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First Aid
 

First Aid

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By Bivin Jose. II MSc in Psychiatric Nursing National Institute of Mental Health and Neurosciences, Bangalore

By Bivin Jose. II MSc in Psychiatric Nursing National Institute of Mental Health and Neurosciences, Bangalore

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    • Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing UNIT- 1 PSYCHIATRIC INTERVIEW Dr. R. Parthasarathy Ms.Shobitha Dr.Nagarajaiah Professor Ph.D Scholar & Psy.Social Worker Associate professor Dept. of psychiatric social work Dept. of Nursing NIMHANS, Bangalore-29 NIMHANS, Bangalore-29Interviewing requires linguistically and culturally effective 7. Medical history: All medical disorders past and presentcommunication skills, interviewing, behavioral observation, and their treatments and childhood disorders thatdata base record review and compressive assessment of the involve the central nervous system. For females,client and relevant systems enables the psychiatric mental pregnancy status - especially if on psycho tropics ornurse to make sound clinical judgments and plan appropriate expecting the use of psycho tropics and precautionsinterventions with the client. against pregnancy and concomitant pharmacological treatment can all patients, but particularity in consult-Interviewing is a specific type of guided and limited liason work, the medical history includes theintercommunication with an identified purpose. An interview interrelation of medical and psychiatric conditions.is usually conducted to collect a database for analysis anddecision making purpose. 8. Social history, pre-morbid personality - early developmental history: Early developmental history,The goal of the initial diagnostic interview is to collect specific, description of pre-morbid personality as baseline fordetailed information about 15 topics. These topics constitute patients best level of functioning. The patientsthe psychiatric evaluation. psychosocial and environmental conditions 1. Identifying data: Patients name, sex, age, marital status, predisposing to precipitating, perpetuating and address, occupation, income, etc protecting against psychiatric disorders. Pre morbid 2. Chief complaints: The chief complaint in the patients versus morbid functioning. Present support system. own words. Alternatively signs of disordered functioning 9. Family history: Psychiatric history of first-degree observed by the interviewer. relatives, including treatment response as possible 3. Informants: A list of all informants, their reliability, and genetic predisposition for the patient. level of cooperation; also previous hospital records, if 10. Mental status examination: Appearance, available. Such informants are essential in consciousness, psychomotor functions, speech, circumstances that prevent the patient from providing thinking, affect, mood, suggestibility and thought adequate information. Choosing the right set of content; cognitive functions such as orientation, informants is more important than having a great memory, intelligence and executive functions; insight number of informants. and judgement. 4. Reason for admission/consultation: the referral source; 11. Diagnostic formulation: Summary of biological, in case of hospitalisation, statement of legal status - psychological and social factors contributing to patients voluntary - and the reason why hospitalisation is the psychiatric disorders. safest and least restrictive environment for treatment. 12. Differential diagnosis: Discussion of diagnostic options 5. History of present illness: Early manifestations and based on overlapping symptomatology recent exacerbations of all psychiatric disorders 13. Multiaxial classification: Information on all five axes present; review of diagnosis and treatments given by other providers. 14. Assets and strengths: Inventory of patients knowledge, interests, aptitudes, education, and employment status 6. Psychiatric disorders in remission: Psychiatric to be used in the treatment plan. disorders presently in remission; especially substance abuse disorders; psychiatric disorders first diagnosed 15. Treatment plan and prognosis: Account of in childhood and adolescence and their treatments. psychopharmacological, psychological and social 1
    • Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing treatment modalities planned, frequency of visits and 3. Guidelines for interviewing list of providers; discharge criteria if inpatient. 1. Build rapport with the patientFor collecting such comprehensive information the interviewer 2. Conduct sessions seated in a private, comfortable areahas to master the styles of interviewing and apply them to the with adequate lighting and hearing distancefour components of the interview: rapport, techniques, mental 3. At the beginning of each session, plan and discussstatus and diagnosing. with the client the length and purpose of the session.2. Five phases of the psychiatric interview and four 4. Observe, listen and use facilitative communicationcomponents techniquesThe psychiatric interview progresses over time, which can be 5. Convey a professional demeanour through dress andarbitrarily subdivided into five phases. These phases cover mannerthe 15 topics of the psychiatric evaluation 6. Summarize the interaction at the end of the sessionPhase I: Warm up and chief complaint (I to IV) and make arrangement with the client for the next sessionPhase II: The diagnostic decision loop (V) 7. Positively reinforce the client for his attention, effort andPhase III: History and database (VI to X) involvementPhase IV: Diagnosing and Feedback (XI to XIV) 8. Maintain unity, progression and thematic continuityPhase V: Treatment plan and Prognosis (XV) 9. Develop a good confidence so that the client is preparedThe five phases divide the psychiatric interview longitudinally. for self disclosureCross-sectionally, the interview consists of four components, 10. Maintain non-judgemental attitude and respond to selfwhich the interviewer must continuously monitor and propel disclosure with honesty, support and acceptancethroughout. 11. Limit your self-disclosure to a minimal level1. RAPPORT: focuses on the therapist - patientrelationship; a good rapport is prerequisite for an effectiveinterviewer. Rapport is established in the opening; with a 4. Interview skillscooperative and insightful patient, there is often little problem Careful listeningin establishing and maintaining a good rapport. However in Attendingpatients who are uncooperative or show poor insight, Demonstration of sincere interestestablishing a workable rapport with the patient becomes acentral issue. Expression of attentiveness through eye contact, body language, verbal back and appropriate use of silence2. TECHNIQUE: refers to the approaches the intervieweruses to keep an interview on track. It includes skills to Concreteness in questions/probingappropriately select questions to arrive at a diagnosis. Good Immediacy - immediate importancetechnique is necessary to therapeutically engage and work Experimental and didactic confrontationwith difficult patients.3. MENTAL STATUS: assessment captures the patientsexperiences, symptoms, signs behaviours, thought content, 5. Some dos and donts while conducting interviewcognitive level of functioning, insight and judgement during 1. Maintain eye to eye contactactual time of the interview; however, in a patient with a 2. Interrupt only when necessarysignificantly altered mental status - whether it be a boisterous, 3. Ask always open ended questionsirritable and uninterruptible manic patient, a minimallyresponsive depressed patient or a paranoid patient - his or 4. Dont be in a hurryher mental status plays a significant role in the interview. 5. Do not pass judgments4. DIAGNOSIS: Pursues a progression in the diagnostic 6. Do not threatendecision process from chief complaint to final diagnosis. 7. Dont belittle 2
    • Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing 8. Be reassuring and supportive also assess the patients non verbal cues in order to get an 9. Clarify accurate picture of the patients mental status. 10. Give time Reference: 11. Prepare 1. Booklet on clinical skills in psychiatric nursing. 12. Record the information after the interview is over Department of nursing. National Institute of Mental Health and Neuro Sciences Bangalore-560 029.india/Getting maximum information, in a short time as possible, 2009.without causing any distress to the client is "good interviewing"and it is an art. By practice one can master it. 2. Kathy Neeb. Fundamentals of mental health nursing. 3rd ed. Jaypee. New Delhi. 2008 3. Sreevani R. a guide to mental health and psychiatricConclusion: nursing. 3rd ed. Jaypee. New Delhi.2010.Interview is a method by which the nurse starts establishing a 4. Vracarolis EM, Halter MJ. Foundations of psychiatrictherapeutic relationship with the patient. The nurses need to mental health nursing- A clinical approach. 6th ed.use her verbal and non verbal communication techniques and Saunders. St. Louis . 2010. 3
    • Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing UNIT-2 PSYCHIATRIC HISTORY-TAKING Dr.Nagarajaiah Associate professor Dept. of Nursing NIMHANS, Bangalore-29A comprehensive, accurate and adequate history from the 11. Income (annual) : Self - Family -patient and reliable informant will help in understanding the 12. Religion : Hindu / Muslim /Christian / othersproblems of the patient and also in planning the appropriatemanagement. With regards to psychiatric patients it is very 13. Reasons for consultation/admission:important to obtain information from a close relative or a person 14. Source of referral and reasons for referral:who knows well about the patient. This is because psychiatricpatients are not aware of the extent of their symptoms always. Source of Information gathered from: adequate/ reliableFor example a schizophrenic patient may not realize how muchembarrassment he has caused by his disturbed behavior and 2. PRESENTING COMPLAINTS (chronological):also in case of alcoholics, they may know their problems but The duration of each presenting complaints should bemay not wish to reveal them. mentioned in chronological orderHistory should always be recorded systematically and in thesame order to ensure that the interviewer does not forgetimportant themes or events. Given below a standard scheme 3. HISTORY OF PRESENT ILLNESS:of history taking in the form of list of topics to be covered. The Durationtrainee must learn by experience how to adjust his questioning Current episode /exacerbation:to problems that emerge as the interview proceeds. This isdone by keeping in mind the decisions about diagnosis and Mode of onset : Abrupt <48 hrs Acute <1wk Insidious 1-2management that will have to be made at the end of the Sub acute few weeks - monthsinterview. Course : Continuous /Episodic /Unclear (Fluctuating /1. SOCIO DEMOGRAPHIC DATA Deteriorating /Improving)1. Name : Precipitating factors : (Describe) this can be physical (e.g febrile illness) or psychological in nature (death/loss).2. Fathers / spouse name: Description :3. Address : Chronological account, describe major abnormal behavior,4. Phone number : associated problems like homicide/ suicide/ disruptive5. Age : behavior/ thought content as expressed in speech/ writing,6. Sex : major mood states, abnormal perceptions and experiences, biological functioning, occupational functioning, effects on7. Languages known : work, social functioning, changes in daily life etc. Description Can speak Can write Can read of the time relations between symptoms and social psychological and physical disorder needs to be mentioned.Mother tongue : Associated disturbances in sleep, appetite, and sexual driveOther languages : have to be mentioned. Any treatment received, improvement and deterioration has to be noted down.8. Marital status : Scheme for substance abuse/ dependence cases:single /married /separated /divorced / widow /widower /other Mode of initiation, duration, quantity of consumption, early9. Education : pattern of intake, progression, salience, tolerance, craving,10. Occupation : physical withdrawal features, pattern of use in recent and past, medical complications (including accidents) neuropsychiatric 4
    • Booklet on Psychiatric Nursing Skills toTeachers of School of Nursingproblems, interpersonal problems, socioeconomic problems(including debts if any) occupational problems, problems withlaw, earlier attempts to abstain, reason for consultation,motivation for abstinence etc.In cases of multi substance use describe separately for eachsubstance.Treatment historyNote the details regarding treatment received. For e.g.:Magic-religious/ other systems like Homeopathy/ Ayurveda/AllopathicPsychiatric pharmacotherapy- name of the drug; duration; D Ddosage; side effects; compliance; others.ECTs- No. of ECTs. ReasonPsychotherapy DFamily interventionsRehabilitative measuresNegative history Major features that are usually present in the given  syndrome History of trauma, fever, headache, vomiting, confusion, memory disturbances, Physical illnesses like, hypertension, diabetes, etc. Other major psychiatric illnesses Organic causes Substance abuse4. PAST HISTORY:Chronological account since childhood has to be noted down.If possible draw an life chart. Describe each episode brieflywith onset, events, major features, course and duration,treatment taken, level of recovery.Psychiatric illness: ^Medical illness:5. FAMILY HISTORY: Describe each family member briefly: age, death, mode ofGenogram - Family of origin death, education, occupation, health status - physical and psychological illnesses, major personality traits, relationshipDraw the tree for three generations on both sides in cases of with client, include other significant members.genetic importance 5
    • Booklet on Psychiatric Nursing Skills toTeachers of School of NursingDetails of family functioning 9. Social support system:1. Type of family : (Nuclear / Joint / Others) 10. Other :2. SES : (Upper / Middle / Lower)3. Leadership pattern: History of illness in family:4. Role functions : Psychiatric: similar illness, other illness, other major behavioural problems like delinquency, personality problems,5. Communication with in the family and others: suicide, substance use, epilepsy, mental retardation.6. Child rearing practices: Medical: (Especially hereditary)7. Interpersonal relationships:8. Social position :6. PERSONAL HISTORY:Birth and development :Antenatal period : Uneventful / Eventful (specify)Birth history : Full term /Premature / Post mature, Normal /Forceps/ Caesarean/ Delayed birth cry / any other complications.Post natal history : Uneventful / Eventful (specify)Physical health during infancy: Good / poor (specify)Immunization schedule : Completed / not completedDevelopmental milestones : Normal / DelayedMotor :Adoptive :Speech :Social :Childhood health : Normal/ Abnormal/ Trauma/ Fever/ Convulsions/ Any other illnessBehavioral and emotionalproblems : (Nail biting, thumb sucking, sleep disturbances, tics, mannerisms, Enuresis, Sleep walking, Temper tantrums, stammering. Look for conduct disturbances like frequent fights, truancy, stealing, gang activities and relationship with parents, siblings and peers)Home atmosphere duringchildhood : Satisfactory / UnsatisfactoryEmotional problems inadolescence : running away / delinquency/ smoking/ drug taking/ over weight/ identity problemsHome atmosphere duringadolescence : Satisfactory / UnsatisfactoryParental lack : Yes / No (Dead/ separated fro more than one year/ habitually absent from home)Anomalous family situation : Yes / No (Step parent, adoption status)Comments :Educational history : 6
    • Booklet on Psychiatric Nursing Skills toTeachers of School of NursingAge of beginning :Age of finishing :Relationship with teachers :Relationship with schoolmates(include nick names, bully orbutt of jokes :Position in class : (Top / Middle / Low)Special abilities :Active participation in games:Other extracurricular activities :Occupational history :Work record : Satisfactory / UnsatisfactoryFrequent changes of jobs : Yes / NoWork position : Raising / Falling / StationaryAge at the time of starting towork :Jobs held in the past (in chronological order, with wages, dates, reasons for change)Present job : Duration:Satisfied with work : Yes / No (Reasons for dissatisfaction)Sexual history:Information about sex : (How acquired, of what kind, how received, adequacy of knowledge, attitude towards opposite sex)Masturbation : Age of starting : Frequency: (Guilt/ attitude if any,)Sexual experience : (Homo/ Hetero/ Pre and extra marital / preferences)Any complaints includingDhat syndrome :Menstrual history :(Age at menarche / how regarded / regularity / duration / cycle / amount / physical / emotional problems)Menopause : (Age / climacteric symptoms)Marital history:Genogram - family of procreationDate / year of marriage (Arranged / affair)Spouse : (Age, education, occupation, personality)Marital relationship : Satisfactory / UnsatisfactorySexual relationship : Satisfactory / UnsatisfactoryContraceptive practices :Children: (Chronological list of children, miscarriage and still births (age, education, occupation, personality for each child, relationship with client) 7
    • Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing7. PREMORBID PERSONALITY: Conclusion:(Give details and cite examples from patients past life) History taking is the first for managing a patient in the psychiatrici. Social relations set up. A well taken history in itself is enough to diagnose asii. Intellectual activities : Hobbies and interests well as management the patient. Therefore the art of taking history should be essentially inculcated in all psychiatriciii. Mood (cheerful, strung up, optimistic, pessimistic, stable, nurses.fluctuating etc.)iv. Character Reference:a. Attitude to work and responsibility 1. Booklet on clinical skills in psychiatric nursing.b. Interpersonal relationships Department of nursing. National Institute of Mental Health and Neuro Sciences Bangalore-560 029. India/c. Standards in moral, religious, social and health matters. 2009.d. Energy and initiative 2. Kathy Neeb. Fundamentals of mental health nursing.v. Fantasy life 3rd ed. Jaypee. New Delhi. 20088. Habits: 3. Sreevani R. a guide to mental health and psychiatric Eating fads / patterns nursing. 3rd ed. Jaypee. New Delhi.2010. Sleeping patterns 4. Vracarolis EM, Halter MJ. Foundations of psychiatric Excretory functions mental health nursing- A clinical approach. 6th ed. Alcohol consumption Saunders. St. Louis . 2010. Tobacco consumption Self-medication with drugs 8
    • Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing UNIT-3 SYMPTOMATOLOGY IN MENTAL DISORDERS Dr. Ramachandra Associate professor Dept of nursing, NIMHANS, Bangalore-29The systematic study of cognition and behavior is called b) Stereotype Movementpsychopathology. Symptoms are the result of many forces.Their origin is usually within the patient. The symptoms may Mannerisms: These are stereotyped movementsbe very bizarre but have a cause and meaning. Various commonly seen in Schizophrenia. Ex: grimacessymptoms observed in mental illness are addressed under repeated gestures and peculiarities of gait etc.the following headings. c) Stereotype Speech1. Disorders of motor aspects of behavior Verbigeration: Repetation of words phrase or sentence2. Disorders of perception is called verbigeration.3. Disorders of thinking 1.5 Automatic Behaviour4. Disturbances of affect In this patient follows compulsively and automatically suggestions and requests. This is seen in two forms:5. Disturbances of attention Echolalia: patient repeats the words or phrases which6. Disorders of consciousness are spoken in his presence.7. Disorders of orientation Echopraxia: patient imitates the action of others.8. Disorders of memory 1.6. Negativism It is a psychological defense reaction manifested by1. DISORDERS OF MOTOR ASPECTS OF BEHAVIOR opposition and resistance to what is suggested. This Motor disturbance are related to action or impulse toward can be exhibited in different forms such as mutism, action. It is called conation. These activities are related refusal of food and noncompliance with requests etc. to attitude and feeling. Negativism provides gratification by the acting out of hostile, revengeful feelings towards significant persons.1.1. Increased activity (over activity) Increased activity may be goal directed. But sometimes 1.7. Compulsions the goal of the activity is constantly changing so no A morbid and often an irresistible urge to perform objective is achieved. Ex: Mania. Even the stream of the purposeless act repetiously is known as compulsion. thought is characterized by flight of ideas. Ex: touching an object twice or may take form of ritual.1.2. Decreased activity 1.8. Violence Patient takes long time to start the activity when it gets started they do it very slowly. They have to make lots of Violence is an expression of aggressiveness in the form effort to do it. In extreme form, the patients are mute and of murders, assaults, rape damaging self and others motion less. Ex: severe depression. and suicide.1.3 Repetitious activities 1.9. Suicide The patient repeats the activity in the same manner for It means self-destruction. People with suicidal ideation an indefinite period. have sense of lack of love and affection and deep sense1.4 Stereotypy of personal rejection. They also suffer from self- derogatory attitude, profound feelings of hopelessness Persistent and constant repetition of certain activities and helplessness. The suicidal attempt is motivated by and may be of position, movement of body or speech. the wish for revenge or by wish-fulfilling fantasies of Stereotypy is seen in the following forms. reunion in death. a) Stereotypy position Catalepsy: A constantly maintained immobility of position is known as catalepsy. It is frequently seen in DISORDERS OF PERCEPTION Schizophrenia. Disorders of perceptions are classified as illusions and Waxy -flexibility: Here patient flex his extremities like wax hallucinations. in awkward position and remains in that position for long time. 9
    • Booklet on Psychiatric Nursing Skills toTeachers of School of NursingIllusions B. Retardation: In this initiation and thought are slow; patient will speak slowly and usually in low tone.Illusions are mistaken or misinterpretations of sense Patient will complain that he has difficulty in thinking.impressions. Ex: patient perceives rope as a snake. Illusions It usually occurs in depressive phase of affectiveoccur due to individual emotional state, needs and fears. psychoses and may be in schizophrenia.Hallucinations C. Perseveration: In this abnormal, persistent repetitionHallucination is a perception without object. Hallucinations or continuance is seen in expression of an idea. Itshould be looked upon as mental products which, arising occurs in aphasia, catatonia and in senile dementia.from within and not related to any external stimulus. They D. Circumstantiality: This is also disturbance of flow ofrepresent a breakthrough of preconscious or thought in which patient includes many unnecessaryunconsciousness in the form of sensory images in response details before the goal is finally reached. This is seento psychological situations and needs. in feeble-minded, epileptics and in advanced senileTypes of Hallucinations mental disorders.1. Auditory Hallucinations: These are most common form E. Incoherence: This is characterized by confusion due of perceptual disturbances. These are sometimes in the to repressed material highly charged affectively. In form of noises but commonly in clear words or complete this one idea runs in to another with logical sequence. sentences addressed to him. It occurs in schizophrenia.2. Visual Hallucinations: These are not common as auditory F. Tangentiality: In this disorder of progression of thought hallucinations. These occur most commonly in delirium patient begins to respond, follows a series of related tremens in which patient sees terrifying images and topics but never reaches the goal finally. It is common causes fear to the patient. in Schizophrenics.3. Olfactory Hallucinations: These are hallucination of smell, G. Blocking: When patient is talking and suddenly he commonly seen in Schizophrenic states and with lesions stops talking. It means sudden interruption in train of of the temporal lobe. They are unpleasant and represent thought. It occurs when one feels strong affect. Eg feelings of guilt. anger or terror and Schizophrenics.4. Gustatory Hallucinations: these are hallucinations of taste. 3. Disorders of content of thought They rarely occur alone but are associated with olfactory A. Overvalued or over determined ideas: When an idea hallucinations. has strongest feeling tones it tends to dominate and5. Tactile Hallucinations: these are the hallucinations of the we call it over valued idea. Overvalued idea becomes touch. They occur principally in toxic states. Ex: delirium most important determinant of behavior. This is how tremens, in cocaine addiction and in Scxhizophrenia also. delusion occurs.6. Kinesthetic Hallucinations: The phantom phenomenon. B. Delusions: The delusion is defined as common false Ex: to feel pain in the amputated part of limb. This is the beliefs, which are irrational, not shared by persons of most common form of kinesthetic hallucinatory experience. same race, age and standard of education, which is held by conviction and which cannot be altered byDISORDERS OF THINKING logical arguments and which are persistent.Thought is the most highly organized psychobiological Types of Delusionsintegration and a form of implicit or internal behavior. I. Delusions of grandeur: Delusional beliefs of great1. Disorders in the form of thought power, wealth and influence. Ex: he may say he isThinking is the product of stimulus and response. Stimuli for god. This delusion arises from feelings of insecuritythought come from various sources. In day dreaming thinking or inferiority.is directed by egocentric wishes and instinctual needs. In case II. Delusions of Self-accusation: it arises when super-of Schizophrenia, thinking is directed by unconscious factors. ego becomes critical became repression getsEx: autistic thinking or drastic thinking. weakened and patient has vague feeling of guilt. This2. Disorders of progression of thought (Stream of thought) sense of guilt takes the form of self-accusation.The following are the disorders of the thought. III. Delusions of persecution: Delusional beliefs of an individual that he is being deliberately interfered with, A. Flight of ideas: This is the disturbance of the stream discriminated against, threatened or otherwise of thought in which thinking process appear to run mistreated. He feels others are planning to harm him. too quickly yet no idea is completed is known as flight These delusions permit a shifting of responsibility of ideas. This happens because of increased inner and otherwise serve to relieve anxiety arising from drive and distractibility. Sometimes a word similar in guilt. It occurs in chronic psychotic disorders. sound but not in meaning calls up the new thought and may lead to senseless rhyme, e.g. Sit, sob, sigh, IV. Ideas of reference: Delusional beliefs that other sorrow. This is called clang- association. people are talking about him referring to him or that 10
    • Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing the remarks or actions of people he meets are 3. Anxiety intended to have some special significance for him. It is a persistent feeling of dread, apprehension and In paranoid states ideas of reference represent a impending disaster. The patient is ignorant of its source. projection of the patients own self-criticism on to the Following are the different states of anxiety. world. In depression, feeling of guilt may stimulate ideas of reference. A. Free-Floating anxiety: It means anxiety is not attached to any ideational content but is felt as a morbid fear V. Delusion of guilt : Impoverishment and illness These without apparent source. occur mostly in depressive cases. In this unconscious hostile tendency may be projected B. Agitation: when anxiety is severe and over flows in outward giving rise to fear of punishment. this way in to the muscular system, producing gross motor restlessness, the reaction of the patient isC. Hypochondria: In this patient shows exaggerated concern called agitation. over physical health. In this anxiety is displaced from unconscious mental sources to organs. It occurs in people C. Tension: In this patient feel restlessness, who have shown previous tendency to evade the dissatisfaction, dread and discomfort. Tension is responsibilities of life through illness. accompanied by neuromuscular setting.D. Obsessions: Thoughts that persistently push themselves D. Panic: It is a pronounced state of anxiety which in to consciousness against the desire of the patient are produces disorganization of ego functions. It occurs known as obsessions. Obsession thoughts are strongly in some long standing insecurity of the personality charged with the emotions of guilt or depression. Ex: which creates tension in threatening form the patient patient keeps on asking why he was born. Obsession may show aggressiveness and about, pupils get thoughts are closely related to compulsive acts. dilated and has difficulty in thinking, appearance of bewilderment. Suicide may occur.E. Phobias: Allied to obsessive thoughts the patient has fears of dirt, bacteria,cancer or of crowds. 4. In adequate AffectDISTURBANCES OF AFFECT This is emotional dulling or detachment in the form of indifference, also called apathy. Patient does not feel pleasureAffect is related to feeling which currently the person is having or pain or any other sentiments. This absence of emotionalwhereas mood is sustained feeling state of considerable responsiveness may cause out of touch with reality. It mayduration. Affect serves as warning signal to refrain from a appear as a protective, defensive reaction against painfulforbidden act. Affect influence our thoughts and ideas. perceptions.1. Pleasurable affects 5. Inappropriateness of affect A. Euphoria: It is the feeling of emotional and physical wellbeing. In this patient has optimistic mental set and It is a disharmony of affect. It is common emotional is confident and assured in attitude. It is present in disturbance, seen in Schizophrenia. hypomanic states and in certain organic state. Ex: 6. Ambivalence general paresis, multiple sclerosis and in frontal lobe tumor. It means existence of contradictory feeling, attitudes toward the same object or person. Both of these conflicting attitudes B. Elation: patient feels overjoyed. Self-confidence are faces of the same coin, while only one may be visible, the radiates from him. Elation is often labile and readily other is nevertheless present. Ex: feeling of love and hate shifts to irritability. It is accompanied with increased towards the parents. activity. C. Exhalation: there is an intense elation accompanied by 7. Depersonalization an attitude of grandeur. It is an affective disorder in which feelings of unreality and a D. Ecstasy: Its a feeling of extreme joy and tranquil sense loss of ones own identity are experienced. The unreality of power. It can occurs in dissociative epileptic, symptoms are of two kinds; a) feeling of changed personality Schizophrenic and affective reactions. b) a feeling that the outside world is unreal. Patient feels that he is no longer himself but he does not feel that he has become2. Depression someone else.it occurs in hypochondria, obsessional statesIt is an effective feeling tone of sadness. It is the commonest and hysteriatype of complaint in psychiatric patient. It can vary from milder DISTURBANCES OF ATTENTIONdepressive syndrome to deeper depression. In milderdepressive syndrome the patient is quiet, restrained, inhibited, Organism examines the external world for useful data is knownunhappy, pessimistic has feeling of inadequacy and as attention.hopelessness and the same feelings are in extreme form indeeper depression. 1. Disordered attentionGrief: it is an effect of sadness due to loss of a close relation, Fatigue toxic states and organic lesions interfere and lowermay be death of a person. attention. 11
    • Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing2. Distractibility a) Registration: it means reception of the mental impression The inability to hold attention for a sufficient length of time is called distractibility. In Schizophrenia the degree of b) Retention: it means preservation of the previous by attention is greatly diminished. acquired impression.DISORDERS OF CONSCIOUSNESS c) Recall: It means reproduction of the impression.Impairments in consciousness from least to the greatest are The following are the disorders of memory arestates of confusion, clouding of consciousness, delirium, 1. Hypermnesia: Its an exaggerated degree of retentiondream and fugue states to complete stupor. and recall. It occurs in mild manic states, paranoia and1. Confusion: It is a disturbance of consciousness catatonia impressions with which strong emotions are characterized by bewilderment, perplexity, disorientation, attached. disturbance of associative functions and poverty of ideas. 2. Amnesia: It means loss of memory or inability to recall It occurs in diffuse impairment of brain tissue functions past experience. It can occur in physiological associated with toxic, infections or traumatic agents. disturbances of neurons through chemical alterations2. Clouding of consciousness: It is a disturbance in which or trauma. In psychogenic amnesia, recall is not present clear mindedness is not complete because of physical or for psychogenic reasons. chemical disturbances producing functional impairment The types of amnesia are of the associative apparatus of cerebrum. A. Anterograde amnesia: confined to recent events and is3. Delirium: It is also designated as the acute brain progressive. syndrome. It consists of much more than clouding of consciousness. Delirious reactions occur in infective B. Retrograde amnesia: involves the past events and is not states, puerperial psychoses. progressive.4. Dream state: This is also called twilight state. There is 3. Paramnesia: It is a falsification of memory as well as consciousness disturbance and patient is not aware of distortions of memory also serves as protection against his surroundings. intolerable anxiety. There are various types as follows:5. Stupor: In this patient is motionless and mute but with A. Confabulation: the patient fills the gaps in his memory relative preservations of conscious. Movement of eyes and by fabrications which are without any basis of fact. This is respiration occur. It can occur in toxic-organic brain seen in senile psychoses and particularly in Korsakoffs disease, intense apathy, profound depression blocking, syndrome. epilepsy and dissociative reaction to overpowering fear. B. Retrospect falsifications: These are illusions of memory,DISORDERS OF ORIENTATION created in response to affective needs. It means unconsciously selecting the memories which suit ourThe process by which one understands his surroundings and interests.locates himself in relation to it is known as orientation. If aperson knows his position in reference to time, place and 4. "Déjà vu": This is an experience of seeing with the feelingperson, he is said to be oriented. Disorientation may occur in that one has seen it before but does not know when andorganic brain syndromes and in acute conflicts. where. This is seen in Schizophrenia, Psychoneuroses, lesions of the temporal lobe including epilepsy and statesDISORDERS OF MEMORY of fatigue or intoxication.The function by which information is acquired and presented Conclusion:to consciousness and attention is stored, later same isrecalled to consciousness is known as memory. It has three Psychiatric symptoms are difficult to identify yet once identifiedprocesses. it forms as the basis of the patients treatment. Therefore, it is crucial on the part of the nurse to know about it. Reference : 1. Gail W. Stuvart and Michele T. Laria. Principles and Practice of Psychiatric Nursing, 8th Edn. Elfvier New Delhi, 2005, 35-38. 2. Lalitha K. Mental Health and Psychiatric Nursing - An Indian Perspective, 1st Edn. VMG Book House, 147-149. 12
    • Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing UNIT-4 MENTAL STATUS EXAMINATION Dr. Sailaxmi Gandhi Assistant Professor, Department of Nursing, NIMHANS, Bangalore - 29The mental status examination (MSE) is a standardized rapport can be established and does the client maintainprocedure where the primary purpose is to gather more adequate eye contact.objective data to be used in determining etiology, diagnosis, 1.3 Overt behaviour and Psychomotor activity (PMA):prognosis, and treatment, and to deal immediately with any Psychomotor activity (PMA) can be simply termed as goalrisk of violence or harm (Kneisl, Wilson & Trigoboff, 2004). directed activity. PMA can be increased, decreased or normal.Definition: The MSE is the part of the clinical assessment that There can be psychomotor retardation; aimless, purposelessdescribes the sum total of the examiners observations and activity; restlessness, wringing of hands, pacing; gestures,impressions of the psychiatric patient at the time of the interview twitches, stereotyped behaviour (repetitive, fixed pattern of(Kaplan & Sadock, 1998). physical action). Catatonic phenomena such as excitement, stupor, rigidity, posturing, mutism, etc. should be noted andUses: The MSE is very useful to the psychiatric nurse. Some recorded.of these uses are: 2.SPEECH: 1) It helps formulate the nursing diagnosis after identifying the clients problems Speech can be described in terms of quantity, rate of production and quality. One has to note whether the client speaks 2) It helps the nurse teacher to teach nursing students spontaneously, amount of speech, tone, tempo, reaction time, about the psychiatric clients symptoms of illness prosody and whether the speech is relevant and coherent. 3) It can be used to test effectiveness of various nursing 3. THOUGHT: interventions on the psychiatric client. Thought can be assessed under the following components 4) It helps to assess changes in the psychiatric client such as - during various stages of nursing interventions 3.1 Form: This is the way a person puts together ideas and 5) It helps the nurse to assess when the client is fit for associations, i.e. the form in which a person thinks. There discharge and to prepare the client for community life may be rapid thinking, which, when carried to the extreme, isA The format for writing up the MSE may vary slightly depending called as "flight of ideas". There may be incoherenton the organization. However, the format must contain certain connections of thoughts (word salad), association by rhymingcategories of information, which is included as follows: (clang associations), etc.1 GENERAL BEHAVIOR: 3.2 Stream: This is best described as flow of thought, train of1.1 Appearance: This is a complete and accurate description thought or continuity of thought. E.g. Loosening of association,of the clients physical characteristics, apparent age, manner blocking, circumstantiality, tangentiality, perseveration, etc.of dress, use of cosmetics, personal hygiene, and responses 3.2 Possessions: These could be thought alienation - thoughtto the examiner. One has to include posture, gait, gestures, insertion (the client describes insertion of strange thoughtsfacial expression, tics, mannerisms, poise, etc. (A tic is an which do not belong to him), thought withdrawal (the clientinvoluntary, spasmodic motor movement. A mannerism is an describes a feeling of emptiness in the head as he feelsingrained, habitual, involuntary movement.). Signs of anxiety thoughts being removed), and thought broadcast (clientto be noted are tense posture, increased sweating, wide eyes, describes a strange situation where all his thoughts aremoist hands, etc. broadcast in the TV, radio, etc.). Obsessions may be elicited1.2 Attitude towards examiner: The clients attitude towards which are pathological persistence of an irresistible thoughtthe examiner may be described as co-operative, friendly, or feeling that cannot be eliminated from consciousness byattentive, interested, seductive, defensive, perplexed, apathetic, logical effort. When these are present, clarify the nature ofhostile, playful, ingratiating, evasive or guarded. Check if compulsive acts - checking, counting or washing and whether 13
    • Booklet on Psychiatric Nursing Skills toTeachers of School of Nursingthey are "controlling" or "yielding". Phobias may also be present. Assessment is done by asking the following questions:These are persistent, irrational, and usually pathological dread a) Have you ever heard voices when no one was aroundof a specific stimulus resulting in a compelling desire to avoid or sounds that no one else could hear?the stimulus. b) Have you experienced any strange sensations in your3.3 Content: Disturbances here include preoccupations body that others do not seem to experience?(which may involve the clients illness), antisocial urges,hypochondriacal and somatic symptoms, and depressive c) Have you seen things that others do not seem to see?ideation (ideas of worthlessness, guilt, hopelessness and 5.2 Types of Hallucinations: Command hallucinations: Falsesuicidal ideas and delusions. Delusions are firm, fixed and perception of orders that a client may feel obliged to obey, Firstfalse beliefs out of keeping with the clients cultural background. person hallucination: False perception of hearing an echo ofSome common delusions are delusion of poverty i.e.a persons ones own thoughts, Second person hallucinations: Falsefalse belief that he or she will be deprived of all wealth, delusion perception of hearing two voices talking to the client, Thirdof persecution i.e. a false belief that he or she is being harmed person hallucinations: False perception of hearing manyor persecuted, delusion of grandeur i.e. a persons voices discussing about the client or in the form of a runningexaggerated conception of his or her importance, power or commentary, De- personalization: A persons subjective senseidentity, etc. of being unreal, strange or unfamiliar, De-realization: A4. MOOD: subjective sense that the environment is strange or unreal.Mood is defined as a pervasive and sustained emotion thatcolours the persons perception of the world (Kaplan & Sadock, 6. COGNITIVE FUNCTIONS:1998). Mood should be assessed by both subjective reportand objective evaluation. Various components should be Here clinical assessment includes the areas of -described such as quality of emotion e.g. Happiness, 6.1 Orientationsadness, anxiety, anger, fear, etc., range of mood which can 6.2 Attention & Concentrationbe broad where the person is able to experience all moodstates or blunted, constricted and flat (with gradual decrease 6.3 Memoryin emotional expression with absolutely no expression in flat 6.4 Intelligenceaffect), lability of mood i.e. rapid and sudden shifts in emotionfrom one emotional state to the other, reactivity i.e. changes in 6.5 Abstractionemotion in relation to environmental factors, congruity i.e. 6.6 Judgementemotional expression in relation to thought processes (e.g.Smiles while talking about success in exams) and 6.7 Insightappropriateness i.e. emotional expression in relation tosituations (E.g. Laughing during a funeral is inappropriate 6.1 Orientation: Orientation is tested with respect to time,while crying during a funeral is appropriate). place and person5. PERCEPTION: 6.2 Attention & Concentration: One has to test whetherThe client may experience perceptual disturbances, such as attention can be aroused and sustained.hallucinations, illusions, depersonalization and derealization.Hallucinations are false sensory perceptions occurring in theabsence of a real stimulus. One should always specify the Tests used in the clinical situation include:sensory modality involved (auditory, visual, olfactory, tactile, 6.2.1 The digit span testgustatory) when hallucinations are experienced and alsodescribe the content of the hallucinations. With respect to 6.2.2. Serial subtractionauditory hallucinations, always enquire whether the 6.2.3 Days or months forward to backwardhallucinations are verbal/non-verbal, continuous/intermittent,single voice/multiple voices, familiar/unfamiliar, pleasant/ 6.2.1 Digit span test:unpleasant, whether commanding, abusive or threatening, a) Forward: The client is given the following instructions: "Imood congruent/mood incongruent and first person/second will be saying some digits, listen to me carefully. When I finishperson or third person. saying them, you will have to repeat them in the same order. 14
    • Booklet on Psychiatric Nursing Skills toTeachers of School of NursingThe examiner after instructing the clients, gives an example Inference is noted as comprehension is good or bad.for digit forward (e.g. If I say 3,7; you say 3,7) and for digit 6.4.3 Arithmetic: Tested by asking the client to solve simplebackward ( e.g. if I say 2, 5; you should say 5, 2) The digits to complex problems in addition, subtraction, division andforward/backward score is the highest number of digits multiplication. Illiterate clients can be asked questions suchcorrectly recalled forward/backward after a maximum of two as - "How many tsp. of sugar and tea leaves are required totrials. make tea for 5 persons?6.2.2 Serial Subtractions: Increasingly difficult tests are Inference is recorded as - arithmetic is good, average or bad.presented. The examiner 6.5 Abstraction: Abstract thinking is the ability to deal with 1. Instructs the client concepts. 2. Gives an example of how to perform the task 6.5.1 Can the client explain similarities between a dog and a 3. Notes the responses verbatim lion? 4. Notes the time taken in seconds 6.5.2 Can the client state the difference between cinema and radio?Task Correct response Time limit 6.5.3 The client is asked if he knows what a proverb is and to20-1 20 to 0 15 secs state one with the meaning. Then the examiner states a40-3 40,37,31, etc 60 secs. proverb and asks for the meaning.100-7 100,93,86,79, etc. 120 secs. The clients response is to be noted verbatim. Inference is made as abstraction present at concrete level (when specific explanation is given) or concrete and abstract level (when both6.2.3 Days or months may be asked for in backward or forward specific and abstract explanations are given).order. 6.6 Judgement: Is assessed in the following areasThe inference is recorded as attention can be aroused andsustained. Concentration is good, average or poor 6.6.1 Personal: Enquire about the clients future plans6.3 Memory: Memory functions are divided into immediate, 6.6.2 Social: Observe the clients behaviour in social situationsrecent and remote. Memory impairment can occur in different or ask how he would dress up for a funeral/wedding?types of schizophrenia, psychosis, depression, dementia, etc.Assessment includes immediate, recent and remote memory 6.6.3 Test: Present the following two problems to the client in a manner in which he can comprehend:6.3.1 Immediate memory - Tested by the digit span test6.3.2 Recent memory - Is tested by enquiring about what the a) Fire problem: What will you do if your house catches fire?client had for breakfast, events of the day and what he ate the b) Letter problem: What will you do if you see an addressed,previous night, etc. sealed and stamped envelope which someone had dropped6.3.3 Remote memory - Test by asking for information on life when you are walking on the roadside?events Inference may be - Personal/Social/Test judgement is intactInference may be noted as follows - eg. Recent memory is or impaired.intact or impaired 6.7 Insight: Insight is the clients degree of awareness and6.4 Intelligence: understanding about being ill.6.4.1 General information: Question the client according tothe educational level and background of the client. Common The level of insight with the inference is as given below:questions can be- Name of the Prime Minister, major cities of a) Complete denial of illness (Insight is absent)India, etc. b) Recognizes the presence of illness but gives explanationInference may be noted as follows - General information is in physical terms i.e. headache, fever, etc. (Insight is partial)adequate or inadequate or average6.4.2 Comprehension: Ask questions of increasing difficulty c) Fully realizes the emotional nature of his/her illness, causeranging from Eg. What will you do when you feel cold? -------- of the symptoms and feels he/she requires treatment (Insight is present)------ to--- Why should we be away from bad company? 15
    • Booklet on Psychiatric Nursing Skills toTeachers of School of NursingB. MINI MENTAL STATUS EXAMINATION (MMSE) 5.4 Read and perform the command "Close your eyes" (1)MMSE is a bed-side screening test which is not timeconsuming and is a formal evaluation of cognitive impairment 5.5 Write any sentence (check subject, verb, object)in the client. It is also a practical clinical examination to track (1)the changes in the clients cognitive state. It is used as a 6. Construction Total score = 1clinical test in mental disorders occurring due to a generalmedical condition, such as delirium, dementia, amnestic 6.1 Copy the design belowdisorders, etc.The MMSE Questionnaire (Folstein M.F., Folstein S, McHugh Total MMSE score = 30P.R.; 1975) is as follows: Inference of score:1. Orientation (Score 1 if correct) Total score = 101.1 Name this hospital or building1.2 What city are you in now? 25 - 30 = Suggests no impairment1.3 What year are you in now? 20 - 25 = Suggests impairment1.4 What month is it? < 20 = Indicates definite impairment1.5 What is the date today?1.6 What state are you in? C EXAMINATION OF NON-COOPERATIVE OR STUPOROUS1.7 What country is this? CLIENTS (Kirby, 1921):1.8 What floor of the building are you on? It may be difficult to get information from non-cooperative or1.9 What day of the week is it? stuporous clients. However, this can lead to delay in assessing the clients problems, formulating nursing diagnosis and1.10 What season of the year is it? planning nursing care. Hence, to avoid this, this format can be followed to assess the mental state of such clients.2. Registration (Score 1 for each object correctly repeated) 1. General reaction and posture:Total score = 3 1.1 Attitude is voluntary or passive2.1 Name 3 objects and have the client repeat them Score the 1.2 Voluntary posture is comfortable, natural, constrainednumber repeated by the client. Name the three objects several or awkwardmore times if needed for the client to repeat correctly (recordthe number of trials----) 1.3 What does the client do if placed in awkward or uncomfortable positions? 1.4 Behaviour toward physicians and nurses is resistive,3 Attention & Calculation Total score = 5 evasive, irritable, apathetic or compliant3.1 Subtract 7 from 100 in serial fashion to 65. Maximumscore = 5 1.5 Spontaneous acts: any occasional show of playfulness, mischievousness or assaultiveness. Defence movements when interfered with or when pricked with4.Recall Total score = 3 pin. Eats and dresses self. Pays attention to bowel and bladder.4.1 Do you recall the 3 objects named before? 1.6 To what extent does the attitude change? (Score 1 for each object named correctly)5. Language tests (Total score = 8) II Facial Expression:5.1 Confrontation naming = watch, pen (2) Alert, attentive, placid, sulky, scowling, perplexed, distressed,5.2 Repetition = "No ifs, ands, or buts" (1) etc.5.3 Comprehension = Pick up the paper in your right hand, Any change of facial expression or signs of emotion - tears,fold it into half, and set it on the floor (3) smiles, flushing, perspiration? On what occasion does this change occur? 16
    • Booklet on Psychiatric Nursing Skills toTeachers of School of NursingIII Eyes: VII Speech:Open or closed. If closed, does he resist having the lid raised? Any apparent effort to talk, lip-movements, whispers,Movement of eyes absent or can be obtained on request? movements of head?Rolling of eyeballs upward. Blinking, flickering, or tremors of Note exact utterances with accompanying emotionallids. reaction (may indicate hallucinations)Reaction to sudden approach to threat to stick pin in eye.Sensory of pupils (reacts equally) VIII Writing:IV Reaction to what is said or done: Offer paper and pencil. Unresponsive or partially stuporous clients will often write when they fail to talk.Shows tongue when commanded to do so, moves limbs &grasps with hand when asked to do so.Reaction to pin-pricks Conclusion: It is of paramount importance that all nurses working with psychiatric patients should know, understandV Muscular reactions: and be skilled in mental status examination. This tool is an Test for rigidity, muscles are relaxed or tense when asset to all nurses as it aids in diagnosing, formulating nursing limbs or body is moved. interventions, observing changes and evaluating care. A Test for negativism shown by movements in opposite nursing teacher also is benefited in that mental status direction or springy or cog-wheel resistance. examination is not only a clinical tool but also a teaching tool. It helps the teacher in demonstrating on the patient how to Test head and neck by movement forward and backward assess presence of psychiatric symptoms. GNM level as well as to side students gain expertise when they return demonstrate this Test also the jaw, shoulders, elbows, fingers and the skill to the teacher. Proficiency in this area will further help lower extremities them to identify and refer psychiatric problems in patients when they work in the general hospitals, the community, schools, Does distraction or command influence the reactions? etc. Teachers teaching psychiatric nursing should definitely Is there closing of mouth, protrusion of lips, holding of gain clinical skills which will help their teaching to be effective! saliva, drooling, etc.VI Emotional responsiveness: References: Is feeling shown when talked to about family or children? 1. Folstein MF, Folstein S, Mc Hugh PR, "Mini-Mental State: Or when sensitive points in history are mentioned or A Practical method for grading the cognitive state of when visitors come? patients for the clinician", J.Psychiatr Res 12:189, 1975 Note whether or not acceleration of respiration or pulse 2. Kaplan.I.Harold, Sadock. J. Benjamin, "Synopsis of occurs. Also look for flushing, perspiration, tears in Psychiatry: Behavioural Sciences/Clinical Psychiatry", eyes, etc. Do jokes elicit any responses? B.I.Waverly Pvt. Ltd. , New Delhi, VIIIth Edition, 1998 Effect of unexpected stimuli (clap hands, flash of electric light) 17
    • Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing UNIT - 5 PHYSICAL & NEUROLOGICAL EXAMINATION Dr. Ramachandra Associate Professor Dept. of Nursing NIMHANS , Bangalore-29Introduction: Moisture-dry, wet or moist?Assessment is an important component of nursing process. Motion-still or vibrating?A complete nursing assessment includes both the collection Consistency of structures-solid or fluid filled?of subjective data and objective data. The complete healthhistory is performed to collect as much subjective data abouta client as possible. Objective data include information about iii) Percussion:the client that the nurse directly observes during interaction Percussion involves tapping fingers or hands quickly andwith him and information elicited through physical assessment sharply against parts of the patients body, usually the chest ortechniques. abdomen. The technique helps to locate organ borders, identify1. Physical Examination: organ shape and position and determine if an organ is solidFour basic techniques must be mastered before professional or filled with fluid or gas.can perform a thorough and complete assessment of the Percussion requires a skilled touch and trained ear to detectclient. By using a systematic approach, examiner will less slight variations in sound. Organs and tissues, depending onlikely to forget an area. their density, produce sounds of varying loudness, pitch andFour techniques used are: duration. For instance, air-filled cavities, such as the lungs,i) Inspection. produce markedly different sounds than do the liver and other dense tissues.ii) Palpation.iii) Percussion. The examiner has to move gradually from areas of resonance to those of dullness and them compare sounds. Also, compareiv) Auscultation. sounds on one side of the body with those on the other side. iv) Auscultation:i) Inspection: Auscultation, usually the last assessment step, involvesInspection involves vision, smell and hearing to observe listening for various breath, heart and bowel sound with anormal conditions and deviations. Performed correctly, stethoscope. To prevent the spread of infection amonginspection can reveal more than other techniques. patients, clean the hearts and end pieces of the stethoscopeInspection begins from first meeting with the patient and with alcohol or a disinfectant after every use.continues throughout the health history and physical 2. Historyexamination. As the examiner assess each body system,observe for color, size, location movement, texture, symmetry, A thorough and accurate history of a neuro patient is often veryodor, and sounds. helpful in assessing their condition. The character of symptoms, distribution, temporal profile of symptoms,ii)Palpation epidemiological associations are often needed in detail inPalpation required examiner to touch the patient with different neurological patients in comparison to other general diseases.parts, using varying degrees of pressure. To do this, examiner The fact that in neurological patients their cerebral dysfunctionneed short fingernails and warm hands. Always palpate tender may limit or distort the account of history third party sources ofareas last. Information about the purpose of touch to different information are most often needed.parts is essential. 3. Neurologic ExaminationEvaluation of the following features are required: Neurological assessment is one of the key components of Texture-rough or smooth? nursing practice. It plays a pivotal role in localization of the Temperature-warm, hot or cold? problem. It encompasses history collection, and the physical examination. Observation is the most important key for 18
    • Booklet on Psychiatric Nursing Skills toTeachers of School of Nursingneurological assessment. The exam ination requires skill and Make a note of the age, height, build and weight. Is thepatience, from the examiner. patient obese or cachectic?A thorough neurologic examination may take 1 to 3 hours; Check the vital signs including temperature, pulse,however, routine screening tests are usually done first. If the respiratory rate and blood pressure.results of these tests raise questions, more extensive Level of consciousnessevaluations are made. Three major considerations determine Glasgow coma scale is an objective method to assess thethe extent of a neurologic examination: level of consciousness in the patients with neurological a. The clients chief complaints disorders. This scale describes conscious level in terms of b. The clients physical condition (i.e., level of eye opening, verbal response and motor response. These consciousness and ability to ambulate), as many parts are having 4, 5, 6 scores each respectively. On examination, of the examination require movement and coordination observer has to assign score to the observed category to each of the extremities parameter. The minimum score is 3 and maximum is 15. c. The clients willingness to participate and cooperate. Eye Opening (E) Verbal Response (V) Motor Response (M) 4= spontaneous 5= oriented 6= obeys commands3.1 Equipments required are 3= to voice 4= disoriented conversation 5= localizes pain 2= to pain 3= non comprehensible 4= withdrawal flexion1. Reflex hammer 1= no response words, 3= abnormal flexion2. 128 and 512 hz tuning forks 2= incoherent sounds decorticate posture 1= no response 2= abnormal extension3. Snellen Chart decerebrate posture4. Pen light 1= no response5. Ophthalmoscope6. Sugar/salt For children under 5, the verbal response criteria are adjusted as follow7. Coffee powder/any scented material8. Disposable safety pin Score 2 to 5 yrs 0 to 23 months appropriate words or9. Tongue depressors 5 smiles or coos appropriately phrases10. Wisps of cotton to assess light- touch 4 inappropriate words cries and consolable persistent cries and/or persistent inappropriate11.T est tubes of hot and cold water for skin temperature 3 screams crying &/or screamingassessment grunts or is agitated or 2 grunts restless 1 no response no response3.2 The components of neurological examination includesassessment of: Children with a Glasgow Coma Scale of 3-8 are considered1. Level of consciousness 5.Sensory System. comatose2. Mini Mental Status Exam 6. Deep tendon reflexes 3.4 Mental Status Examination3. Cranial nerves 7.Coordination and balance Evaluation of mental status is a part of the neurological4. Motor System 8. Brain stem reflexes examination. The appearance, behaviour, level of consciousness, attention, concentration, memory, orientation, abstraction, judgement, language and speech are assessed3.3 Assessment of Level of consciousness as discussed in earlier chapterGeneral appearance: 4. Examination of the Cranial NervesNote the patients personal hygiene and dress. Is it appropriate The following is a summary of the cranial nerves and theirfor the environment situation or not respective functioning. 19
    • Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing I. Olfactory- Smell 4. Repeat two or three times to test both temporal fields. II. Optic-Visual acuity, visual fields and ocular fundi 5. If an abnormality is suspected, test the four quadrants III, IV, VI. Oculo motor, Trochlear & Abducens- extra-ocular of each eye while asking the patient to cover the opposite movements, pupillary reactions including opening of eye with a card. the eyes Using an ophthalmoscope, observe the optic disc, V. Trigeminal- Facial sensation, movements of the jaw, physiological cup, retinal vessels. Note the pulsations of the and corneal reflexes optic vessels, check for a blurring of the optic disc margin and a change in the optic discs colour form its normal yellowish VII. Facial-Facial movements orange. The initial change in the ophthalmoscopic VIII. Vestibulo cochlear -Hearing and balance examination in a patient with increased intracranial pressure IX, X. Glassopharngeal, Vagus-Swallowing, elevation of the is the loss of pulsations of the retinal vessels. palate, gag reflex and gustation In the assessment of pupils note: XI. Spinal accessory,- shrugging the shoulders and turning Size (small- miosis/ large-mydriasis) the head. Shape XII. Hypoglossal-Movement and protrusion of tongue Equality Reaction to light: Both pupil constrict when light is4.1 Cranial Nerve I (olfactory) shown in either eye.Evaluate the patency of the nasal passages bilaterally. Ask the Reaction to accommodation and convergence.patient to close their eyes, occlude one nostril, and place any 4.3 Cranial Nerves III, IV and VI (Oculomotor, trochlear,familiar scented substance near the patent nostril and ask abducens)the patient to report what it is. Switch nostrils and repeat.4.2 Cranial Nerve II (optic) Observe for PtosisThe components of testing include visual acuity, visual field, Test Extra ocular Movementsoptic fundus and pupillary reaction. 1. Stand or sit 3 to 6 feet in front of the patient.Visual acuity: 2. Steady the patients head and ask him to follow yourSevere deficit can be assessed testing whether patient can finger with their eyes without moving their head.see light or movements, or can the patient count fingers. Patient 3. Check gaze in the six cardinal directionsmay also be assessed to read newspaper or book having 4. Check for nystagmus.bigger letter size. To examine mild deficit, examiner recordreading activity with Snellens chart or hand chart. 5. Question the patient about diplopia.Perform this part of the examination in a well-lit room and 4.4 Cranial Nerve V (Trigeminal)make certain that if the patient wears glasses, during the exam. Assess for pain, temperature and touch. Palpate the masseterHold the chart 14 inches from the patients face, and ask the muscles while you instruct the patient to bite down hard. Alsopatient to cover one of their eyes completely with their handand read the lowest line on the chart possible. Have themrepeat the test covering the opposite eye. For Snellens chart,6 meters distance is expected to read letters. Test each eyeseparately.Assessing visual fields by confrontation test 1. Stand two feet in front of the patient and have them look into your eyes. 2. Hold your hands about one foot away from the patients ears, and wiggle a finger on one hand. 3. Ask the patient to indicate which side they see the finger move. 20
    • Booklet on Psychiatric Nursing Skills toTeachers of School of Nursingnote masseter wasting on observation. Next, ask the patient bone behind the ear.to open their mouth against resistance applied by the instructor 4. When the patient no longer hears the sound, hold theat the base of the patients chin end of the fork near the patients ear (air conduction is Test the three divisions (maxillary, mandibular & normally greater than bone conduction). ophthalmic) for temperature sensation, pain & touch. 4.7 Cranial Nerves IX and X (glossopharyngeal and vagus) Test the Corneal Reflex Listen to the patients voice. If there is vocal cord 1. Ask the patient to look up and away. paresis(X nerve palsy)voice may be high pitched. 2. From the other side, touch the cornea lightly with a fine Ask Patient to swallow, to note swallowing difficulty. wisp of wet cottonwool. Watch the movements of the soft palate and the pharynx 3. Look for the normal blink reaction of both eyes. by asking the patient to Say "Ah" 4. Repeat on the other side Test Gag Reflex Unconscious/Uncooperative Patient 4.5 Cranial Nerve VII (Facial) Stimulate the back of the throat on each side. It is normal Observe for any facial droop or asymmetry or eye to gag after each stimulus closure. 4.8 Cranial Nerve XI (spinal accessory) Ask Patient to do the following, note any lag, weakness, Look for atrophy or asymmetry of the trapezius muscles. or asymmetry Ask patient to shrug shoulders against resistance. 1. Raise eyebrows(to wrinkle forehead) Ask patient to turn their head against resistance. Watch 2. Close both eyes to resistance and palpate the sternocleidomastoid muscle on the 3. Smile opposite side. 4. Frown Repeat this manoeuvre on the opposite side. The patient should normally overcome the resistance 5. Show teeth applied by the examiner. Note any asymmetry. 6.Puff out cheeks 4.9 Cranial Nerve XII (hypoglossal)4.6 Cranial Nerve VIII (Vestibulocochlear) The hypoglossal nerve controls the intrinsic musculature ofAssess hearing by instructing the patient to close their eyes the tongue and is evaluated by having the patient stick outand to say "left" or "right" when a sound is heard in the respective their tongue and move it side to side. Normally, the tongue willear. Vigorously rub your fingers together very near to, yet not be protruded from the mouth and remain midline. Notetouching, each ear and wait for the patient to respond. After deviations of the tongue from midline, a complete lack of abilitythis test, ask the patient if the sound was the same in both to protrude the tongue, tongue atrophy and fasciculations onears, or louder in a specific ear the tongue. Test for lateralization (Waber) 4.10 sensory assessment 1. Use a 512 Hz or 1024 Hz tuning fork. The sensory modalities tested include pain, 2. Start the fork vibrating by tapping it on your opposite temperature, vibration, joint position and touch. hand. Pain: Break off the wooden part of a cotton swab to 3. Place the base of the tuning fork firmly on top of the make a sharp object or use a disposable, sterilized patients head. safety pin. Ask the patient with eyes closed to distinguish sharp end of the pin from dull. 4. Ask the patient where the sound appears to be coming from (normally in the midline). Temperature: Test coldness with metal tuning fork. The patient should be able to identify cool vs. warmer objects Compare air and bone Conduction (Rinne) or take two test tubes filled with hot water and cold 1. Use a 512 Hz or 1024 Hz tuning fork. water separately. Surface on the body at different times 2. Start vibrating the tuning fork by tapping it on your and observe reaction. opposite hand. Vibration: Test with low-frequency (128) tuning fork. The patient should be able to sense the vibration of the 3. Place the base of the tuning fork against the mastoid 21
    • Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing tuning fork 4.12 Deep Tendon Reflexes Joint position or Proprioception: With eyes closed, Observing reflexes is the most objective part of the neurological patient distinguishes whether finger and toe are moved exam, since the reflexes are not under voluntary control and up or down. testing does not depend on the patients cooperation, attitude, Touch: Test light touch with a cotton swab. The patient or awareness. distinguishes touch vs. no touch. Biceps reflex tests C5-6: The biceps reflex is elicited bySpecial tests of sensory function placing your thumb on the biceps tendon and striking Stereognosis: With eyes closed, patient identifies pen, your thumb with the reflex hammer and observing the paper clip or coin placed in hand. This tests the parietal arm movement. sensory cortex and posterior columns Brachioradialis reflex also tests C5-6. The Graphesthesia: With eyes closed, patient identifies Brachioradialis reflex is observed by striking the numbers or figures or shapes written on palm. This Brachioradialis tendon directly with the hammer when tests the sensory cortex and integration. the patients arm is resting. Strike the tendon roughly 3 inches above the wrist. Note the reflex supination. Two-point discrimination: Patients should be able to distinguish two simultaneous points of different Triceps: tests C7-8. The triceps reflex is measured by intensity 2 to 10 mm apart on fingers and hands. striking the triceps tendon directly with the hammer Compare patients two sides. while holding the patients arm with your other hand Quadriceps (knee jerk): tests L2-L4 With the lower leg hanging freely off the edge of the bench, the knee jerk4.11 Assesement of Motor System is tested by striking the quadriceps tendon directly withThe motor system evaluation is divided into the following: the reflex hammer.Muscle bulk, muscle tone, involuntary movements and muscle Achilles (ankle jerk): tests L5-S2 The ankle reflex isstrength. elicited by holding the relaxed foot with one hand andSystematically examine all of the major muscle groups of the striking the Achilles tendon with the hammer and notingbody. plantar flexion. 1. Note the muscle bulk (atrophy, hypertrophy, normal). Deep tendon reflex grading 2. Feel the tone of the muscle (flaccid, clonic, normal). 4+ very brisk, hyper reflexive, with clonus 3+brisker or more reflexive than normally 3. Presence of any abnormal movements like tremor, fasciculations, tics. 2+normal 4. Test the strength of the muscle group. 1+ normal, diminished Muscle strength grading: If pyramidal weakness is 0 no response suspect test the power of muscle with reference to pressure and gravitation. Assign scores as follows: 4.12 Co-ordination and Balance 0-No muscle contraction is detected The stance (attitude of standing) and the gait of the patient 1-A flicker or trace contraction is noted in the muscle have to be observed for irregularities. The tests of co-ordination while the patient attempts to contract it. include Finger -nose test, heel -shin test, rapid alternating 2-The patient is able to actively move the muscle with movements. Balance is tested using the Rombergs sign test. gravity eliminated. Finger -nose test: Ask the patient to extend their index finger 3-The patient may move the muscle against gravity but and touch their nose, and then touch the examiners not against resistance from the examiner outstretched finger with the same finger. Ask the patient to go back and forth between touching their nose and examiners 4-The patient may move the muscle group against finger. This tests the upper extremity co-ordination. some resistance from the examiner. Heel- shin test: ask the patient to place the heel on the opposite 5-The patient moves the muscle group and overcomes shin and run up to the knee and back to ankle. The patient the resistance of the examiner. This is normal muscle should be able to perform it quickly and without side-to-side strength. wavering. 22
    • Booklet on Psychiatric Nursing Skills toTeachers of School of NursingRapid Alternating Movement canal while, the eyes are held open by an assistant.Ask the patient to place their hands on their thighs and then The eyes should be observed for one minute afterrapidly turn their hands over and lift them off their thighs. Ask irrigation is completed before repeating the test on thethe patient to repeat it rapidly for 10 seconds. Normally this is other side. An intact Oculovestibular reflex causes tonicpossible without difficulty. Dysdiadochokinesia is the clinical deviation of the eyes towards the irrigated ear. Anyterm for an inability to perform rapidly alternating movements. movement of one or both eyes, whether conjugate or not, excludes the diagnosis of brain death. In a brainRombergs test dead patient the eyes remain fixed. Combined ice-coldAsk the patient to stand still with their heels together, arms on water caloric stimulation and head rotation has beenthe side and close their eyes. If the patient loses their balance, suggested as the most pro-found stimulation for deeplythe test is positive. unconscious patients.4.13 Assessment of brain stem reflexes Conclusion Pupillary response to light: The response to bright light A thorough physical examination including history with focus should be absent in both eyes. The pupil should be on neurological examination helps the nurse in nursing observed closely for one minute to allow time for a slow assessment and formulation of diagnosis. An accurate and response to become evident. Widely dilated pupils are timely neurological examination performed by a nurse can not a necessary criterion for brain death but fixed pupils pick up the subtle changes in patients, which often prove crucial with no response to light are mandatory. in areas like emergency department and critical care units. Oculo cephalic reflex (Dolls eye phenomenon): This Practicing the examination and examining the practice makes test must not be performed in patients with an unstable one confident and skilled in the neurological examination. cervical spine. The head is turned from starting position to a new steady position and briskly to the opposite References: side. The eyes move denoting the integrity of the medial longitudinal fasciculus in the brain stem. 1. Kozier & Erbs, Fundamentals of Nursing, Concepts, process, and practice: Pearson education, 8th edition, Gag reflexes: A tongue depressor is used to stimulate 2007. each side of the oropharynx and the patient observed for any pharyngeal or palatal movement. 2. Potter and Perry, Fundamentals of Nursing, Mosby publications, second edition, 2005. Cough reflex: A suction catheter is introduced into the endotracheal or tracheostomy tube to deliberately stimulate the carina. The patient is closely observed for any cough response or movement of the chest or diaphragm. Oculovestibular reflex: Slow irrigation with at least 5-ml of ice-cold water is performed into the external auditory 23
    • Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing UNIT-6 INTERPERSONAL RELATIONSHIP AND COMMUNICATION SKILLS IN PSYCHIATRIC NURSING Dr. Nagarajaiah, Associate Professor, Dept. of Nursing, NIMHANS, BangaloreINTRODUCTION or interchanging thoughts, attitudes, emotions, opinions, or information by speech, writing, or signs. Nurses can use thisThe concept of therapeutic relationship is the corner stone of dynamic and interactive process to motivate, influence,mental health - psychiatric nursing practice. The therapeutic educate, facilitate mutualsupport, and acquire essentialnurse - patient relationship is complex. It has a positive effect information necessary for survival, growth, and an overallsenseon patients outcomes.The relationship between the nurse of well-being (Howells, 1975; Kleinman, 2004)and the client is voluntary based on principles of agreement ina concept of negotiation through the years it leads to a task Communication- communication as a process by whichcalled contracting. Secondly, the goal directed characteristic information is exchanged between individuals through aof the one to one relationship, the focused effort or the common systems, signs or behavior.- Websters Dictionaryexpectations. The clients expectations arrives from a broad Therapeutic communication- it is a process in which the nurserange of life experiences, desires and levels of personal consciously influences a client or helps the client to a betterbelieves the nurses expectations arise from what she understanding through verbal or nonverbal communication.considers to be helpful. Therapeutic goals aimed at clients Therapeutic communication involves the use of specificgrowth and developments through elements of relationship strategies that encourage the patient to express feelings anditself. Thirdly, the concepts of mutual collaboration, the basic ideas and that convey acceptance and respect. - Mosbysto this concept are issues of responsibility and accountability. Medical Dictionary (2009).Both the nurses and client bring personal abilities andcapacities to the relationships. Interpersonal relationships refer to reciprocal social and emotional interactions between the patient and other personsMEANING in the environment.Communication stems from the Latin word, "to impart, Nurse- patient relationship- it is a mutual learning experienceparticipate, convey, and share information about" Websters and a corrective emotional experience for the patient. the nurseNew Collegiate Dictionary, (1974). uses personal attributes and specified clinical techniques inCommnuication- Communication refers to the reciprocal working with the patient to bring about behavioral change.exchange of information, ideas, beliefs, feelings and attitudes JOHARI WINDOWbetween persons or among a group of persons. It is a goal-directed process in which people use asystem of symbols A Johari window is a cognitive psychological tool created byand signs to convey a message Joseph Luft and Harry Inghamin 1955 in the United States, used to help people better understands their interpersonalInterpersonal relationship-The nurse-client relationshipis a communication and relationships.dynamic partnership that defines, directs, and evaluatestreatment outcomes.(Antai-Otong and Wasserman 2003) The Johari Window is a communication model that can be used to improve understanding between individuals andTherapeutic Relationship- An interaction between two people increase self-awareness.(usually a caregiver and a care receiver) in which input fromboth participants contributes to a climate of healing, growth Two key ideas behind the tool:promotion, and/or illness prevention. • Individuals can build trust between themselves byNurse-patient relationship-it is an interpersonal process disclosing information about themselves.between a professional nurse and a client that helps the client • They can learn about themselves and come to termsto foster and promote growth of personality, to help the client with personal issues with the help of feedback fromimprove in construction and productive way of living. others.DEFINITIONS Using the Johari model, each person is represented by theirCommunication- It is the act or reciprocal process of imparting own four-quadrant, or four-pane, window. Each of these 24
    • Booklet on Psychiatric Nursing Skills toTeachers of School of Nursingcontains and represents personal information - feelings, Key Points:motivation - about the person, and shows whether the • In most cases, the aim in groups should be to developinformation is known or not known by themselves or other the Open Area for every person.people. • Working in this area with others usually allows for enhanced individual and team effectiveness and productivity. The Open Area is the space where good communications and cooperation occur, free from confusion, conflict and misunderstanding. • Self-disclosure is the process by which people expand the Open Area vertically. Feedback is the process by which people expand this area horizontally. • By encouraging healthy self-disclosure and sensitive feedback, you can build a stronger and more effective team. THERAPEUTIC COMMUNICATION IN PSYCHIATRIC NURSING The nurse-client relationship is the foundation on which psychiatric nursing is established.The therapeutic interpersonal relationship is the process by which nurses provide care for clients in need of psychosocial intervention. Mental health providers need to know how to gain trust and gather information from the patient, the patients family, friends and relevant social relations, and to involve them in an effective treatment plan. Therapeutic use of self is the instrument for delivery of care to clients in need of psychosocial intervention. Interpersonal communication techniques are the "tools" of psychosocial intervention. THERAPEUTIC NURSE-CLIENT RELATIONSHIP- Therapeutic relationships are goal- oriented and directed at learning and growth promotion. Components of Therapeutic RelationshipThe four quadrants are: • Rapport- Its a relationship or communication especiallyQuadrant 1: Open Area when useful and harmoniousWhat is known by the person about him/herself and is also Its a willingness to become involved with anotherknown by others. personQuadrant 2: Blind Area, or "Blind Spot" Its growth towards mutual acceptance and understanding of individualityWhat is unknown by the person about him/herself but whichothers know. This can be simple information, or can involve It promotes self-disclosedeep issues (for example, feelings of inadequacy, • Trust- To trust another, one must feel confidence in thatincompetence, unworthiness, rejection) which are difficult for persons presence, reliability, integrity, veracity, andindividuals to face directly, and yet can be seen by others. sincere desire to provide assistance when requested.Quadrant 3: Hidden or Avoided Area It is imperative for the nurse to convey an aura of trustworthiness, which requires that he or she possessWhat the person knows about him/herself that others do not. a sense of self-confidence.Quadrant 4: Unknown Area • Respect- Every client deserves the respect of nursesWhat is unknown by the person about him/herself and is also participating in the clients care. Respect is a point ofunknown by others. view that says to another. It is also called non possessive 25
    • Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing warmth or unconditional positive regard. Client is patient has increased self esteem and a strong sense regarded as a person of worth and is respected as of identity and has achieved the planned treatment such. Her attitude is non judgmental, it is with out outcomes.. criticism, ridicule or reservation. Nurse has to establish reality of separation, mutually explore • Genuineness- it involves being ones own self. This feeling of rejection, loss, sadness, anger and related behavior. implies that the nurse is aware of her thoughts, feeling, She review the progress of therapy and attainment of goals. values and their releveance in the immediate interaction She have to formulate plans for meeting future therapy needs with a client. and plan for continuing care. • Empathy- its an ability to feel with the patient while INTERPERSONAL COMMUNICATION retaining the ability to critically analyse the situation. It • Interpersonal communication is a transaction between is the abiltiy to put oneself in another person the sender and the receiver. Both persons participate circumstances and feelings. simultaneously. • Concreteness- It involves using specific terminology • In the transactional model, both participants perceive easy to understand, rather than abstraction, when each other, listen to each other, and simultaneously discussing the clients feelings, experiences and engage in the process of creating meaning in a behavior. It avoids vagueness and ambiguity and is the relationship, focusing on the patients issues and opposite of generalizing, labeling and making assisting them learn new coping skills. assumptions about the clients experiences. • Both sender and receiver bring certain preexistingPhases of a Therapeutic Nurse-Client Relationship conditions to the exchange that influence the intended • Pre-interaction phase- this phase begins when the message and the way in which message is interpreted nurse is assigned to initiate a therapeutic relationship and this includes obtaining information about the patient from charts, significant others or health team THERAPEUTIC COMMUNICATION TECHNIQUES members. In this phase the nurse starts with initial 1. Using silence - allows client to take control of the assessment, she evaluate her own feeling, explore discussion, if he or she so desires fantasies, fears and ambivalence, strengths and 2. Accepting - conveys positive regard limitations and she plan her first meeting. In this phase she feels difficulty in self analysis, self acceptance, 3. Giving recognition - acknowledging, indicating anxiety, boredom, anger, indifference and depression. awareness • Orientation/Introductory Phase- Nurse and patient 4. Offering self - making oneself available meets for the first time. The task involves in this phase 5. Giving broad openings - allows client to select the topic are to establish trust and rapport, establish a contract 6. Offering general leads - encourages client to continue for intervention, assessment and examination of the patientsproblems and needs, identifies the patients 7. Placing the event in time or sequence - clarifies the strengths and limitations. Then she sets realistic goals relationship of events in time mutually agreeable by patient and the nurse. Developing 8. Making observations - verbalizing what is observed or a plan of action. Both explore the feelings of each other perceived • Working Phase- therapeutic work is carried out in this 9. Encouraging description of perceptions - asking client phase. The nurse maintains the trust and rapport. She to verbalize what is being perceived uses the problem solving approaches to over come the resistances. She continuously evaluates and 10. Encouraging comparison - asking client to compare explore for stressors. She promotes Insight and similarities and differences in ideas, experiences, or constructive coping mechanism to overcome the interpersonal relationships patients problems. 11. Restating - lets client know whether an expressed • Termination- it is a difficulty phase. The goal of this statement has or has not been understood phase is to bring an therapeutic end to the relationship. 12. Reflecting - directs questions or feelings back to client The nurse should recognize that the patients so that they may be recognized and accepted functioning has improved, relief from the problems, the 26
    • Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing 13. Focusing - taking notice of a single idea or even a single thoughts or behaviors on others word Belittling feelings expressed - causes client to feel 14. Exploring - delving further into a subject, idea, insignificant or unimportant experience, or relationship Making stereotyped comments, clichés, and trite 15. Seeking clarification and validation - striving to explain expressions - these are meaningless in a nurse-client what is vague and searching for mutual understanding relationship 16. Presenting reality - clarifying misconceptions that client Using denial - blocks discussion with client and avoids may be expressing helping client identify and explore areas of difficulty 17. Voicing doubt - expressing uncertainty as to the reality Interpreting - results in the therapists telling client the of clients perception meaning of his or her experience 18. Verbalizing the implied - putting into words what client Introducing an unrelated topic - causes the nurse to has only implied take over the direction of the discussion 19. Attempting to translate words into feelings - putting into THERAPEUTIC IMPASSES words the feelings the client has expressed only Therapeutic impasses are blocks in the progress of the nurse- indirectly patient relationship. It proke intense feelings in both the nurse 20. Formulating plan of action - striving to prevent anger or and the patientthat may range from anxiety and apprehension anxiety escalating to unmanageable level when to frustration, love, or intense anger. Five specific therapeutic stressor recurs impasses and ways to overcome are to be learnt to develop therapeutic nurse-patient relationship. 1. Resistance.Nontherapeutic Communication Techniques or barriers 2. Transference. Giving reassurance - may discourage client from further expression of feelings if client believes the feelings will 3. Counter transference. only be downplayed or ridiculed 4. Gift giving. Rejecting - refusing to consider clients ideas or 5. Boundary violations. behavior Resistance- it is the patients attempts to remain unaware of Approving or disapproving - implies that the nurse has anxiety-producing aspects within him. It is natural or learned the right to pass judgment on the "goodness" or reluctance to avoidance of verbalizing or even experiencing "badness" of clients behavior troubled aspects of self. It is caused by the patients Agreeing or disagreeing - implies that the nurse has unwillingness to change when the need for change is the right to pass judgment on whether clients ideas or recognized or secondary gain.it ocurs in working phase and opinions are "right" or "wrong" as this phase encompasses problem-solving process. Resistance occurs due to over involvement of nurse, lack of Giving advice - implies that the nurse knows what is respect, nurses inappropriate role model behavior. best for client and that client is incapable of any self- direction Transference- it is an unconscious response of the patient in which he experience feelings and attitudes towards the nurse Probing - pushing for answers to issues the client does that were originally associated with significant figures, in his not wish to discuss causes client to feel used and early life. It reduces the patients self-awareness and the nurse valued only for what is shared with the nurse is viewed as an authority figure from the past, such as a parent, Defending - to defend what client has criticized implies lost loved object, former spouse.it may be hostile and that client has no right to express ideas, opinions, or dependent reaction transference. feelings Interventions to resolve resistance and transference: Requesting an explanation - asking "why" implies that 1. The nurse must be prepared to be exposed to powerful client must defend his or her behavior or feelings negative and positive emotional feelings coming from Indicating the existence of an external source of power the patient. - encourages client to project blame for his or her 27
    • Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing 2. Make therapeutic contracts, develop a mutually resistance by patient. acceptable goals or plan of action, defining the goals, Through the use of immediacy, the nurse can identify counter purpose and roles of the nurse and patient in the transference in of its various forms. relationship. Sometimes resistance occurs because the nurse and patient have not arrived at mutually Forms of Counter Transference Displayed by Nurses acceptable goals or plans of action. This may occur if 1. Inability to empathize with the patient in certain problem the contract was not clearly defined in the orientation areas. stage of the relationship. The appropriate action then 2. Depressed feelings during or after the session. is to return to clarifying the goals, purposes and roles of the nurse and patient in the relationship. 3. Carelessness about implementing the contract by being late, running overtime etc. 3. Listen to patients analysis of the resistance or transference. Use clarification and reflection of feelings. 4. Drowsiness during sessions. Clarification gives the nurse more focused idea of what 5. Feeling of anger or impatience because of the patients is happening. Reflection of the content may help the unwillingness to change. patients become aware of what has been going on in 6. Encouragement of the patients dependency, praise or their own minds. Reflection of feelings acknowledges affection. the resistance and mirrors it to the patient. For example 7. Arguing with the patient or a tendency to push the patient the nurse may say, "I sense that you are struggling with before he is ready. yourself. Part of you wants to explore the issue of your marriage and another part says No- am not ready yet." 8. Trying to help the patient in matters not related to the identified nursing goals. 4. Explore the possible reasons for resistance and work through the transference reactions with the patient. The 9. Involvement with the patient on a personal or social depth of exploration and analysis engaged in by the level. nurse and the patient is related to the nurses 10. Dreaming about or preoccupation with the patient. experience and knowledge basis. 11. Sexual or aggressive fantasies towards the patient.Counter transference- Counter transference is a therapeuticimpasse created by the nurse. It refers to the specific emotional 12. Recurrent anxiety, unease or guilt feelings about theresponse generated by the qualities of the patient. This patient.response is inappropriate to the content and context of 13. A tendency to focus repeatedly on only one aspect ortherapeutic relationship and inappropriate in the degree of way of looking at the information presented by theintensity of emotion. Counter transference is the transference patient.applied to the nurse. Inappropriateness is the important 14. A need to defend nursing interventions used with theelement of this impasse, just as it is with transference. patient to others.It is natural, for example, that the nurse will feel warmth toward Advantages of Counter Transferenceor liking for some patients more than others, and the nursewill be genuinely angry at times in regard to the actions of Different forms off counter transference occur because thecertain patients. But in the case of counter transference, the nurse is involved with the patient as a participant observer,nurses responses are justified by reality. In this case the and not a detached bystander. They function asnurse identifies the patient with individuals from his or her 1. Powerful tool in exploration and potent instruments inpast, and the personal needs will interfere with therapeutic uncovering inner states. They are destructive only if theyeffectiveness. are brushed aside, ignored or not taken seriously.Types of counter transference 2. Counter transference can lead to further information,Counter transference reactions are usually of the following can bring to light new materials, and help in developingthree types: insight. 1. Reactions of intense love or caring. 3. Nurse understanding of counter transference and her own feelings help to maintain a working relationship 2. Reactions of intense hostility or hatred. with the patient. 3. Reactions of intense anxiety often in response to 28
    • Booklet on Psychiatric Nursing Skills toTeachers of School of NursingInterventions to Counter Transference Tangible gifts may include box of sweets, a bouquet of flowers or hand painted picture. Intangible gifts can be expression of 1. Experience of working with psychiatric patients. thanks to a nurse by a patient who is about to be discharged 2. Constantly lookout for counter transference. or a family members gratitude at being able to share an 3. Hold counter transference in abeyance or utilize it for emotional burden with another caring person. promoting therapeutic goals. Gift giving is a controversial issue in nursing. The taboo against 4. Apply self-examination throughout the course of nurse accepting gifts from patients has been long accepted. relationship, particularly when the patient attacks or However, some have questioned the theoretical rationale for criticizes. Asking oneself the following questions may this position and suggest that gift giving can sometimes serve be helpful: discrete therapeutic goals. Whether gift giving is an impasse depends upon the timing of the particular situation, the intent How do I feel about the patient? of the giver, and the contextual meaning of the giving of the gift. Do I look forward to seeing the patient? Occasionally it may be most appropriate and therapeutic for Do I feel sorry for or sympathetic toward the patient? the nurse to accept a patients gift; on other occasions it may be quite inappropriate and detrimental to the relationship. In Am I bored with the patient and believe that we are not the orientation phase of the relationship, gift giving can be progressing? harmful if it meets personal needs rather than therapeutic Am I afraid of the patient? goals. By giving a gift, the patient may be trying to manipulate Do I get extreme pleasure out of seeing the patient? the nurse and control the relationship. In contrast, by giving gift to the patient, the nurse may be attempting to relate through Do I want to protect, reject or punish the patient? objects instead of the therapeutic use of self and to avoid Do I dread meeting with the patient and feel nervous exploring feelings of inadequacy or frustration. during the sessions? In the working phase gift giving may take on a different Am I impressed by or try to impress the patient? significance. For example the patient offering a cup of coffee can be a sign of respect for the nurse and in their work together. Does the patient make me very angry or frustrated? As an isolated incident, the nurses acceptance of it can 5. Pursue to find out the source of the problem. enhance the patients confidence, self esteem, and a sense 6. Exercise control over counter transference. of responsibility. 7. Have individual or group supervision. Gift giving most often arises in the termination phase of relationship, and in is in this phase that the meaning behind it 8. Weekly clinical seminars, peer consultation, and can be the most complex and difficult to determine. At this time professional meetings can also offer emotional gifts can reflect a patients need to make the nurse feel guilty, support. delay the termination process, compensate for feelings ofGIFT GIVING inadequacy or an attempt to transform the therapeutic nurse-Receiving a gift from the patients make the nurse to inhibit patient relationship in to social one that can go on indefinitely.independent decision-making, create a feeling of anxiety or The nurse can initiate gift giving for similar reasons. If feelingsguilt. Gift is that of something of value is voluntarily offered to are identified and clarified, then a small gift that reflectsanother person, usually to convey a gratitude. gratitude and remembrance can be exchanged, accepted and valued.Gifts can be divided into following five types (Morse, 1991). Boundary violations- A boundary indicates a border or a limit. It Gifts to reciprocate for care given. determines the extent of acceptable limits. Many types of Gifts intended to manipulate or change the quality of boundaries exist. Examples include the following: care given or the nature of nurse-patient relationship. Material boundaries Gifts given as perceived obligation by the patient. Social boundaries Serendipitous gifts or gifts received by chance. Personal Gifts given to organization to recognize excellence of Professional boundaries (College and Association of care received. Registered Nurses of Alberta [CARNA], 2005).Gifts can be tangible or intangible; Lasting or temporary. 29
    • Booklet on Psychiatric Nursing Skills toTeachers of School of NursingConcerns regarding professional boundaries are commonly 4. Friendship or romantic association. When a nurse isrelated to the following issues: acquainted with a client, the relationship must move from one of a personal nature to professional. If the nurse is unable to1. Self-disclosure. Self-disclosure on the part of the nurse accomplish this separation, he or she should withdraw frommay be appropriate when it is judged that the information may the nurse-client relationship. Likewise, nurses must guardtherapeutically benefit the client. It should never be undertaken against personal relationships developing as a result of thefor the purpose of meeting the nurses needs. nurse-client relationship. Romantic, sexual, or similar personal2. Gift-giving. Individuals who are receiving care often feel relationships are never appropriate between nurse and client.indebted toward health care providers. Indeed, gift-giving may CONCLUSIONbe part of the therapeutic process for people who receive care(CARNA, 2005). Accepting financial gifts is never appropriate, Effective communication is the core skill in mental health carebut in some instances nurses may be permitted to suggest in primary care settings. Self-awareness and ability toinstead a donation to a charity of the clients choice. If collaborate with other health care providers are also skillsacceptance of a small gift of gratitude is deemed appropriate, that will facilitate accurate inquiry into the patients truethe nurse may choose to share it with other staff members concerns and the context in which they occur.who have been involved in the clients care. In all instances,nurses should exercise professional judgment when decidingwhether to accept a gift from aclient. Attention should be given REFERENCESto what the giftgiving means to the client, as well as to 1. Lalitha, k. Mental health and psychiatric nursing: Aninstitutional policy, the ANA Code of Ethics for Nurses, and the Indian perspective. Bangalore: V.M.G. book house;ANA Scope and Standards of Practice. 2010.161 - 165.3. Touch. Nursing by its very nature involves touching clients. 2. Stuart GW Principles and Practice of psychiatric nursing.Touching is required to perform the many therapeutic 7th edition, Mosby, Philadelphia, 2001:15-49procedures involved in the physical care of clients. Caring 3. Epstein RM, Borrell F, Caterina M . Communication andtouch is the touching of clients when there is no physical need mental health in primary care. In New Oxford Textbook(Registered Nurses of Psychiatry (Edrs. Gelder MG, López-Ibor JJ,Association of British Columbia [RNABC], 2003). Caring touch Andreasen NC), Oxford University Press, 2000.often provides comfort or encouragement and, when it is used 4. Sreevani R, A guide to mental health and psychiatricappropriately, it can have a therapeutic effect on the client. nursing. 1st edition, New Delhi, Japee Brothers,However, certain vulnerable clients may misinterpret the 2004:32-35meaning of touch. Certain cultures, are often uncomfortablewith touch. The nurse must be sensitive to these cultural 5. MARY C. Essentials of Psychiatric Mental Healthnuances and aware when touch is crossing a personal Nursing, 4th edition. F. A. Davis Company,philadelphia,boundary. In addition, clients who are experiencing high levels 2008:96-108of anxiety or suspicious or psychotic behaviors may interprettouch as aggressive. These are times when touch should beavoided or considered with extreme caution. 30
    • Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing UNIT-7 PROCESS RECORDING Dr. Ramachandra Associate professor Dept. of nursing NIMHANS Bangalore-29INTRODUCTION 3. Assists the nurse to plan, and evaluate the interaction on a conscious level rather than an intuitive level.One of the best ways to increase communication and interviewskills is by reviewing the clinical interaction exactly as they 4. To gain the patients confidence and get his co-occur between the nurse therapist and the patient. This process operation.offers the opportunity to identify themes and patterns in both 5. To establish rapport with the patient.the nurse therapist and the patients communications. Clinical 6. To know about the patients illness and to understandreviews also helps students learn to deal with the variety of the psychodynamics of illness.situations that arise in clinical interview. As a nurse working 7. To identify the role of the socio-cultural background ofwith mental illness is always a challenge. Conducting a the patients behavior.process recording gives the opportunity to improve the 8. To practice various communication interviewcommunication skill, note taking, self-awareness, techniques to get information from the patient and toassessments, learning to listen, observations, and role playing. help him.A process recording provides with an additional opportunity topractice nursing values and ethics. The brief conversation 9. To increase the observational skills as there is abased on the therapeutic goals, symptoms of illness and the conscious process involved in thinking, sorting andverbal and non verbal behavior of the patient also are explored classifying the interaction under the various headings.during the process. 10. To increase the ability to identify problems and gain skills in solving them.Process recording is written record of a segment of the nursepatient session that reflect as closely as possible the verbal GUIDELINES FOR PROCESS RECORDING:and non-verbal behaviour of both patient and nurse. Process Recording includes a brief description about theDEFINITION patient regarding his name, age, educational status, occupation, marital status, health problems, and the duration 1. A process recording is a written record of a verbatim of stay in the hospital. conversation between a nurse and a client. Describe about the environment in which the interaction 2. It is written account or verbatim recording of all that occurred, date, time, place of interaction. This will provide cues conversed, during and immediately following the nurse about the patients thoughts and feelings. Details such as patient interaction. personal history, family, socio-economic condition of the family, 3. It is a systematic method of collecting, interpreting, medical problems, current issues and complaints, past analyzing and synthesizing data collected during a illnesses can be collected through systematically planned nurse- patient interaction, by using various process recording. communication techniques. Setting the goals: set appropriate goals and time. It shouldThe verbal communication is written from the students focus on correcting the altered psychodynamics, therapeutic,memory. Both the verbal and non verbal cues are noted. The rehabilitative, continuation of the care.record includes noting therapeutic communication techniques Interaction: record the factual information collected. What thethat are used. It also includes the students analysis of the nurse asked and did? What the patient said and did? Note thecommunication. non-verbal cues during the interaction. Nurse must aware ofPURPOSE her own non-verbal behavior and its effect on the interaction. She can observe her own thoughts and feelings for self- 1. To critically analyze communication and its effect on evaluation. Use techniques like offering self, broad opening, behavior of the individual reflection, clarifying, validating, focusing, silence, etc. during 2. To modify subsequent behavior resulting in improved the conversation. quality of therapeutic communication and nursing care. 31
    • Booklet on Psychiatric Nursing Skills toTeachers of School of NursingInterpretation and analysis: interpret the verbal and non-verbal Disadvantage:behavior of the patient, along with the thoughts and feelings. 1. Process recording relies on memory and so subject toAnalyze the findings and come to inferential conclusion. distortions.Advantages: 2. Taking notes or recording during the conversation may 1. Useful tool for identifying communication patterns. be distracting for both the interviewer and the patient. 2. It is possible to take notes, verbatim or recording of the interview or conversation in a private area immediately after the interaction takes place. 3. Careful recording of Nurse Therapist words and patients words helps in identifying whether Nurse Therapist responses are Nurse Therapists or not, and recall Nurse Therapist thinking and emotions at the time. PROCESS RECORDING FORMATDate; time; duration.Venue:Diagnosis:Setting and situation:Appearance of the patient:Therapeutic communication goals: 32
    • Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing ANALYSIS (ANALYZE CLIENT (VERBAL NURSE(VERBAL AND WHETHER EACH INFERENCE AND NON VERBAL NON VERBAL TECHNIQUES USED TECHNIQUE CONVERSATION) CONVERSATION) WORKED AS YOU PLANNED) Good morning again, Mrs. Laxmi, I am the I am so nervous! I feel student nurse who is Offering self like I am impersonating going to spend some a nurse! I hoped she time talking with you.” would talk to me. (smiling) Good morning sister?” {looks down and no eye Patient appears not to eye contact interested in talking maintained} I was hoping to start You appear sad today. with a broad opening Making observation Can you brief me about so she could take Broad opening it? whatever direction she wanted. Sister I have a feeling that my family is making plan to kill me. Appears to have My husband is delusion of unfaithful to me so they persecution and are trying to poison my jealously food. Hence I have not eaten my breakfast. I thought may be she would talk more about Yes, Go On Yes go no Offering general leads her feeling if I could keep her talking. What else to say sister. I am scared that I am Continues to justify not safe even in the the delusion hospital It’s hard to believe that any one can harm you Duh! This like a stupid . Clarifying in the hospital. What question. makes you say so? No you do not know sister. It is true I feel Systematizes the they have kept some delusion spies around to check on me. See, Mrs. Laxmi We all are See Laxmi. here. There are staff nurses, doctors, security everybody around you. So do not get scared that some one will harm you. When you tart getting I was trying to get her these thoughts come to find the way she Planning for coping and share it with a staff could talk to the nurse so that she can peoples. help you. In the midst of so many people I find it hard that anyone can harm you. If you feel scared you can come and sit in the nurse’s station. I was glad she was Thank you sister. I will I was trying to do talking to me. It seems Smiles and appears do as you say. planning for coping. like she lightened up, relaxed became calmer. Thank You Mrs. Laxmi (I gotto Thank you for talking Showing the end of the up to Laxmi.{ shook her to me leave and I got up conversation and I hand), and squeezed leave wanted her to know I her hand} care about her.Discuss the issues related to patients concern, fix next relationship with the patient. Therefore this art should beappointment essentially inculcated in all psychiatric nurses.Summary: While summarizing, list all the inferences drawn, Reference:any difficulties faced during the interaction by patient and the 1. Booklet on clinical skills in psychiatric nursing.nurse and techniques used to overcome the difficulties, Department of nursing. National institute of mentalimportance of care plan. health and neuro sciences.bangalore-560 029.india/Termination : when patient is ready for discharge, inform him 2009.about the need for termination, tell the patient he can contact if 2. Kathy neeb. Fundamentals of mental health nursing.need arises. 3rd ed. Jaypee. New Delhi. 2008 Signature of the nurse: 3. Sreevani R. A guide to mental health and psychiatric nursing. 3rd ed. Jaypee. New Delhi.2010.Conclusion: Process recording is a method by which a nurse 4. Varcarolis EM, Halter MJ. Foundations of psychiatricestablishes her rapport with the patient. by the use of mental health nursing- A clinical approach. 6th ed.therapeutic communication the nurse can establish a helping Saunders. St. Louis . 2010. 33
    • Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing UNIT- 8 NURSING CARE PLAN Dr. Sailaxmi Gandhi Assistant professor Dept. of Nursing NIMHANS, BangaloreNursing documentation is the maintenance of records To accurately observe and document the clientsregarding the nursing assessment, planning implementation behaviourand evaluation of the patients condition in relation to the To protect the patient from self injury and injury to othersnursing care provided. The nurse is responsible for data To help the patient to identify his own potentialscollection and assessment of health status of the client;determination of the nursing care plan directed towards To develop a sense of well being to maintain personaldesignated goals; evaluation of the effectiveness of nursing hygiene and be self sufficientcare in achieving the goals of care; and subsequent To assess the patient, plan for comprehensive nursingreassessment and revision of the nursing care plan. One of care and evaluate the outcomethe most important professional functions of the psychiatric To provide opportunities for the client to make decisionnurse is evaluation of the patients responses to nursing care. and assume responsibilities for his life.Psychiatric patient records are legal documents which may To identify factors involved in relationship of the client tobe used in the courts of law and is the only written evidence of his family situationthe patients problems and the care provided. To recognise and involve family as a tool in promotingDefinition: It is defined as the collection and assessment of and improving care of the patient.health status; determination of the nursing care directedtowards designated goals and evaluation of the effectivenessof nursing care in achieving the goals of care (Corponito, 1983) 3. Components of Nursing Care Plan1. Purpose of Nursing Care Plans Diagnostic statements (collaborative problems or nursing diagnoses) They represent a priority set of diagnosis (collaborative problems or nursing diagnosis) for a client. Outcome criteria or nursing goals They provide a "blue print" to direct charting Nursing orders or interventions Evaluation (status of diagnosis and clients progress) They communicate to the nursing staff what to teach, what to observe, and what to implement. They provide outcome criteria for reviewing and Each nursing care plan should project individually the problems evaluating care. that the patient presents on priority basis and should be written They direct specific interventions for the client, family in nursing diagnostic statements. For a psychiatric patient, if and other nursing staff members to implement. the physical problem is more severe (e.g. in catatonia if the patient refuses to eat), then the physical problem becomes a They provide legal protection priority. The nursing objectives or the nursing goals should They are used for accreditation, licensure, and be planned accordingly. Having set the nursing goals, the certification interventions are implemented based on scientific principles They help to comply with regulatory standards in to achieve the nursing goals. Status of the diagnosis/problem nursing and client progress is evaluated accordingly. They help in auditing evidence based nursing care 4. Model Nursing Care Plan4 Objectives of Formulating Nursing Care Plans They help in auditing evidence based nursing care To recognise and accept the client as an individual 34
    • Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing Sl Nursing Nursing Diagnosis Nursing Nursing interventions Rationale or Evaluation No. Problem objectives scientific principal 1. Subjective: Impaired sensory Short term 1.Establish rapport with 1.To improve the 1. Patient’s Patient says, perception related to goal: The the patient interpersonal hallucinatory “I can hear psychopathology patient’s relation and trust behavior several As evidenced by subjective which helps in reduced people inappropriate distress reduces verbalization 2. Reduced or scolding me responses & Long term goal: no verbalization and telling disordered thought Sensory 2.Provides of auditory me to kill sequencing perception 2.Assess the presence, baseline hallucination myself. And occurs only in content and severity of information about 3. Reduced or this happens the presence of alteration in client’s the patient’s no verbalization when no one real stimuli in perception behavior, potential of subjective is with me” the environment for violence, distress Objective: observe changes in The patient response to is seen interventions, etc. always 3. To avoid talking to 3. Take suitable incidents of self although precautionary measures violence/self- she is alone depending on the harm/suicide, etc. and appears content of the voice frightened 4. Set limits on the 4. Helps the and patient’s impulsive patient to distressed behavior in response to differentiate altered perceptions between desirable & un-desirable 5.Encourage reality behavior based conversation 5. Helps the patient to correctly interpret the 6. Engage the patient in stimuli within the activities of his/her milieu choice 6. Helps the patient in 7. Engage the patient in distracting from activities such as the ‘voices’ reading loudly, 7. Since the listening to music, etc. sensory perception impairment is in the auditory area, related activities will help blocking 8.Positively reinforce the ‘voices’ reduced incidents of hallucinatory 8. This will behavior/reporting of increase repetition the ‘voices’ of desirable 9. Administer behaviors prescribed antipsychotics, watch 9. Antipsychotics for, report & document alter the the effect, side-effects biochemical mechanisms and help controlling the hallucinationsConclusion: Formulating a comprehensive care-plan which A Practical method for grading the cognitive state ofis individually tailored and prioritized based on the patients patients for the clinician", J.Psychiatr Res 12:189, 1975needs is a very important function of the psychiatric nurse. 2. Lynda Juall Carpenito, "Nursing Care Plans andCare plans should be flexible and the nurse should be prepared Documentation", Third Edition, Lippincott, 1983to change the intervention and prioritization based on changes 3. Kaplan.I.Harold, Sadock. J. Benjamin, "Synopsis ofin the patient. The nurse should also remember to always Psychiatry: Behavioural Sciences/Clinical Psychiatry",document the care plan. B.I.Waverly Pvt. Ltd. , New Delhi, VIIIth Edition, 1998References: 1. Folstein MF, Folstein S, Mc Hugh PR, "Mini-Mental State: 35
    • Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing UNIT-9 LEGAL ASPECTS OF PSYCHIATRIC NURSING Dr. K. Lalitha, Professor and Head, Dept. of Nursing, NIMHANS, Bangalore 560 029.Nursing practice is governed by laws that specify her home: This chapter deals with terms andresponsibilities towards patients, laws that affect the nurse conditions related to establishment ofas an employee, laws that regulate her relationship with psychiatric hospitals and psychiatricphysicians and laws that specify her duty to protect the nursing home.public and laws that specify her duties for record keeping and Chapter IV: Admission and Detention in psychiatric hospitalreporting. or psychiatric nursing home. This chapterLegal aspects of psychiatric nursing relates to the treatment explains the procedures to be followed whileand care of persons with mental illness in least restricted admitting psychiatric patients and detainingenvironment, to make better provision to respect, to protect them in psychiatric hospitals. It classifies (I)and to fulfill the human rights of persons with mental illness Admission on voluntary basis (Major, Minor), (II)based on the guidelines given by Mental Health Act (1987), Admission under special circumstances, (iii)National Mental Health Policy (1982 and 2003), Standards of Temporary treatment order (iv) Reception Orderpsychiatric nursing and Consumer Protection Act (1986). - on application, on production before the Magistrate; (v) Admission in emergencies and(1) Introduction: Safe nursing practice includes an (vi) Miscellaneous admission.understanding of the legal boundaries in which nurses mustfunction. An understanding of the implication of the law Chapter V: Inspection, Discharge, Leave or Absence, andsupports critical thinking on the nurses part. Laws are removal of mentally ill person; This chapterchanging constantly to reflect changes in society, changes in explains the composition of Board of Visitors,the delivery of health care and advancement in medical their responsibilities, dischargetechnology. The legal aspects of psychiatric nursing in India procedure to be followed by for the voluntaryis based upon NMHP (1982& 2003), MHA (1987), CPA(1986) admission patients and for other than a voluntaryand psychiatric nursing standards. patient in psychiatric hospital.(2) Mental Health Act, 1987 (MHA), notified in 1993. It is not Chapter VI: Judicial Inquisition: This chapter givesfully implemented in many states. It has 98 sections. MHA, guidelines about judicial inquisition regarding1987 also contains 10 chapters. Contents of MHA largely alleged mentally ill person possessing property.written with an administrative purpose. Details are, Chapter VII: Liability to meet cost of maintenance of mentallyChapter I : Preliminary (and definitions): This chapter ill persons: This chapter provides guidelines to consists of definition of terms Mentally ill person, meet the cost of maintenance of mentally ill Mentally ill prisoner, cost of maintenance, District persons in the psychiatric hospital. Court, Inspecting Officer, License, Licensee, Chapter VIII: Protection of human rights of mentally ill person: licensed psychiatric hospital (or nursing home), This chapter confirms the human rights of the licensing authority, medical officer, Medical mentally ill person. Officer In-Charge, Medical Practitioner, Minor, Psychiatric Hospital or psychiatric nursing Chapter IX: Penalties and procedures: This chapter deals home, psychiatrist, Reception order, and with nature of penalties and punishment Temporary treatment order. procedures applicable for those who violate the provisions given in Mental Health Act, 1987Chapter II: Mental Health Authority: This chapter describes and much emphasis is given to the provision of the roles and responsibilities of authorities to Chapter III. regulate, to develop, to direct and coordinate the mental health services in the country. Chapter X: Miscellaneous : This chapter focuses on the duties and responsibilities of the medical officerChapter III: Psychiatric hospitals & psychiatric nursing in-charge of psychiatric hospital. 36
    • Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing(3) Admission procedures to be used in psychiatric hospital. the least capable of protecting their own rights.(a) Admission on voluntary basis Psychiatric problems may cause patients to lack social skills or may cause an inability to make a point clearly understoodMajor: Application on prescribed form to be submitted to the because of difficulties in concentration. As a result, the rightsmedical officer in charge of psychiatric hospital for admission. of psychiatric patients have been ignored and abused forMinor: The nearest guardian of patient applies for admission centuries.(b) Admission under certain special circumstances: When a psychiatric patient enters a hospital, he loses hisRelatives or friends can produce the patient to medical officer freedom to come and go, to schedule his days, to choose histo admit the patient along with two medical certificates (one activities, and to control his activities of daily living. If he is alsofrom a Gazetted Medical Officer). Only for 90 days patient can adjudicated incompetent, he loses his freedom to managebe admitted. his financial and legal affairs and make many important decisions. Because of the loss of these important freedoms,(c) Temporary treatment order the authorities of health care agencies closely guard and valueMedical officer obtains reception order from Magistrate by those rights that the psychiatric patient retains. Some of thesubmitting one medical certificate and detains patients for 6 rights of the psychiatric patients are:months (only). (i) The right to wear their own cloths(d) Reception order (ii) The right to keep and use their own personal(i) On application: Relative or a friend who has seen patient possessions, including toilet articles.within 14 days can apply for reception order with two supporting (iii) The right to keep and be allowed to spend a reasonablemedical certificate (one from a Gazetted Medical Officer). sum of their money for canteen expenses and smallMedical Officer of a psychiatric hospital writes to Magistrate purchases.and gets reception order to detain patient for 6 months for in (iv) The right to have access to individual storage space forpatient treatment. their private use.(ii) On production before the Magistrate: Police officers produce (v) The right to see visitors everydaypatient to Magistrate within 24 hours, with 2 medical certificatesto get reception order. Relatives who willfully neglect the patient (vi) The right to have reasonable access to telephone bothmay be punishable with fine upto Rs. 1,000/-. to make and to receive calls(e) Admission in emergencies: Medical Officers admit the (vii) The right to have ready access to letter writing materialspatient first & applies for reception order within 72 hours. (viii) The right to mail and receive unopenedMagistrate has to personally see the patient. correspondence(f) Miscellaneous: Any public can bring patient for admission. (ix) The right to refuse electro convulsive therapyBut the reception order should be arranged by Medical Officer (x) The right to manage and dispose of propertyIn-Charge of psychiatric hospital. (xi) The right to excuse wills(4) Discharge procedures: (xii) The right to hold civil service statusMedical Officer in-charge of the hospital can discuss any patientexcept criminals or those admitted on voluntary basis. It (xiii) The right to treatment in the least restrictive setting.requires the consent of 2 Medical Officers of his team. In Section 81 of MHA (1987) the following rights are explained.Voluntary admission patients (major) writes a request letter 81.1 Right to protection against inhuman, cruel andfor discharge and the medical officer discharges or gives leave degrading treatment: provision of a safe and hygienicof absence for 60 days within24 hours of request. environment; adequate sanitary conditions in theAny mentally ill person (other than a voluntary patient) may be mental hospital facilities; facilities for leisure,transferred to any other psychiatric hospital with the consent recreation, education & religious practices; personsof the Govt. of the state. privacy is protected; not forced to undertake work in a mental health facility; adequate provision is made for(5) Rights of mentally ill patients: preparing the person for living in the community.It is the responsibility of the nurses to ensure that their actions 81.2 Non-discrimination: Treated equal to persons withpromote the welfare of patients. Psychiatric patients are often 37
    • Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing physical illness in the provision of health care and (i) Management of property & affairs health services: Right to obtain medical insurance for (ii) Marriage treatment of mental illness; Right to emergency facilities eg: Ambulance living conditions in hospitals same as (iii) Testamentary they are for patients with physical illness (7) The Narcotic Drugs and Psychotropic Substance Act81.3 Protection in research: Free & informed consent of the (1985) person for participation in research; The Act includes the nature of punishment and or fine when a When the person cannot consent, consent of person produces, possesses, transports, imports, sells, purchases or uses any narcotic drugs or psychotropic - SMHA who in turn to have consent of substances. - Nominated representative & Legal role of the nurse - Subject to certain specific conditions (i) Observing the legal aspects of admission, discharge&81.4 Right to information: oPerson & Nominated leave of absence procedure representative have the same right to information; (ii) Providing safe & secured environment in the wardRight to make application to MHRC to review admission; (iii) Following the principles of therapeutic communityNature of the illness for which they are being treated. In alanguage & manner, that the patients and family members (iv) Assisting for diagnostic & therapeutic procedurescan understand. (v) Protecting the rights of patientsNurses have to closely guard and value these rights that the (vi) Preventing nursing malpractice - negligence; care ispsychiatric patients retain. to be taken in the areas of staffing, educationalLegal responsibilities of a mentally ill person. qualifications, competencies and job descriptions.(i) Criminal responsibility: Mc Naughten Rule protects (vii) Documentation the psychiatric patient from punishment (IAC, 1957) (viii) Informed/Substituted consent when he does an offensive act without knowing the (ix) Confidentiality nature and quality of act and when he cannot discriminate between right & wrong act. (x) Responsible record keeping(ii) Durham Rule (1954) The accused is not criminally Conclusion: Rules and regulations framed by statutory bodies responsible if his act was the "product of mental must be strictly followed at all levels. Nursing students must disease". be aware of legal aspects in nursing in general and in psychiatric nursing in particular for improving patient safety(iii) American Law Institutes (ALI) Test: says that "a person and professional development. is not responsible for criminal conduct if at the time of such conduct as a result of mental disease or defect References: wherein he lacks adequate capacity either to appreciate 1. Lalitha K, "Mental Health and Psychiatric Nursing -An the criminality of his conduct to conform his conduct to Indian Perspective", VMG Book House,Bangalore, 2007, the requirement of the law. p. 610-634.(6) Civic responsibility Mentally if patients are kept away from 38
    • BOOKLET ON PSYCHIATRIC NURSING SKILLS TOTEACHERS OF SCHOOL OF NURSING EDITED BY: DR. K.LALITHA DR. NAGARAJAIAH DR. RAMACHANDRA DR. SAILAXMI GANDHI DEPARTMENT OF NURSINGNATIONAL INSTITUTE OF MENTAL HEALTH AND NEUROSCIENCES BANGALORE 560 029 2011
    • A C K N O W L E D G E M E N TWe feel extremely happy to express our heartfelt gratitude to Our sincere thanks to Dr.R.Parthasarathy, Professor,Prof. P. Satish Chandra, Director/Vice-Chancellor of NIMHANS Department of Psychiatric Social Work, for being a resourcefor permission, extending total support and encouragement person.to research project on Effect of training programme on Our profound thanks to all our nursing colleagues in theKnowledge, Attitude and Clinical Skills of Nursing Teachers of Department of Nursing at NIMHANS for their moral supportSchool of Nursing Towards Psychiatric Nursing and ensuing and encouragement throughout this endeavour.the booklet. This booklet would not have been possible without theWe sincerely thank Dr. V. Ravi, Registrar, for administrative dedicated and conscientious effort of Mrs. Leelavathy. A. &support in this academic venture. Mrs. Kalyani S. stenographers, at Department of Nursing,Our sincere thanks to Prof. Shoba Srinath, Dean, Behavioural NIMHANS.Sciences, for support and guidance. We are grateful to the principals of the various Schools ofWe sincerely thank the chair-person and members of ethical Nursing, who have permitted their faculty to participate in thiscommittee for their valuable suggestions in this endeavour. research project.We are sincerely grateful to the President, Indian Nursing Last, but not the least, the authors owe their thanks M/s.Council, for financial assistance. Manjushree Printers for quality printing of this booklet.We extend our heart-felt thanks to Prof. K.Reddemma, FormerDean, Behavioural Sciences and Professor of Nursing, for Dr. K. Lalithaher continuous encouragement and involvement. Dr. K.Thennarasu Dr.Nagarajaiah Dr. Ramachandra Dr.Sailaxmi Gandhi
    • C O N T E N T S CONTENTS Articles Author Name Page 1. PREFACE 2. ACKNOWLEDGEMENT 3. UNIT 1- PSYCHIATRIC INTERVIEW DR. R. PARTHASARATHY & MS. SHOBITHA 4. UNIT 2- PSYCHIATRIC HISTORY TAKING DR.NAGARAJAIAH 5. UNIT 3- SYMPTOMATOLOGY IN MENTAL DISORDERS DR. RAMACHANDRA 6. UNIT 4- MENTAL STATUS EXAMINATION DR. SAILAXMI GANDHI 7. UNIT 5- PHYSICAL & NEUROLOGICAL EXAMINATION DR. RAMACHANDRA 8. UNIT 6- INTERPERSONALRELATIONS AND DR. NAGARAJAIAH COMMUNICATION SKILLS 9. UNIT 7- PROCESS RECORDING DR.NAGARAJAIAH 10. UNIT 8- NURSING CARE PLAN DR. SAILAXMI GANDHI 11. UNIT 9- LEGAL ASPECTS OF PSYCHIATRIC NURSING DR. K. LALITHA