicating with someone they know rather than with 25. Verbalizing the implied - voicing what the client has hinted at
strangers (McCall, 2017). People from the United States, Canada, and or suggested
many Eastern European nations generally observe four distance
Nontherapeutic Communication Techniques
zones:
1. Advising - telling the client what to do
1. Intimate zone (0-18 in between people): This amount of
2. Agreeing - indicating accord with the client
space is comfortable for parents with young children,
3. Belittling feelings expressed - misjudging the degree of the
people who mutually desire personal contact, or people
client's discomfort
whispering. Invasion of this intimate zone by anyone else is
4. Challenging - demanding proof from the client
threatening and produces anxiety.
5. Defending - attempting to protect someone or something from
2. Personal zone (18-36 in): This distance is comfortable
verbal attack
between family and friends who are talking.
6. Disagreeing - opposing the client's ideas
3. Social zone (4-12 ft): This distance is acceptable for
7. Disapproving - denouncing the client's behavior or ideas
communication in social, work, and business settings.
8. Giving approval - sanctioning the client's behavior or ideas
4. Public zone (12–25 ft): This is an acceptable distance
9. Giving literal responses- responding to a figurative comment
between a speaker and an audience, small groups, and other
as though it were a statement of fact
informal functions (Hall, 1963).
10. Indicating the existence of an external source - attributing
the source of thoughts, feelings, and behaviors to others or to
outside influences
Active Listening and Observation 11. Interpreting - asking to make conscious that which is
unconscious; telling the client the meaning of his or her
Active listening means refraining from other internal mental experience
activities and concentrating exclusively on what the client says. 12. Introducing an unrelated topic
13. Making stereotyped comments - offering meaningless clichés
Active observation means watching the speaker’s nonverbal actions or trite comments
as he or she communicates. 14. Probing - persistent questioning of the client
A. Verbal communication skills 15. Reassuring - indicating there is no reason for anxiety or other
feelings of discomfort
Concrete message - the words are explicit and need no 16. Rejecting - refusing to consider or showing contempt for the
interpretation; the speaker uses nouns instead of pronouns client's ideas or behaviors
17. Requesting an explanation - asking the client to provide
Abstract messages - are unclear patterns of words that often contain reasons for thoughts, feelings, behaviors, and events
figures of speech that are difficult to interpret. They require the 18. Testing - appraising the client's degree of insight
listener to interpret what the speaker is asking. 19. Using denial-refusing to admit that a problem exists
Follow Through • Break-up
• Accepting- indicating reception
• General leads- giving encouragement to continue 3. Adventitious - social crises, disasters (not part at a daily life)
• Restating-repeating the main idea expressed Ex:
• Silence-absence of verbal • Natural disasters
• National disaster (Terrorism)
Working Through • Crime or violence (Rape)
• Consensual validation- searching for mutual understanding, for
accord in the meaning of the words. Levels of Anxiety:
• Encouraging comparison - asking that similarities and differences - fear of the unknown
be noted asking - feeling of dead or apprehension
• Formulating a plan of action - asking the client to consider kinds - used to describe uncertainty, measures, tension
of behavior likely to be appropriate in future situation
• Placing event in time or sequence - clarifying the relationship of Types of Anxiety
events in time 1. Signal anxiety - a response to an anticipated event.
• Suggesting collaboration - offering to share, to strive, and to work 2. Anxiety trait a component of personality that has been present
with the client for his or her benefit over long period of time.
3. Anxiety state the result of situation in which the person loser
How the nurse expresses her views
control of his or her emotion.
• Making observations- verbalizing what the nurse perceives
4. Free floating anxiety - always present, accompanied by feelings
• Offering self-making oneself available of dread.
• Giving recognition -acknowledging, indicating awareness

B. NONVERBAL COMMUNICATION SKILLS Levels of Anxiety

- Nonverbal communication is the behavior a person exhibits while
delivering verbal content. 1. Mild
- sharpened sense
• Facial expressions/ movements connect with words to illustrate - increased motivation
meaning; this connection demonstrates the speaker's internal - effective problem solving
dialogue. - Increased learning ability
• Closed body positions, such as crossed legs or arms folded 2. Moderate
across the chest, indicate that the interaction might threaten the - perceptual field narrows
listener who is defensive or not accepting. -selective attention.
• Vocal cues are nonverbal sound signals transmitted along with -cannot connect thoughts
the content: voice volume, tone, pitch, intensity, emphasis, speed, 3. Severe
and pauses augment the sender's message. - perception is reduced to one detailed of scattered
• Eye contact, looking into the other person's eyes during -cannot complete task
communication, is used to assess the other person and the - doesn't respond to redirection
environment and to indicate whose turn it is to speak. - feels awe, dread, horror,
-cries.
• Silence or long pauses in communication may indicate many
4. Panic
different things. The client may be depressed and struggling to
- cannot process stimuli
find the energy to talk.
- distorted perception
THE THERAPEUTIC COMMUNICATION SESSION - Loss of rational thoughts
-cannot recognize potential
• Establish rapport with the client by being empathetic, genuine, - cannot communicate danger verbally.
caring, and unconditionally accepting of the client regardless of - nervous breakdown.
his or her behavior or beliefs.
• Actively listen to the client to identify the issues of concern and GRIEF AND LOSS
to formulate a client-centered goal for the interaction. • Grief - Subjective emotions that affect normal response to the
• Gain an in-depth understanding of the client's perception of the experience of loss
issue and foster empathy in the nurse-client relationship. • Grieving / Bereavement - It is the process by which the person
• Explore the client's thoughts and feelings. experience the grief
• Facilitate the client's expression of thoughts and feelings. • Anticipatory Grieving- When people facing an imminent loss
• Guide the client in developing new skills in problem-solving. • Mourning - The outward expression of grieving
• Promote the client's evaluation of solutions.

CHAPTER 7 Client’s Response to Illness TYPES OF LOSS

Human Responses 1. Physiological Loss - Amputation
2. Safety Loss - Domestic Violence
• Crisis 3. Self-Esteem Loss - Change in the view of the person
- overwhelming emotional response or reaction to any stress
- self-limiting, results within 4-6 weeks GRIEVING PROCESS
• Crisis Intervention time limited treatment strategies - (Kübler-Ross Stages of Grieving)
- to help cope the person ➢ D – Denial
Goal: return the client to a pre-crisis state ➢ A – Anger
Focus: here I now only ➢ B – Bargaining
➢ D – Depression
Types of crisis: ➢ A – Acceptance
1. Maturational - to predictable event in life
Ex: Denial – Shock and disbelief
• Death Anger – Resentment towards other
• leaving for college. Bargaining – An attempt to reverse/postpone the loss
• birth Depression – intense feelings of loss and depression
• getting married Acceptance – final stage/brings peace/brings peace

2. Situational - sudden events unanticipated HUMAN SEXUAL RESPONSE

Ex: Sexuality – individually expressed & highly personal phenomena
• Loss of job Sexual Self Concept – values as a sexual being
Body Image - the central part of the sense of self - A thorough understanding of the patient's past and its relation to the
Gender Identity - Self-image as a male or female present problem
S – Sexual Orientation
G – Gender Contents of Anamnesis:
I – Identification A. Prenatal and Perinatal hx
E – Expression Ex: NSVD/CS
Full term/Premature
FACTOR AFFECTING SEXUAL B. Infancy and Early
➢ FAMILY ➢ Relationship with mother
➢ CULTURE ➢ Significant milestones
➢ RELIGION C. Middle Childhood
➢ Pre-school / school experiences
- Peeping Tom ➢ Friends / friendship formed
D/O - Necrophilia ➢ Play
Paraphilia - Zoophilia ➢ Methods of Discipline
- Urophilia D. Adolescence stage
➢ Onset puberty
SEXUAL RESPONSE STAGES ➢ Sports
1. Excitement ➢ Areas of special interest
➢ Physical and Psychological Stimulation ➢ Romantic experience/sexual
➢ Erection, scrotal thickening ➢ Drug and alcohol/use
➢ ^ RR, HR ➢ Work experience
➢ Winding od Vagina E. Young Adult
2. Plateau ➢ Meaningful long term relationship
➢ Reached just before orgasm ➢ Academic and career decision
➢ Full distention of penis ➢ Work History
➢ Vagina becomes extremely congested ➢ Leisure
3. Orgasm F. Middle Adulthood and Old Age
➢ A point which body discharge accumulation sexual tension ➢ Changing family
Male: 3-7 propulsive ejaculation at 0.8 seconds ➢ Social Activity
Female: 8-15 contractions at 0.8 sec. ➢ Aspirations
➢ Major Losses
4. Resolution Stage ➢ Retirement and aging
➢ External and internal organs return to aurosal state
MENTAL STATUS EXAM
Sleep – Purpose of sleep is unknown - Cross-section of the patient's psychological and some of the nurse's
observations and impressions at the moment.
STAGE OF SLEEP
a. non rapid eye movement (NREM) I. General Appearance
b. REM (Rapid eye movement) - The nurse takes note of the client's general presentation
1. Awake – active mental concentration Appearance:
2. Stage 1 ➢ Apparent age
- Lightest stage of sleep ➢ Mamner of dress
- Pulse, RR, BP ➢ Cleanliness
3. Stage 2 ➢ Posture, Gait
- Largest percentage of sleep time ➢ Facial Expression
4. Stage 3 ➢ Eye contact
- Blood Flow to the cortex
5. Stage 4 II. Speech
- Deepest, most relaxed stage ➢ Rapid/Slow
- Sleep Disorder ➢ Volume
- Sleepwalking, bed-wetting ➢ Amount of the speech
- Bruxism (teeth grinding) ➢ Paucity and pressured speech
6. Stage 5
- Dreaming III. Motor Activity
- Penile and clitoral erection ➢ Describe the clients physical movement
- Absence of skeletal movement ➢ Check level of Activity -> lethargic, tense, restless or
agitated
PSYCHIATRIC NURSING ASSESSMENT
- Psychosocial assessment TYPES OF ACTIVITY
- factual info ➢ Tics (involuntary movement)
- observation of the client ➢ Grimaces
➢ Tremors
PSYCHIATRIC NURSING HISTORY ➢ Usual gesture and compulsion
➢ Psychiotic -> Vital
➢ Anamnesis Motor Disturbance
➢ Genogram (pedigree) I. Catatonic
➢ Mini-mental status exam ➢ Motor anomalies in non-organic d/o
➢ Mental status exam a. Catalepsy
➢ Physical Assessment ➢ For an immobile position that is maintained for a long
➢ Spiritual Assessment time.
➢ Cultural Assessment b. Catatonic
➢ Diagnostic Studies ➢ Uncontrolled motor activity
Anamnesis c. Catatonic Posturing
➢ Vol. assumption of an inappropriate or bizarre posture, b. Visual- see images that does not exist
maintain for long time c. Olfactory- smells and odors
d. Catatonic Rigidity d. Tactile- refers to sensations
➢ Fixed and sustained position e. Gustatory- involves the taste
➢ Resistance to change f. Cenesthetic- reports bodily functions
e. Catalepsy/Waxy Flexibility g. Kinesthetic- client reports bodily movements but motionless
h. Fornication- tactile, insects are crawling
➢ Person maintains body position in which they are placed.
i. Haptic- hallucination of touch
j. Hypnagogic- occuring while falling asleep
II. Echopraxia - Imitation of posture of others k. Hypnopompic- occuring while awakening from sleep
III. Ataxia - Loss of balance
IV. Akathesia - Extreme Restlessness ( subjective) Thought Content
V. Excessive Body Movements - is the specific meaning expressed in the patient’s communication
➢ Anxiety - “what” is the persons thinking
➢ Manic - Delusion- false fixed beliefs.
➢ Substance Abused
VI. Little Body Movement - Depression or drug induced Examples of Delusions:
VII. Tics and Grimaces - Side effect of medication a. persecutory/paranoid – excessive irrational suspicion & distrust to
VIII. Repeated Motor Movement - OCD others
IX. Akinesia - Loss of movement b. religious - one is favoured by a higher being
c. somatic - one’s body are diseased or distorted.
X. Bradykinesia – slow movement
d. Grandiose - one possesses greatness or special power
e. Alien Control- one thoughts, feelings or actions are controlled by
Next Topic external force.
Interaction During Interview f. Nihilistic- denies reality or existence or part of self.
- Describe how the patient relates to the nurse g. Poverty - one will bereft of all material possessions.
- hostile h. Thought Broadcasting - one thought is aired in the outside world
- uncooperative i. Thought Insertion - one’s thought are being placed into one’s mind
- irritable (anxiety) by outside people
- guarded (paranoid) j. Depersonalization - having lost identity
- suspicious (paranoid) k. Ideas of reference- incorrect interpretation of causal incidents &
- seductive external events.
l. Hypochondriasis- over somatic concern w/ morbid attention to
details
II. Mood m. Obsession- an idea or emotion or impulse that repetitively &
- Client reports of self-prevailing emotional state insistently forces into consciousness
- Changes from time to time Types of obsession:
- Ask the rate of the mood (0-10) ✓ Dipsomania- compulsion to alcoholic beverages
a. Dysphoria- unpleasant mood ✓ Kleptomania- compulsion to steal
b. Euthymic mood- normal range of mood ✓ Monomania-preoccupation to one subject
c. Labile mood- oscillations between euphoria ✓ Nymphomania- excessive insatiable desire of a woman for sex
d. Euphoria- intense elation of feelings ✓ Satyriasis- insatiable sexual need of men
e. Depression- psychopathological feelings of sadness n. Phobia - morbid or extreme anxiety
f. Apathy- lack of emotions, interest, or concern o. Delusion of infidelity- one’s love is unfaithful
g. Ambivalence- two opposing feelings p. Delusion of accusation- false feeling or remorse or guilt
h. Alexithymia- inability to describe emotions q. Erotomania/declerabault syndrome- common to women, someone
i. Expansive mood- expressions of feelings without restraint is deeply in love with them
j. Irritable mood- easily annoyed or provoked
k. Ineffiability- ecstatic state indescribable feeling V. Thought Process
- “how” the patients think can be observed through speech
III. Affect a. circumstantiality- inclusion of excessive & unnecessary detail in
- apparent emotional tone answer
- outward expression of emotions b. Tangentiality - excessive details does not answer the question
c. Flight of ideas - rapid shifting from one topic to another; (bipolar)
Described terms: d. Loose Association - lack of logical relationship; no connection
1. Range from one topic to another; (Schizophrenia)
2. Duration e. Word Salad - series of words seem totally unrelated
3. Intensity f. Clang Association - rhyming of the words
4. Appropriateness g. Stilted language- excessive flowery words
h. Neologism – forming of new words
Findings i. Echolalia - imitation of words
a. Blunted affect- severe reduction or limitation in the intensity j. Verbigeration - repetition of words or phrases without meaning
b. Flat affect- absence or near absence of any signs of affective k. Perseveration - persistent adherence to a specific
response l. Thought Blocking- sudden stop in the train of thoughts
c. Inappropriate affect- lock of harmony of one’s movements and m. Confabulation - filling in memory gaps the detailed fantasy
thoughts
d. Labile affect- abnormal fluctuation of one’s expression VI. LEVELS OF CONCIOUSENESS
e. Restricted affect- reduction in one’s expressive range
- Ask the px regarding orientation to time, person and place
FINDINGS:
IV. Perceptions 1. Confusion - disoriented
Illusions- false sensory perception to a stimulus 2. Cloudy of consciousness- disturbance of perception
Hallucinations- False sensory perception without stimulus
3. Stupor- the client does not react or unaware of his surroundings
4. Coma- loss of consciousness
Examples of Illusions:
a. Micropsia- visual perceptions that objects or persons are reduced VII. MEMORY
to size
1. Ability to recall
b. Macropsia- objects are larger 2. Recent memory (ex. 12495)
3. Long-term memory (ex. birthday)
Examples of Hallucinations:
a. Auditory- command hallucination; most common type of
TYPES OF MEMORY
hallucination
1. Immediate – seconds to minute
2. Recent- few days to 2 weeks • Jerky movements
3. Recent past- over the past months Alcohol Delirium
4. Remote- event in distant past •Withdrawal delirium: The state delirium usually peaks 48 to 72
hours after cessation or reduction of intake (although it can occur
FINDINGS: later) and lasts 2 to 3 davs
a. Confabulation- filling out memory gaps •Withdrawal delirium is a medical emergency.
b. Dejavu- visual recognition in which new situation is incorrectly
Death can occur from myocardial infarction, fat emboli, peripheral
regarded as previous experience
vascular collapse, electrolyte imbalance, aspiration pneumonia, or
c. Jamais vu- false feeling of unfamiliarity to real situation
d. Deja entendu- one has heard previously suicide.
e. Deja pense- though never entertained before is incorrectly regarded Alcohol defense mechanism
as repetition Nursing Intervention
f. Presque vu- cannot recall a familiar word or name •Monitor vital signs and neurological signs (every 15 minutes) and
g. Amnesia- memory loss provide one-to-one supervision
➢ Retrograde- distant pass memory loss •Orient frequently.
➢ Anterograde- immediate past •Initiate seizure precautions.
➢ Lacunar amnesia- amnesia on specific or specific isolated •Provide small, carbohydrate foods.
memory •Administer vitamins
h. Hypermnesia- abnormally pronounced memory Medications
i. Paramnesia- falsification of memory Acamprosate: Works by reducing the physical distress and emotional
j. Anomia- inability to recall object
discomfort people usually experience when they quit drinking
k. Amimia- inability to make gestures or comprehend gestures
l. Autopagnosia- cannot recognize own body parts Naltrexone: Works by blocking in the brain the "high" feeling that
m. Spatial agnosia- cannot recognize spatial relations people experience when they drink alcohol.
n. Prosopagnosia- inability to recognize familiar faces Disulfiram: Works by causing a severe adverse reaction when
someone taking the medication consumes alcohol.

Next Topic
Disulfiram therapy
ALCOHOL ABUSE •The client must abstain from alcohol for at least 12 hours before the
Physical dependence initial dose is administered.
- is a biological need for alcohol to avoid physical •Adverse effects usually begin within several minutes to 30 minutes
withdrawal symptoms, whereas psychological dependence after consuming alcohol and may last 30 minutes to 2 hours.
refers to craving for the subjective effect of alcohol •The client must avoid drinking alcohol for 14 days after disulfiram
Psychological dependence therapy has been discontinued; otherwise, the client is at risk for a
- Craving for the subjective effect of alcohol disulfiram-alcohol reaction.
Risk Factors Adverse effects :
• 1. Biological predisposition; genetic and familial predisposition •Facial flushing
may also be a risk factor. •Sweating
• 2. Depressed and highly anxious characteristics •Throbbing headache
• 3. Low self-esteem •Neck pain
• 4. Poor self-control •Nausea and vomiting
• 5. History of rebelliousness, poor school performance, and Autistic Disorder and ADHD
delinquency Autistic Disorder pervasive developmental disorder
• 6. Poor parental relationships •more prevalent in boys than in girls
Assessment •identified usually by 18 months
• 1.Slurred speech •Autism does have a genetic link
• 2. Uncoordinated movements Assessment
• 3. Unsteady gait •LIMITED
• 4. Restlessness •eye contact
• 5. Confusion •facial expressions toward others
• 6. Sneaking drinks, drinking in the morning, and •gestures to communicate
• experiencing blackout •capacity to relate to peers or parents.
•7. Binge drinking •NO
•8. Arguments about drinking - Enjoyment
•9. Missing work
- Mood or emotional affect
•10. Increased tolerance to alcohol
- No fear
Complications associated with chronic alcohol use
•Hand flapping
• Vitamin deficiencies
•Body Twisting
a. Vitamin B deficiency causing peripheral neuropathies
•Head Banging
b. Thiamine deficiency, causing Korsakoff's Syndrome
Asperger
(memory disorder)
- Difficulty interpreting non-verbal communication
•Alcohol-induced persistent amnesic disorder, causing severe
- No significant delays in cognitive and language
memory problems.
- Repetitive pattern
•Wernicke's encephalopathy
- Common to boys
- (lack of VitB1),
- causing confusion,
Treatment
- ataxia, and
•reduce behavioral symptoms
- abnormal eye movement.
•acquisition of language skills
•intramuscular injection of vitamin B1 (thiamine)
•(Haldol) or risperidone (Risperdal)
Alcohol Withdrawal
Tantrums, aggressiveness, self-injury and stereotyped behaviors.
Early signs develop within a few hours after cessation of alcohol
- naltrexone (ReVia),
intake.
- clomipramine (Anafranil),
• Hyper alertness
- clonidine (Catapres), and stimulants:
• Hypertension
-self-injury
• Insomnia
-hyperactive
• Irritability
-obsessive behaviors.
Nursing interventions • Client/family education and support
- provide safety • Listen to parent's feelings and frustrations.
- give its favourite toy Oppositional Defiant D/O
Rett's Disorder - Over aggressiveness and tendency to purposely bother
•Loss of motor of language skills or irritable to others
•Very common to girls - Ages 1-3 years
•develops between birth and 5 months of age Etiology:
Childhood Disintegrative Disorder - Hereditary
•regression in multiple areas of functioning after at least 2 years of Signs and Symptoms
apparently normal growth and development. - Uncooperative / hostile
•onset is between 3 and 4 years. - Disobedience
•More common to boys - Lose temper
Attention deficit hyperactivity disorder - Manipulative
- inattentiveness, overactivity and impulsiveness - Inducing discord to others
- common to boys Conduct disorder
- diagnosed during preschool or school - Oppositional behaviors plus anti-social activities
Asperger's Disorder - Aggression to people and properties
• Impairments of social interaction Asocial
• Restricted stereotyped behavior - Absence of socialization
•No language and cognitive delays Signs and Symptoms
•More common to boys - Cruel behaviour to others
•lifelong - Bullying
Inattentive Behaviors - Physical and sexual assault
•Misses details - Setting fires
•Makes careless mistakes - Vandalism
•Has difficulty sustaining attention - Serious violations
•Doesn't seem to listen
• Does not follow through on chores or homework Feeding and Eating Disorder
•Has difficulty with organization
Hyperactive/Impulsive Behaviors 1. PICA
• Fidgets - Persistent eating of non-nutritive food
• Often leaves seat (e.g., during a meal) - At least 1 month
• Runs or climbs excessively - 12-24 mos onset
•Can't play quietly and ss always on the go; driven
• Talks excessively 2. RUMINATION DISORDER
• Blurts out answers - Initiate regurgitation
• Interrupts or Can't wait for turn Signs and Symptoms
• Is intrusive with siblings/ playmates - Repeated regurgitation
Etiology - The food is ejected and re-swallowed
•decreased metabolism in the frontal lobes Elimination D/O
•Exact cause is unknown - Encopresis
• Abnormalities in catecholamine and possibly serotonin metabolism ▪ Pattern of passing feces inappropriate
Treatment places
•Drug of Choice: methylphenidate (Ritalin) Common to:
• amphetamine compound (Adderall). - Harsh toilet training (punish)
•Methylphenidate (Ritalin) - Sexually abused
-10-60 mg in 3-4 divided doses Enuresis
-Monitor for appetite suppression or growth - Repeated voiding of urine
delays. - Onset is 5 year old
- Drug of choice
• Dextroamphetamine (Dexedrine) ▪ Tofranil
▪ 5-40 mg in 2-3 divided doses Monitor Tic D/O
for insomnia. - Abnormal movements and vocalization
▪ Sustained release (Dexedrine-SR) 10- TYPES:
30 in the morning Give last dose in a. Simple tics – simple blinking
early afternoon. b. Vocal tics – coughing, sniffing
▪ Monitor for appetite suppression. c. Complex motor tics- grooming, smelling object,
▪ Alert client that full drug effect takes 2 echopraxia, copropraxia
days. d. Complex vocal tics- repeating of words, echolalia,
Nursing Interventions coprolalia
•Ensuring the child's safety and that of others Etiology
•Stop unsafe behavior. - Dopamine system involvement
• Provide close supervision. Interventions
• Give clear directions about acceptable and unacceptable behavior - Behavioural techniques
•Improved role performance - DOC:
•Give positive feedback for meeting expectations. ▪ Resperidone
•Manage the environment (e.g., provide a quiet place free of ▪ Haloperidol
distractions for task completion).
•Simplifying instructions/directions SCHIZOPHRENIA
• Get child's full attention. -CAUSES DISTORTED and bizarre thoughts, perceptions, emotions,
• Break complex tasks into small steps. movements, and behavior.
• Allow breaks. •usually is diagnosed in late adolescence or early adulthood.
• Structured daily routine •prevalence of schizophrenia is estimated at about 1% of the total
• Establish a daily schedule. population.
• Minimize changes.
Types of Schizophrenia
1. Schizophrenia, paranoid type:
•characterized by persecutory (feeling victimized or spied on
•grandiose delusions,
•hallucinations,
• excessive religiosity (delusional religious focus)
•hostile and aggressive behaviour
2. Schizophrenia, disorganized type:
•Grossly inappropriate or flat affect
•incoherence
• Loose associations
•Extremely disorganized behaviour
3. Schizophrenia, catatonic type:
•psychomotor disturbance, either motionless or excessive motor
activity.
• Peculiar or Motor immobility ( way flexibility and stupor).
• mutism
• Echolalia and echopraxia
4. Schizophrenia, undifferentiated type
- Mixed schizophrenic symptoms (of other types) along
with disturbances of thought, affect, and behavior.
5. Schizophrenia, residual type:
•one previous, though not a current, episode;
social
•withdrawal; flat affect; and looseness of

DSM 5 - renamed schizophrenia to «schizophrenia spectrum disorder

and other Psychotic Disorders»

•Why? schizophrenia is a variable and complex condition. The

symptoms of schizophrenia can vary significantly among individuals.
A person must experience at least 2 or more symptom to receive a
diagnosis of schizophrenia spectrum disorder.
These are:
•delusions
•hallucinations
• disorganized speech
• disorganized or catatonic behavior
• negative symptoms, such as not showing feelinas or havina a
complete lack of motivation
At least 6 months period with 1 month symptom

Schizoaffective disorder
•psychotic symptoms of schizophrenia and meets the criteria for a
major affective or mood disorder
Causes
Genetic
•identical twins have a 50% risk for schizophrenia.
•Fraternal twins have only a 15% risk.
•one biologic parent with schizophrenia have a 15% risk
Other causes
"exposure to a virus or the body's immune response to a virus could
alter the brain physiology.
Treatment
•Antipsychotics or neuroleptics
• conventional, antipsychotic medications are dopamine antagonists (
positive signs)
•atypical, antipsychotic medications are both dopamine and serotonin
antagonists ( negative signs)
•Antipsychotics or neuroleptics
• depot injection (fluphenazine) (Prolixin) in decanoate and enanthate
preparations and haloperidol (Haldol) in decanoate.
• Effects can last 2 to 4 weeks
• Duration of action begins 7 to 28 days for fluphenazine and 4 weeks
for haloperidol
• Not best for acute episodes, best for needs supervision