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PSYCHIATRIC NURSING PSYCHIATRIC NURSING A specialized area of

By Dale Kelly,2014-06-28 13:45
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PSYCHIATRIC NURSING PSYCHIATRIC NURSING A specialized area of ...

    ? PSYCHIATRIC NURSING

    ? PSYCHIATRIC NURSING

    - A specialized area of nursing practice employing theories of human behavior as its science and purposely use of self as its

    art.

    - Includes the continuous and comprehensive services necessary for the promotion of optimal mental health, prevention

    of mental illness, health maintenance, management and referral of mental and physical health problems, the diagnosis

    and treatment of mental disorders and their sequela, and rehabilitation

    ? BASIC PRINCIPLES OF PSYCHIATRIC NURSING

    ? Accept and respect the client regardless of his behavior.

    ? Limit or reject the inappropriate behavior but not the individual

    ? Encourage and support expression of feelings in a safe and non-judgmental environment. Increase verbalization,

    decreases anxiety.

    ? Behaviors are learned.

    ? All behavior has meaning.

    ? INTERDISCIPLINARY TEAM PRIMARY ROLES

    Psychiatrist:

     The psychiatrist is a physician certified in psychiatry by the American Board of Psychiatry and Neurology, which

    requires 3-year residency, 2-years of clinical practice, and completion of an examination. The primary function of the psychiatrist

    is diagnosis of, mental disorders and prescription of medical treatments.

    Psychologist:

     The clinical psychologist has a doctorate (Ph.D.) in clinical psychology and is prepared to practice therapy,

    conduct research, and interpret psychological tests. Psychologists may also participate in the design of therapy programs for

    groups of individuals.

    Psychiatric nurse:

     The registered nurse gains experience in working with clients with psychiatric disorders after graduation from an

    accredited program of nursing and completion of the licensure examination. The nurse has a solid foundation in health promotion,

    illness prevention, and rehabilitation in all areas, allowing him or her to view the client holistically. The nurse is also an essential team member in evaluating the effectiveness of medical treatment, particularly medications. Registered nurses who obtain a

    master’s degree in mental health may be certified as clinical specialist or licensed as advanced practitioners, depending on individual

    state nurse practice acts. Advanced practice nurses are certified to prescribe drugs in many states.

    Psychiatric social worker:

     Most psychiatric social workers are prepared at the master’s level, and they are licensed in some states. Social

    workers may practice therapy and often have the primary responsibility for working with families, community support, and referral.

    Occupational therapist:

     Occupational therapist may have an associate degree (certified occupational therapy assistant) or a baccalaureate

    degree (certified occupational therapist). Occupational therapy focuses on the functional abilities of the client and ways to improve client functioning such as working with arts and crafts and focusing on psychomotor skills.

    Recreation therapist:

     Many recreation therapists complete a baccalaureate degree, but in some instances persons with experience fulfill

    these roles. The recreation therapist helps the client to achieve a balance of work and play in his or her life and provides activities that promote constructive use of leisure or unstructured time.

    Vocational rehabilitation specialist:

     Vocational rehabilitation includes determining clients’ interests and abilities and matching them with vocational choices. Clients are also assisted in job-seeking and job-retention skills, as well as pursuit of further education if that is needed and desired. Vocational rehabilitation specialists can be prepared at the baccalaureate or master’s level and may have different levels of autonomy and program supervision based on their education.

    ? 3 LEVELS OF PSYCHIATRIC NURSING (Levels of Health)

    I. Primary

     Objective: PROMOTION & PREVENTION

     A. Client and Family Teaching (Health Teaching)

1.Teaching adolescent in preventing contracting STDs

     CHLAMYDIA: #1 STD in the U.S.

     #1 Sign: Greenish & purulent urethral discharge

     PID (Pelvic Inflammatory disease) #1 cause of sterility in women

     #1 Drug of choice Erythromycin

     2nd drug of choice Cephalosporin

2. Teaching pregnant women relaxation techniques

     Objective: to prevent complication in labor, fetal distress, perineal laceration (also can be prevented by Kegel’s

    exercise)

    Stage I of labor (LAT-CAP)

     L atent C chest breathing

     A ctive A bdominal breathing

     T ransitional P ant blow breathing 3. Teaching couples on contraceptives BON (Barrier, Oral Contraceptive, Natural)

     Barrier - CONDOM

     Oral - Artificial

     Natural - not for M A M (Malnourished, Anemics &

     Menses irregular)

     4. Conducting rape prevention classes is an example of primary level of prevention. B. Herbal Medicines

    C. Psychosocial Support family/friends/peers

    Needs most support (ASA): Addicts, Suicidal, Alcoholics,

     Suicide = Major depression, despair, hopeless, powerless

     Prone: Male Age bracket prone for suicide

     #1. Adolescent (identity crisis)

     2. Elderly (ego-despair)

     3. Middle age men (40 y.o. above) 4. Post partum depression

     (7days/2-4 weeks)

    D. Giving Vaccines

    II. Secondary : Screening, Diagnosis & Immediate Treatment

    A. Screening

     > Denver Development Screening Test (DDST) #1 test for PDD

Pervasive Development Disorder (PPD)

     1. Autism: Age of onset (3 y.o.)

     2. ADHD: Age of onset (6 y.o.)

     Diet: Finger Food (high caloric, high CHO)

     Rx: Ritalin (Methylphenidate); dextroamphetamine (Dexedrine)

     3. Conduct disorder: Age of onset (6 y.o.)

    ? B. Suicide Prevention / Intervention

     Impending signs of Suicide

     1. Sudden elevation of mood/sudden mood swings

     2. Giving away of prized possessions

     3. Delusion of Omnipotence (divine powers)

     Used by SS (Suicidal, Schizophrenia)

     4. When the patient verbalizes that the 2nd Gen TCA is working.

     less than 2-4 wks (telling a lie)

    ? Suicide Interventions:

    1. One-on-one supervision and monitoring

    2. No suicide contract 24 hrs monitoring

     - Patient is required to verbalize suicidal ideas

    3. Non metallic/plastic/sharp objects: ex. belts, curtains

    4. Avoid dark places

    C. Case Finding (Epidemics)/Contact Tracing (STDs)

    D. Crisis Intervention

    Objective: To return the client to its normal functioning or pre crisis level.

     Duration: (4-6 wks)

     Disorganization is a phase in the crisis state which is characterized by the feelings of great anxiety and inability to perform

    activities of daily living

     A patient in crisis is passive and submissive, so the nurse needs to be active and should direct the patient to activities that

    facilitate coping.

    ? Types of Crisis:

    1. Developmental Maturation Crisis

     - Adolescence (identity crisis)

     - Mid-life crisis;

     - Pregnancy

     - Parenthood

    2. Situational / Accidental crisis

     - Most common: Death of a loved one

     NSG DX: Ineffective Individual Coping/ Denial

     - ex. murder, abortion , rape and fire

    3. Adventitious calamity, disaster

     ex. World War I & II, epidemic, tsunami

     In a DISASTER 1st assess/survey the scene

    ? E. Emergency drugs and antidotes

    ? III. Tertiary

    Objective: Rehabilitation, which start upon admission

    A. Occupational Therapy

     - Usually use behavior modification for PDD (Pervasive Developmental Disorders), anorexia & depression

     - Also use fine motor rehabilitation for Post M.I. & Post CVA B. Vocational Skills (Entrepreneur skills)

    C. Aftercare Support follow-up.

     Needed by: addicts & residual schizophrenia due to remission & exacerbation

    ? CRITERIA OF MENTAL HEALTH

    (Jahoda, 1953; Staurt and Sundeen, 1995)

    Reality perception:

     Ability to test assumptions about the world by empirical thought; includes social sensitivity (empathy)

     Growth, development, & self-actualization

    (by Maslow) which includes fully functioning person” (by Rogers)

    Autonomy:

     Involves self- determination, self- responsible for decisions, balance between dependence and independence, and

    acceptance of the consequences of one’s action

    Positive attitudes

     toward self; includes self-identity, self-acceptance, self-awareness, belongingness, security and wholeness

    ? COMPONENTS OF ASSESSMENT OF MENTAL STATUS

    ? DSM V (Diagnostic and Statistical Manual for Mental Health) Axis I Clinical Syndrome (S&Sx)

     II Personality Disorders

     III Pathological Disorders

     IV Environmental & Psychosocial stressors

     V Global Functioning (assessment)]

    ? CONCEPTUAL MODELS OF PSYCHIATRIC TREATMENT

    ? PSYCHOANALYTICAL/PSYCHOSEXUAL MODEL. (Freud); Focus- Intrapsychic process (conflicts, anxiety, defense

    mechanisms, impulses).

    ? BEHAVIORAL FRAMEWORK: Focus- learned behavior; Pavlov’s Theory: Classical Conditioning; Skinner’s Theory: Operant

    Conditioning.

    ? INTERPERSOAL MODEL (Sullivan and Peplau); Focus- Interpersonal relationships

    ? PSYCHOSOCIAL THEORY (Erik Erickson); Focus-Psychosocial tasks

    ? EXISTENTIAL MODEL / HUMANISTIC MODEL (Rogers); Focus- Conscious human experiences

    ? BIOMEDICAL MODEL (Meyer, Kraeplin, Frances); Focus Disease approach, syndromes, diagnoses, etiologies.

    ? PSYCHOSOCIAL THEORY OF ERIC ERIKSON

    Most commonly used theory by health professionals.

    Describes the human cycle as a series of eight EGO developmental stages from birth to death; Focus: PSYCHOSOCIAL TASKS

    throughout the life cycle.

    ? STAGES OF PSYCHOSOCIAL DEVELOPMENT:

    ? PSYCHOSEXUAL (PSYCHOANALYTICAL) THEORY

    OF SIGMUND FREUD

    ? Infancy: Oral Phase; Stage of the Id

    ? Toddler: Anal Phase; Stage of the Ego

    ? Preschooler: Phallic Phase; Stage of the Superego (conscience)

    ? Attachment of the child to the parent of the opposite sex and jealousy toward the parent of the same sex

    ? Oedipal Complex: Attachment of the son to his mother and jealousy toward the father.

    ? Electra Complex: Attachment of the girl to her father and jealousy toward the mother.

    ? Schooler: Latency phase; Stage of the Strict Superego

    ? Adolescent: Genital phase

    ? FREUDIAN THEORY COMPONENTS:

    1. LEVELS OF AWARENESS:

    ? Conscious

     Composed of past experiences, logical and governed by REALITY PRINCIPLE; are remembered and

     easily recalled or available to the individual

    ? Subconscious

     the Preconscious; composed of material that has been deliberately pushed out of conscious level;

    helps repress unpleasant thoughts or feelings and can examine or censor certain desires or thinking; can be recalled with

    some effort

    ? Unconscious

     Composed of the LARGEST BODY OF MATERIAL- the thoughts, memories and feelings that are

    repressed and not available to the conscious mind, not logical and governed by PLEASURE PRINCIPLE and since it is usually painful and unacceptable to the individual, it cannot be deliberately brought unacceptable to the individual, it cannot

     be deliberately brought back into awareness unless in disguised or distorted form (dreams)

    ? Three Elements of Personality

    ? IMBALANCE or ABNORMAL FUNCTIONING OF THE THREE ELEMENT OF PERSONALITY

     ?Id + ?SE = Conduct Disorder and Antisocial Personality Disorder

     ?Id + ?SE = Obsessive Compulsive Disorder

    ID:

    Psychoanalytic term for that part of the psyche that is UNCONSCIOUS, the reservoir of INSTINCTS, primitive drives governed by

    the PLEASURE PRINCIPLE and is SELF- CENTERED. The Ids says, “I want, what I want, when I want it”. EGO:

     Psychoanalytic term for that part of the psyche that is CONSCIOUS, The “I” that is shown to the environment

    and most in touch with REALITY and the MEDIATOR between the primitive, pleasure- seeking, instinctive drives of the ID and the

    self- critical, prohibitive forces of the SUPEREGO and is directed by REALITY PRINCIPLE. This is the thinking- feeling part of

    personality. The Ego says, “I would want to have it if only I can afford it;” “Not now, I am not yet ready; perhaps next week.”

    SUPEREGO:

    Psychoanalytic term for that part of the psyche that RESTRAINS, controls, inhibits and prohibits impulses and instincts, is self- critical, and is called the CONSCIENCE or EGO IDEAL. The Superego says, “I should not want that; It is not good to even wish for it.”

    ? ESSENTIAL ELEMENTS OF A NURSE- CLIENT CONTRACT

    1. Names of RN and patient

    2. Roles of RN and patient

    3. Responsibilities of RN and patient

    4. Goals / Expectations

    5. Purpose of a relationship

    6. Meeting location / time

    7. Condition for termination

    8. Confidentiality

    ? FOUR PHASES OF NURSE- CLIENT RELATIONSHIP (NCR)

     A. Pre-interaction/Pre-orientation (For the Nurse)

     - Stage of Self-Awareness To prevent Counter Transference

#1 CORE VALUE OF Psychiatric Nursing

B.ORIENTATION (INITIATION)

    ? Assessment of problems, needs, expectations of clients

    ? Identify anxiety level of self and client

    ? Set goals of relationship.

    ? Define responsibilities of nurse and client. Stage of testing.

    ? Establish boundaries of relationship. Stress confidentiality.

     Contract 2 famous psychiatric contracts:

1. No suicide contract Major depression = emergency

     TWO definitions of no suicide contract:

     A. 24 hrs monitoring

     B. Verbalization to the nurse of all suicide ideas

    2. Diet contract ? Eating disorder

    The start of termination phase: “Good morning, full name, RN, shift, session, date start & end.”

    C. WORKING PHASE

    ? Promote acceptance of each other

    ? Accept client as having value and worth as a unique individual.

     - Stage of resistance

     - Counter transference phase

     - Most difficult phase

     -- NCP is on going

     - Identification of the problem/exploration

     - The #1 Psychiatric Core Value is Consistency For manipulative patients

    Be consistent to patient with: BAAAM COPS

     B orderline C onduct d/o

     A ntisocial O ral/eating disorder

     A lzheimer’s P aranoid

     A utistic S uicidal

    Use therapeutic and problem- solving techniques

    ? Maintain PROFESSIONAL, therapeutic relationship

    ? Keep interaction reality- oriented- here and now

    ? Provide ACTIVE LISTENING and REFLECTION of feelings

    ? Use non- verbal communication to support client

    ? Recognize blocks to communication and work to remove them

    FOCUS on client’s:

    ? Confronting and working through identified problems

    ? Problems- solving skills

    ? Increasing independence

    ? Help client develop alternative, adaptive coping mechanisms

    Personal biases (manifestation by counter-transference & vice versa) are seen during working phase

     D. TERMINATION

    ? Plan for termination of relationship early the relationship

     - Stage of Separation Anxiety

     Signs & symptoms: Regression: Temper tantrums, thumb sucking, apathy, fetal position when crying.

- Phase of prognosis Evaluation

    ? Maintain boundaries

    ? Anticipate problems of termination:

     Increased dependency on the nurse

     Recall of previous negative experience- rejection, depression, abandonment, etc.

     Regressive behaviors

    ? Discuss client’s feelings and objectives achieved

    ? THERAPEUTIC COMMUNICATION

    DEFINITION:

     Continuous, dynamic process of SENDING and RECEIVING MESSAGES by various verbal or non- verbal means

    (words, signals, signs, symbols) utilized in a goal- directed professional framework.

    ? THERAPEUTIC COMMUNICATION TECHNIQUES

    a. Offering of self safety, service, comfort

    “I am here. I will sit here beside you.

     I will lead you to the group therapy session.”

    *Ursula, age 25, is found on the floor of the bathroom in the day treatment cleaning with moderate lacerations to both wrists.

    Surrounded by broken glass, she sits staring blanking at her bleeding wrist while staff members call for an ambulance. The best

    way the nurse should do is to approach Ursula slowly while speaking in the calm voice, calling her name and telling her that the

    nurse is here to help her. This approach provides reassurance for a patient in distress. b. Reflection: (mirror of feelings) “It must be difficult for you.” “You seem angry. You seem concerned.”

     When patient with symptoms of severe depression says to the nurse “I can’t talk; I have nothing to say.” And

    continues being silent. The most appropriate response of the nurse is to say, “It may difficult for you to speak at this time;

    perhaps you can do so at another time”. This response will convey that the nurse is willing to wait for the patient’s readiness to

    engage in conversation.

     Daughter of patient newly diagnosed w/ Alzheimer’s says, “I can’t be. Nobody in the family is senile,” correct 5response of

    RN includes statement like, “It sounds as if you are shocked over the diagnosis.”

c. Elaboration/Exploration

     “Tell me more about your feelings”

     “Everyone is on my back. My husband says, ‘I don’t do anything right,’ & my boss wants me to do things differently.”

    RN’s response to elaborate feelings includes statement like,

     “Have you discussed this with your husband about how to cope with these problems? Tell me.”

     Appropriate response for an 80 y/o who says, “I told my children that I’m ready to die.” Includes statement like “Tell me

    about your feelings & I will stay w/ you.”

    d. Clarification used in neologism and word salad SAM (seen in Schizophrenia, Alzheimer’s, Manic)

     “What do you mean by…?”(Used in Neologism and word salad)

     “I could not follow you.” –(Used in flight of ideas and looseness of association)

     “The ground is watching us.”, appropriate intervention includes clarify the meaning of the word.

     Brilliant & charming patient says, “I’ll be better off dead.” Best response of the RN includes asking questions like,

    “Do you have plans of suicide”?

     Pt says, “I’d like to take you out & give you a good show.” best response by the RN is asking pt, “What do you mean by a good show?”

    e. Reality Orientation/Reality Testing

     - Nsg Dx: Altered Sensory Perception

     - Delusion; Hallucination, Illusion & delusion

     Client: “Help! Help! There are spiders on my back!”

     Nurse: “I don’t see spiders but for you that is real.”

     Alcoholic pt with delirium tremens states, “There are spiders crawling on my back”. The appropriate response of

    the nurse would be, “there are no spiders, its only part your illness”.

    f. Giving Leads

     “Aha..then…mmmh… go on… yes…”

    g. Therapeutic Silence

    h. Paraphrasing/restating repeating

    Repeats the MAIN IDEA; restate what the client says. (Patient: “I can’t believe I cannot go home today.” Nurse: “You can’t believe that you can’t go home today?”)’

    i. Summarizing recap

     Nurse: “Today you have described your understanding of how you feel when you are upset with your son.” j. Validation interpret

     Client: “I see a shadow.”

     Nurse: “You’re frightened.”

     A patient admitted to be listening to voices should be assessed by asking, “What does the voice tells you?

     “I know that Prof. Draper tried to rape me, rape my mind...& he’s still trying to rape me”, correct of RN includes

    questions like “Are you frightened being unable to control your thoughts?” Post-menopausal woman says, “I’m pregnant by God in heaven.” Appropriate response by the nurse includes statement like, “You believe something special happened to you?’

     “It must be frightening to feel that way.” is an appropriate response for a suspicious pt saying, “I think that my food is

    being poisoned”

     RN’s correct response of pt w/. OCD who checks door 10-15 times includes statement like, “It sounds as if you have much

    anxiety.”

k. Open-ended question / broad openings

     Questions NOT answerable by ‘YES’ or ‘NO’; encourages further or broadened communication.

     “How are you?” “How’s your day?” “What are your favorite things?”

    ? BLOCKS TO THERAPEUTIC COMMUNICATION

    a. Never use why it demands an explanation and also anxiety provoking b. Closed Ended Question questions answered by “yes” or “no”

     Note: The only therapeutic closed-ended question Suicidal pt. “Are you planning to commit suicide?”-Confrontation

    c. False Assurance

     “Do not worry” To patient who are dying & w/ incurable illness

     “You have the best doctor; everything will be all right.”

     “Relax that is nothing to worry about.”

    e. Belittling the patient CHANGING THE SUBJECT

    f. Non therapeutic silence/touch

    g. Advising never advise because they are sometimes persona; opinions

     “I believe it would be better if you…”

    h. Stereotyping

    ? BEHAVIORAL THERAPY

    A. TERMINOLOGIES

    ? STIMULUS: Any event affecting an individual

    ? PROBLEM BEHAVIOR: Deficient, excessive, condemned, unwanted behavior

    ? OPERANT BEHAVIOR: Activities that are strongly influenced by events that follow them.

    ? TARGET BEHAVIOR: Activities that the nurse wants to develop or accelerate in the client.

    ? REINFORCER: A reward positively or negatively influences and strengthens desirable behaviors.

    ? POSITIVE REINFORCER: A desirable reward produced by specific behavior (TV time after doing homework)

    ? NEGATIVE REINFORCER: A negative consequence of a behavior (Spanking child for wetting the floor)

    ? A. Classical Conditioning

    (pairing of two stimuli in order to gain a new learning behavior by Ivan Pavlov)

    1. Acquisition (newly acquired behavior or the by product of classical conditioning) 2. Extinction

    ? B. Operant conditioning

    Burrhus Skinner

     - used in Behavior Modification

    1. Positive reinforcement (Reward Orientation)

     Token Economy use tokens as a source of reward.

     Used in eating disorders and depression

     > Token economy is also effective for toddlers

     2. Negative Reinforcement (Punishment Orientation)

     Aversion Therapy/Aversion Technique

    ? Behavioral Treatments

    1. Desensitization gradual exposure to the feared object

     -- #1 treatment for phobia

    2. Flooding/.Implosive Therapy sudden exposure

    3. Relaxation Technique light stroking = labor

     - Purse Lip Breathing Exercise = COPD/CAL (Chronic Airflow Limitation) 4. Biofeedback mind over matter. Ex. HPN ?BP, palpitations, headache 5. Guided Imagery (Child) & Visualization (Adult)

    ? GROUP THERAPY

    DEFINITION:Psychotherapeutic processes that occur in formally organized groups designed to change maladaptive or undesirable

    behavior.

     Knowledge of therapeutic modalities enhances the performance of nursing interventions during therapy. 8-10

    patients are the optimal number of patients in a group.

    ? TYPES OF GROUPS

    1. Structured

    ? Goals: Pre- determined

    ? Format: Clear and specific

    ? Factual material: Presented

    ? Leader: Retains control

    2. Unstructured

    ? Goals: Not pre- determined. Responsibility for goal is shared by group and leader

    ? Format: Discussion flows according to group members’ concern

    ? Materials and topics are not pre- elected.

    ? Leader: Nondirective

    ? Emphasis: More on FEELINGS rather than facts ADVANTAGE OF GROUP THERAPHY

    1. Economical: Less staff used.

    2. Increased feelings of closeness Reduction on feelings of being alone. 3.With feedback group

    ? Corrects distortions of problems

    ? Builds self- image and self- confidence

    ? Increases reality- testing opportunities

    ? Gives info on how one’s personality and behavior appear to others 4. With opportunities for practicing alternative behaviors and methods of coping with feelings 5. Provides attention to reality and provides development of insight into one’s problems by expressing own experiences and

    listening to others in groups

    ? PRINCIPLES OF GROUP THERAPY

    1. Verbalization: Members express feelings and group reinforces appropriate communication.

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