Psychiatric Nursing.drjma

PSYCHIATRIC NSG
DR. JAMES M. ALO, RN, MAN, MAP, PhD

Models of Mental Health
Mental health:
• state of emotional, psychological & social wellness (effective coping,
(+) self-concept, emotionally stable).
Mental disorder:
•Defined generally as health conditions marked by alterations in
thinking, mood or behavior taht cause distress, impair ability to
function, or both (USDHHS, 1999).
Mental illness
• Is considered a clinially significant behavioral or psychological
syndrome experienced by a person and marked by distress, disability,
or loss of freedom (APA, 200).
Biomedical model
James M. Alo, RN, MAN, MAP, PHD. 7/26/2011

What you see is just the tip,
what lies beneath is the truth about it.
James M. Alo, RN,MAN,MAP,PHD. 7/26/2011

Factors influencing mental health — INDIVIDUAL – person’s biologic make-up, autonomy and
independence, self-esteem, capacity for growth, vitality, ability
to find meaning in life, emotional resilience, sense of belonging,
reality orientation and coping or stress management abilities.
— INTERPERSONAL – or relationship, may include effective
communication, ability to help others, intimacy, and a balance of
separateness and connectedness.
— SOCIAL / CULTURAL or ENVIRONMENTAL - include a
sense of community, access to adequate resources, intolerance of
violence, support of diversity among people, mastery of the
environment, and a positive, yet realistic, view of one’s world.

CONCEPT OF POSITIVE MENTAL HEALTH
— 1.Attitudes toward the individual SELF
— Involves aspect related to :
a. Self-acceptance - regard for oneself with a
realistic concept of strengths & weaknesses.
b. Self-awareness - is noticing how the self feels,
thinks, behaves and senses at any given time.
c. Self-concept - encompasses all what a person
perceives, knows and holds to be true about
his/her identity.

Aspects of self-concept
BODY IMAGE
PERSONAL
IDENTITY
SELF-ESTEEM
ROLE
PERFORMANCE

2. Growth, Development, Self-Actualization
Is what a person does with his abilities and potentialities over a period of
time.
— Future goals and investments in living are involved
3. Integrative Capacity
— Core Concept : the relatedness of all processes & attributes in an
individual which influence unified or synchronized personal
function.
— Concerns the ability of the individual to tolerate anxiety and
frustration during resistance to stress.
— Psychoanalysts view : a balance of psychic forces.
(id,ego,superego)

4. Autonomous Behavior
— individual’s ability to personally regulate his
decision-making & actions so that these functions
relatively independent of physical and social
influences.
— ability to refuse to conform when to do is a social
expectation that conflicts with one’s value system.

5. Perception of Reality
— How the individual views and reacts toward the world around him .
- ability to perceive reality while being free of needs which could
distort individual perceptions.
6. Mastery of One’s Environment
— ability to ADAPT, ADJUST and BEHAVE appropriately in situations
and in accordance with culturally approved standards so that
satisfactions are achieved in love, work, play and interpersonal
relations.
- ability to solve problems with expression of appropriate feeling
tones and direct attack.

HISTORICAL BACKGROUND
— ANCIENT TIMES
…people believed that any sickness indicated displeasure of
the Gods and in fact was punishment for sins and wrong
doings.
… mental disorders were
viewed as either being
divine or demonic
depending on their
behavior.

Renaissance (1300-1600)
— People with mental illness were distinguished from criminals
— Those considered harmless were allowed to wander and live in the
rural areas
— Those “dangerous lunatics” were thrown in prison, chained, and
starved

1547
Hospital of St. Mary of Bethlehem, first hospital for the
insane was built

1775
visitors at the institution paid to view and ridicule the
inmates like animals

Mentally ill patients were considered evil or
possessed and were burned at the stake

Period of enlightenment
— 1790s
– Phillippe Pinel and
Willian Tukes formulated
the concept of asylum
as a safe refuge or haven
offering protection to
mentally-ill people

— Dorothea Dix
(1802-1887)
– began a crusade
in the USA to reform
treatment of the
mentally ill.
She opened 32 state
hospitals that offered
asylum.

Period of scientific discovery
— Period of scientific study and treatment of mental illness began
with:
— Sigmund Freud (1856-1939) – studied the mind, its disorders
and treatment
— Emil Kraepelin (1856-1926) – classified mental disorders
according to their symptoms
— Eugene Bleuler (1857-1939) – coined the term “schizophrenia”

LINDA RICHARDS
first American psychiatric nurse.
She believed that, the mentally sick
should be at least as well cared for
as the physically sick
The first training of nurses
to work with persons with
mental illness was in 1882
at McLean Hospital in
Waverly,Mass.

The first psychiatric nursing
book – Nursing Mental
Diseases by Harriet Bailey was
published in 1920
In 1913 John Hopkins was the
first school of nursing to
include a course in psychiatric
nursing in its curriculum
Two early nursing theorists
shaped psychiatric nursing
practice: Hildegard Peplau and
June Mellow.

1845
first authentic book on psychiatric disorder was
released
1950s
birth of psychotropic drugs; first to be created
were:
Thorazine – antipsychotic drug
Lithium – antimanic drug

NEUROSCIENCE: Biology & behavior

Neuron
Dendrites Receive impulses
Axon •Semd impulses away
Neuromuscular
junction(NMJ)
•Connects nerve to muscles
Glial
cell/neuroglia
•Are supporting cells, they include:
üOlegodendrocytes – produce myelin in the CNS
üMicroglia – phagocytes/scavengers of the CNS
üAstrocytes – structural supporting cells
Myelin •Insulates axons & allow faster impulse conduction
üSchwann cell - #schwann cell myelinates #axon in the PNS
üOlegodendrocyte – myelinates several axons in the CNS

Neurotransmitters
Acetylcholine (Ach)
• Is both excitatory (depolarizes membranes) & inhibitory
(hyperpolarizes membranes); is used by all motor
neurons, the brain, & both sympathetic, & parasympatetic
systems.
• Reduced in alzheimer’s dementia & myastenia gravis.
Biogenic amines
• Tyrosine " Dopamine "Norepinephrine "Epinephrine
• Tryptophan "serotonin; "histidine "histamine
• Metabolized by Monoamine Oxidase (MAO) & Cathecol-
O- Methyl Transferase (COMT)

Dopamine §Excitatory, seen in midbrain for control of
complex movement, motivation, cognition
& emotion.
§$ In Parkinson’s d’s & depression
§#in schizophrenia, mania, Tourette’s
syndrome
Norepinephrine
(Noradrenaline)
§Excitatory, in postganglionic sympathetic neurons
(figt or flight) & in the brain (attention, memory)
Epinephrine
(adrenalin)
§In anxiety disorders
§$in depression, low impulse control
Serotonin §Inhibitory, in brainstem, linked to impulse control
§#in depression, low impulsecontrol
Histamines §Modulator, seen in hypothalamus, #in allergies

Amino acids hamino
butyric acid
(GABA)
•Primary inhibitory transmitter in CNS
•$in anxiety, #by benzodiazepines &
barbiturates
Glutamate •Primary excitatory transmitter in CNS
•#in Huntingtons chorea, alzheimers
Glycine •Inhibitory in spinal interneurons
Nitric Oxide §Inhibitory, gas form, affects central & enteric
nervou system
§Relaxes vascular smooth muscle causing
vasodilation.

Neuromodulators
Neuropeptides
• Enkephalins,endorphins, substance P, somatostatin,
VIP, CCK, Neurotensin, ACTH, angiotensin
Alter sensitivity of synaptic membranes to
neurotransmitters
• (my enhance, prolong,, or inhibit transmitter
effects.

Central Nervous System
Cerebral Cortex
— Divided into 2
hemispheres:
— Left: controls right side of
the body as well as logical
reasoning & analysis fxns;
(reading, writing, &math).
— Right: controls left side of
the body as well as;
creative thinking, intuition,
& artistic abilities.

Further divided into 4 lobes Function Impairment
Frontal lobes
Motor cortex Found in precentral gyrus
For voluntary motor activity
Mono or hemiplegia depending
on the extent
Premotor cortex Planning of movement
Contralateral head & eye turning
Bowel & bladder inhibition
Apraxis – loss of learned
movement
Paralysis of head & eye to
opposite side
Incontinence
Broca’s area Expression, motor for speech Expressive aphasia – can’t speak
right
Prefrontal area Personality & emotion, judgment
& inhibition, concentration &
elaboration of thought
Personality changes: antisocial
behavior, loss of
inhibitions/impulsive, poor
concentration.

PSCHOANALYTIC THEORY
SIGMUND FREUD
(1856-1939)
Father of …
Psychoanalysis
Modern Psychiatry

Psychoanalytic theory
— Supports the notion that all human behavior is caused and can
•• Supbep oexrptlsa itnheed notion that all human behavior is
caused and can be explained
•• He believed that repressed sexual impulses and
desires motivated much human behavior

Theory of Psychosexual Development by
Sigmund Freud
— Oral Phase- 1 yr. old
— Greatest need- security
— Greatest fear- if anger anxiety
— Narcissistic- pleasure seeking
is through eating & sucking;
primary narcism( self-love)
— Mouth- erogenous zone,
area of satisfaction
— Insecurity in parting with
breast or bottle may cause fixation
— Tension is relieve by sucking & swallowing
— Sucking need is independent of hunger satisfaction.

— Anal phase -Primary source of pleasure is
elimination/retention
— This is the critical period
for toilet training
— Anus- site of tension
& sexual gratification
— Greatest need: power
— first experience with
discipline & authority
— retention & expulsion (forcing out are experienced as pleasurable
especially because these functions come under the child-control.)
Child uses his new skill to please or annoy parenting adult.

Theories of Personality
— Freudian Concept
— Sigmund Freud – the father of psychoanalysis stressed that early
childhood experiences is important in the development of
personality.

Three Components of Personality

ID
— part of personality in which we are born
— it is primitive, it demands immediate satisfaction
— functions according to pleasure principle
— unconscious part of the person which serve as the reservoir of primitive
& biologic drives & urges
— reflects basic or innate desires such as pleasure seeking behavior,
aggression &
sexual impulses.
— Totally self-centered
— Developed during infancy
— Seeks instant gratification
— Impulsive, unthinking behavior
— No regard for rules or social
convention
James M. Alo, RN,MAN,MAP,PHD. “too much id”7/26/2011

Ego
— the self or the I
— known as the integrator of personality
— Part of the mind which acts with the outside world, partly conscious &
partly unconscious
— operates on reality- principle. If it develops it supercedes the pleasure
principles in guiding behavior
— this is developed during the toddler period
— conscious self. the “ I ” that deals with reality
— part of personality that’s evident to the environment
— Balancing or mediating force between the id and the superego.
— Represents mature and adaptive behavior that allows a person to
function successfully in the world.
— ANXIETY results from ego’s attempt to balance the impulsive instincts
of the id with the stringent rules of the supergo.

Superego
— the conscience
— the automotive or parental directions which incorporated in the
personality as the CENSORING FORCE.
— this is developed during the preschool age
— Strict Superego- leads to rigid, compulsive, unhappy person
— Weak/Defensive Superego – leads to antisocial behavior, hostility
— reflects moral & ethical concepts, values, parental and social
expectations
— controls, inhibits & regulates impulses & instincts whose
uncontrolled expression would endanger the emotional well-being
individual & the stability of the society.
— Direct opposition to the id.

MENTAL DISORDER

FREUD’S
Psychoanalytic/psychodynamic model

Personality functions @ 3 levels of
awareness:

= Neurotic benhavior is a result of childhood
trauma or failure to complete tasks or needs of
psychosexual development:

Narcissistic defenses

Anxiety/Neurotic defenses

Immature defenses

Mature defenses

Examples of psychiatruc disorders &
defenses used:

ERIKSON’S Psychosocial development
model
?Psychosocial growth occurs in a series of 8 developmental stages w/
each stage involvinf a task w/ (+) & (-) experiences.
?Completion of said task allows one to achieve life virtues.

PIAGET’s Cognitive Developmental Model
= Focus of child dev’t is on genetics, envi., moral, &
intellectual dev’t.

KOHLBERG’s Moral Developmental Model
= Expanded Piaget’s Moral Developmental Model

MASLOW’s Heirarchy of Needs Model
— Basic human needs are elements, shared by all people that are
necessary for human survival & health
— Certain needs are more basic than others .i.e. Some needs must
be met before others.

Self-actualization
Self-esteem
Love & Belonging
Safety & security: Physical &
psychological
Physiologic: O2, fluids, food, temp.,
elimination, shelter, sex

PAVLOV’s & SKINNER’s Behavioral Model
— Behavior is observable, predictable & controllable.
— It can be changed by a system of rewards & punishments.

PAVLOV’s Classical Conditioning

SKiNNER’s Operant Conditioning
Behavior is learned from repeatedly reinfirced experiences
(+) reinforcement /reward “ a
Continuous (+) reinforcement (reward each time behvior occurs) is
the fastest way to #a behaviors recurrence but be havior is short-lived
after after the rewards have ceased.
Random intermittent reinforcement (reward for desired behavior
once in a while) is the slower but more permenent of increasing
desired behavior.
behaviors recurrence
(-) reinforcement/ punishment $ a
behaviors recurrence

SYSTEMATIC DESENSITIZATION
Application of
conditioning as
clients are helped
to overcome their
Untill fear
responses is
EVENTUALLY
Gradual exposure
to feared stimulus
while clients are
relaxed
PHOBIAS
EXTINGUISHED

SELYE’s Stress Adaptation Model
Physiological response to stress correlated to anxiety level
GENERAL ADAPTATION SYNDROME (GAS)
Stage 1.Alarm Reaction (fight/flight response)
• Physical; #Epinephrine & Nor-epinephgrine= sympathetis response
• Psychosocial:Alert. #anxiety (1+, 2+), inefficient problem-solving
Stage 2. Ressistance (Optimal adaptation to nstress)
• Physical: adrenal cortex & it’s hormones readjust, weight normalizes
• Psychosocial: #Coping mechanisms, defense oriented behavior
Stage 3. EXHAUSTION (Inability to cope, depleted resources)
• Physical: $immune response, hormones, weight"organ failure
• Psychosocial: exaggerated behavior, disorganized thought & personality, delusions,
hallucinations, stupor/violence.

PSYCHIATRIC ASSESSMENT
— PSYCHIATRIC HISTORY

MENTAL STATUS EXAM
I. GENERAL DESCRIPTION

II. EMOTIONS

III. SPEECH – described terms of quantity, rate of
production & quality: ex. Talkative, non-spontaneous,
hesitant, slurred

IV. PERCEPTUAL SIDTURBANCES – process by which
physical stimuli are brought to mental awareness

V. THOUGHT
A. Process/ form of thought – way a person puts together
ideas & assoc., form in w/c a person thinks.

B. CONTENT OF THOUGHT – What person is actually
thinking about: beliefs, ideas, obsessions, preoccupations.

VI. CONSCIOUSNESS (state of awarenes), SENSORIUM
(awareness of special senses), & COGNITION (awareness of
thought).

PSYCHIATRIC DIAGNOSIS

— NANDA Accepted Nursing Diagnosis

INTERVENTION: Therapies
THERAPEUTIC NURSE-CLIENT REL. (Peplau)
— Therapeutic use of self focus on both client-nurse needs
— Has 4 PHASES:

TECHNIQUES OF THERAPEUTIC COMMUNICATION

PYSCHOPHARMACOLOGY

NURSING INTERVENTION

— STIMULANT DRUGS

CLASSIFICATION OF MENTAL
DISORDERS
A. Disorders usually evident in infancy, childhood & adolescence
1. MR
2. PDD
3. Disruptive behavior disorders
4. Anxiety disorders of childhood & adolescence
5. Eating disorders
6. Gender identity disorders
7. Tic disorders
8. Elimination d’rs
9. Speech dr’s

B. Organic mental syndromes disorders
1. Organic mental syndromes
a. Delirium
b. Dementia
2. OMD (dementias arising in the sensium & presensium)
a. Primary degenerative dementia (senile onset)
b. Primary degnerative demntia (presenile onset)
3. Psychoactive substance use dr’s

C. Psychoactice substance use dr'

ANXIETY DISORDERS

LEVELS OF ANXIETY

NURSING INTERVENTIONSTO $ANXIETY

SOMATOFORM DISORDERS

DISSOCIATIVE DISORDERS

FACTITIOUS DISORDERS

ACHIZOPHRENIAS & OTHER PSYCHOTIC
DISORDERS

OTHER PSYCHOTIC DISORDERS

NURSING INTERVENTIONS FOR
PSYCHOTIC DISORDERS

Mood Disorders

Depressive Disorder
A. Major Depressive D’r

Intervention for Depressed Px

Bipolar Disorders

INTERVENTION FOR MANIC PX

COGNITIVE DISORDERS

Types of Dementia

NURSING INTERVENTION FOR COGNITIVE D’R

PERSONALITY DISORDERS

DEVELOPMENTAL DISORDER

Classification

Elimination Disorders

Tic Disorders

SUBSTANCE RELATED DISORDERS

Alcohol Abuse

— Psychoactive Drug Abuse

— COMMONLY ABUSE DRUGS

EATING DISORDERS

SEXUAL DISORDERS

DEATH & GRIEVING

ONCOLOGY NURSING
— NEOPLASTIC DISEASES
— A. Characteristics
1. Etiology
a) Healthy cells transformed into malignant cells upon exposure to
certain etiological agents: viruses, chemical & physical agents.
b) Failure of immune response

2. Pathophysiology
a) Rapid cell division
b) Malignant cells metastasize
1. Extending directly into adjacent tissue
2. Permeating along lympathic vessels
3. Traveling through lymph system to nodes
4. Entering blood circulation
5. Diffusing into body cavity

— 3. Classification of tumors
a. Accdg to type of tissue from which they evolve
1) Carcinomas begin in epithelial tissue (ex: skin, GI tract lining, lung,
breast, uterus)
2) Sarcomas begin in non-epithelial tissue(ex: bone, muscle, fat, lymph
system)
b. Type of cell in which they arise; cell types affect appearance,
rate of growth & degree of malignancy.

— 4. Staging
a. Describes extent of tumor
ü T= primary tumor
ü N= regional nodes
ü M= metastasis
b. Describes extent of malignancy to which malignancy has # in size
ü To= no evidence of primary tumor
ü Ts= carcinoma in situ
ü T1,T2,T3,T4= progressive #in tumor, size & involvement
ü Tx= tumor cannot be assessed
c. Involvement of regional nodes
ü No= regional lymph nodes not abnormal
ü N1-4= #degree of abnormal size
d. Metastatic dev.
ü Mo= no evident of distant metastasis
ü M1-M3= #degree of metastasis

— B. Manifestations > Malignant d’s (ACS 7 warning signs)
1. Change in bowel/bladder movement
2. Sore that does not heal
3. Unusual bleeding /discharge
4. Thickening/lumps in breast/ elsewhere
5. Indigestion/difficulty of swallowing
6. Obvious change in wart/mole
7. Nagging cough/hoarseness

— C. Cancer therapy
1. Objective: to cure
1. Prevent further metastasis
2. Relieve manifestations
3. Maintain high quality life
2. Surgery
1. Radical
2. Prophylactic
3. palliative
3. Chemotherapy
1. Drugs interfere w/ cell division

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