PSYCHIATRIC NURSING

PSYCHIATRIC
NURSING
Mental Health Hygiene
BY: ROMMEL LUIS C. ISRAEL III
BY: ROMMEL LUIS C. ISRAEL III 1

I. INTRODUCTION
CONCEPTS OF MENTAL
HEALTH AND MENTAL
ILLNESS

Health (DOH) -
Mental health refers to the ability of people (couples, families
and communities) to respond adaptively to internal and external
stressors.
- A balance in persons internal life and adaptation
to reality.
- a state of well being in which a person is able to
cope with the normal stresses of daily life and his
ability to realize his potentials.

MENTAL HEALTH IS RELATIVE
AND DYNAMIC
Relative – not the same to all people
Dynamic – changes at different point in
time

Mental Hygiene – the science that deals with the
measures to promote mental health, prevent
mental illness and suffering and facilitate
rehabilitation.
Mental Illness – A state of imbalance characterized
by a disturbance in person’s thoughts, feelings
and
behavior.
- Poverty and abuses are major factors which
increase the risk of mental illness in the
home.

DEFINING CHARACTERISTICS OF GOOD
MENTAL HEALTH
• Positive state in which one is
responsible, display’s one’s self-
awareness, self directed, reasonably
worry free and can cope with daily
tensions
• Simultaneous success at working,
loving, and creating with the capacity
for mature and flexible resolution of
conflicts between instinct conscience,
important other people and reality.

• It is the state in the relationship of the
individual and environment in which the
personality structure is relatively stable
and the environmental stresses are within
its absorptive capacity (good mental
health).
• Ability to solve problems.
• Fulfill one’s capacity for love and work.
(could satisfy one’s relationship)

• Mental illness- is a mental disorder
or condition manifested by
disorganization and
impairment of function that
arises from various causes
such as psychological,
neurobiological and genetic.

Psychiatric Mental Health Nursing - is organized
around eight human response processes:
1. activity,
2. cognition,
3. ecological ,
4. emotional,
5. interpersonal,
6. perception,
7. physiologic,
8. and evaluation.

Psychiatric Nursing - is an
interpersonal process that
promotes and maintains
behavior that contributes to
integrated functioning. It is a
specialized area of nursing
practice employing theories
of human behavior as its
science and purposeful use
of self as it part.

GOALS OF MENTAL HEALTH
Moving towards assisting client to:
(CAMP F)
- Cope with mental illness
- Attain mental health
- Maintain mental health.
- Prevent mental Illness
- Find meaning in mental
illness experienced and
suffering.

CONCEPTUAL APPROACHES
TO MENTAL HEALTH
• Attitude towards the individual self.
• Growth and Development and Self –
Actualization.
• Integrative Capacity
• Autonomous Behavior
• Perception of Reality
• Mastery of One’s Environment

Attitude towards the individual self.
This involves aspects related to persons:
• self awareness
• self – acceptance
• confidence
• level of self – esteem
• sense of personal identification in relation to roles
SELF- CONCEPT– the term given to the type of self that lies
between conscious awareness.
- a collection of attitude and ideas about the self.
- a product of life experienced
- it encompasses all that the person perceives
knows and holds to be true about his or her
identity.
- what you believe you can do
- perceive (how you perceive yourself)

4 ASPECTS OF SELF – CONCEPTS
1. Body image – physical dimension of self – concept.
2. Personal Identity – refers to psychological aspect of self –
concept.
3. Self – esteem - emotional component.
4. Role performance – expression of self – concept.
• Self awareness – noticing how self – feels, things behave,
and senses at any given time.
• Self acceptance – a regard to oneself with realistic
concept of strength and weakness.
• related to introspection – involves evaluation or
determining why self – reacts at it
does

2. Growth and Development and Self –
Actualization.
Growth – increase in size of a structure
- more on physical
Development - maturation of structures.
- more on psychological.
Self – Actualization – when all
individual goals have been
achieved. Top most level of
Abraham Maslows hierarchy of
needs

Growth and development
– refers to what a person does to his
abilities and potentialities.
- refers to person’s involvement with
outside interest and relationship and
concerns with an occupation or ideas as
well as its goals.

3. Integrative Capacity
• Refers to the balance of psychic forces (ex. Id, ego, superego)
• Ability to tolerate anxiety and frustration in stressful situation.
• Mild anxiety – good thing cause it will cause you to push
things.
• Moderate or severe anxiety – will cause you panic and
emotional paralysis

3 PSYCHIC ENERGY
ID Sexual and aggressive drive
Born with it
Operates on pleasure principle (reduce tension by immediate
gratification)
PRIMARY PROCESS THINKING (imagery)
IRRATIONAL and NOT BASED ON REALITY
EGO CHIEF EXECUTIVE OFFICER
Operates on REALITY PRINCIPLE
SECONDARY PROCESS OF THINKING (logical and oriented on
time)
Major personality mechanisms that meditates between the person and
the environment
Major functions: adaptation to reality; modulation of anxiety; problem
solving; control and regulate instinctual drives; mediate in drives and
demands of reality; evaluate and judge the external world; REALITY
TESTING; store of experiences in “memory”; direct motor activities
and actions USE DE FENSE MECHANISMS to protect self
SUPEREGO CONSCIENCE, punishes one for something wrong that was done.
EGO-IDEAL, rewards one for something good that was done.
Residue of internalized values and moral training of early childhood.

4. Autonomous Behavior
- Ability to make one’s own decision and react
accordingly to his own convictions
regardless of outside environment
pressures
and accept responsibilities for his actions.
5. Perception of Reality
- The person’s perceptions of his environment
and other people as well as his reactions
towards them.
- React depending on the culture

6. Mastery of One’s Environment
- Ability to adapt, adjust and behave
appropriately in situations according
to approved standard so that satisfactions
are achieved.
- Refers to the problem-solving ability
of a person.

FACTORS INFLUENCING
MENTAL HEALTH
• Inherited Characteristics
• Nurturing During Childhood
• Life Circumstances

1. Inherited Characteristics
• Theorists believe that no one is completely
normal and that the ability to maintain a
mentally healthy outlook on life is, in part,
due to one’s genes.
Ex. Cognitive disability
Schizophrenia or bipolar disorder

2. Nurturing During Childhood
- Refers to familial – child interactions
Ex. Obsessive compulsive – comply on the impose of their parents.
• Positive Nurturing – starts with bonding at child
birth and includes feelings of love,
security, and acceptance. The child
experiences positive interactions with
parents and siblings.
• Negative Nurturing – circumstances such as
maternal deprivation, parental rejection,
sibling rivalry and early communication failures.
Poor nurturing – develop poor self – esteem,
poor communication skills.

3. Life Circumstances
- Can influence one’s mental
health from birth.
• Positive circumstances - are generally emotionally
secure and successful in school and establish
healthy interpersonal relationship.
• Negative circumstances – poverty, poor physical health,
unemployment, abuse, neglect and unresolved
childhood loss generally precipitate feelings of
hopelessness, helplessness, and worthlessness.
These negative responses place a person at risk for:
- depression,
- substance abuse
- Other mental health disorders.

CHARACTERISTICS OF EMOTIONAL
MATURITY
• Ability to deal constructively with reality
• Capacity to adapt to change
• Relatively free from symptoms produce by tensions and
anxiety.
• Capacity to find more satisfaction in giving and receiving
(more of reciprocation)
• Ability to relate to other people in a consistent manner with
mutual satisfaction
• Capacity to redirect one’s instinctive hostile energy into
creative constructive outlets.
• Capacity to love.

FACTORS THAT INFLUENCE THE ABILITY TO
ACHIEVE AND MAINTAIN EMOTIONAL
MATURITY
1. Interpersonal Communication
2. Ego Defense Mechanisms
3. Significant Others or Support People
4. Personal Strategies.

1. Interpersonal Communication
- communication between two
or more person
- only as good as the interaction that
occurs
Intrapersonal Communication – within self

5 LEVELS OF COMMUNICATION
(POWELL)
Level 5 – Cliché’ Conversation
Level 4 – Reporting facts
Level 3 – Revealing Ideas and Judgments
Level 2 – Spontaneous, Here and Now Emotions
Level 1 – Open, Honest Communication

• Level 5 – Cliché’ Conversation
• no sharing of oneself occurs during this interaction.
• No real answers are expected
• No personal growth can occur at this level
• Ex.: “How are you doing?”
“How’s your new job?”
“Talk to you later”
• Level 4 – Reporting facts
• reveals very little about oneself
• minimal or no interactions is expected from others
• No personal interaction occurs at this level

Level 3 – Revealing Ideas and
Judgments
- Communication occurs under strictcensorship
by the speaker, who is watching the listener’s
response for an indication of acceptance or approval.
Level 2 – Spontaneous, Here and Now
Emotions
-Revealing one’s emotions take courage because
one faces the possibility of rejection by the listener.
Powell (1969) – states that if one reveals the contents
of the mind and heart, one may fear that such
emotional honesty will not be tolerated by
another.
• RESULT: the speaker may resort to dishonesty and
superficial conversation to maintain contact with
another person.

Level 1 – Open, Honest
Communication
- occurs if two people share emotions
- they are in tuned with each other capable of experiencing
or duplicating each other’s reaction
• interaction is termed: complete emotional and
personal communication – it helps one
maintain emotional maturity.
• Open communication – may not occur until people
relate each other over a period of time,
getting to know and trust each other.

2. Ego Defense Mechanisms
• Referred to as defense mechanism, described
as mental processes
• Identified as usually unconscious, protective
barriers that are use to manage instinct and
affect in the presence of stressful situations.
• It can be therapeutic or pathologic, because all
defense mechanisms include a distortion of
reality, some degree of self-deception, and
what appears to be irrational behavior.

USES OF DEFENSE MECHANISMS
• Self security protection
• Anxiety and fear Reduction
Anxiety – unexplained feeling of
apprehension, tension or
uneasiness
Fear – is an emotional response to recognizable object
or threat, it decreases when the danger or
threat subsides.
• Mental conflict resolution.
• Esteem (self) protection.

Four Levels of Defense Mechanisms
Level 1: Psychotic Mechanisms (common in health individual before Age 5)
● Delusional Projection
● Denial
● Distortion
Level 2: IMMATURE MECHANISMS (common in ages 3 – 15)
● Projection
● Schizoid fantasy
● Hypochondriasis
● Passive-aggressive behavior
● Acting Out
Level 3: NEUROTIC DEFENSE (common in aged 3 – 90)
● Intellectualization
● Repression
● Displacement
● Reaction
Formation
● Dissociation
Level 4:MATURE MECHANISMS
● Altruism
● Humor
● Sublimation

SPECIFIC DEFENSES
1.) Regression – the backward turning to earlier patterns of behavior to solve
personal conflict.
• Example: A hospitalized patient making unnecessary request and demands for
care and attention.
2.) Suppression – conscious and deliberate withholding of words or deeds that
reflect an unfavorable light on the self.
• Example: A rape victim consciously forgetting about experience.
3.) Repression – An involuntary, automatic banishment of unacceptable ideas
or
impulses into the unconscious.
- The earliest type of defense available.
- Considered the principal defense in early years.
• Example: Mrs. de la Cruz, a victim of incest, does not know why she has always
hated her uncle.

4.) Compensation – A conscious or unconscious attempt to balance a real or
imagined deficiency in one area by developing
other
personal qualities to hide weakness.
• Example: An academically weak high school student become a star in the
school play.
5.) Conversion – Transforming an emotional problem into a physical symptom or
outlet. An unconscious device.
• Example: Mr. del Mar suddenly develops impotence after his wife discovers he is
having an affair with his secretary.
Malingering – Conscious, deliberate attempt to escape from an unpleasant
task.
6.) Denial – The UNCONSCIOUS disapproval of thoughts, feelings, wishes,
needs
which are consciously unacceptable.
- Closely related to rationalization.
- Not the same as lying which is conscious.
- It protects the persons from finding out that he may be wrong.
• Example: Mr. Carpio who is alcohol dependant states that he can control his
drinking (when in fact he cannot).

7.) Rationalization – Attributing acceptable motive to thoughts,
feelings or behavior which really have
unrecognized motives.
- Stating other motives instead of the genuine one.
- Used to avoid the full honesty of the situation.
• Example: A student states, “I got a 70 on the test because the teacher asked poor
questions”.
• MR. Bruno, a paranoid schizophrenia, states that he cannot go to work because he
is afraid of his co-worker instead of admitting that he is mentally ill.
8.) Intellectualization – The overuse of intellectual concepts of words to avoid
effective experience or expression of feelings.
• Example: Mr. Salvo talks about his son’s death bout with cancer as being
mercifully
short without showing signs of sadness.
9.) Fixation – The arrest of maturation at an earlier level of psycho sexual
development.
- Behavior appropriate at an earlier age is maintained at a time such
behavior should have been outgrown.
• Example: A child’s attachment to a nursing bottle beyond the oral period.
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10.) Identification – The unconsciousness, wishful adoption (internalization) of
the
personality characteristics or identity of another individual generally one
possessing attributes which the subject envies or admires.
IMITATION – their behavior in contrast to identification is conscious.
• Example: Julia state to the nurse, “when I get out of the hospital, I want to be a nurse just like
you.
11.) Introjections – The symbolic assimilation or talking into one’s self a loved or hated
persons or external object. This is a form of identification.
• Example: Without realizing it, a patient talks and acts like his therapist.
12.) Projection – Unconsciously making another persons or circumstances responsible for
one’s unacceptable thought or actions
- It involves repression of undesirable qualities.
• Example: A parent’s fulfilled desire may be projected on the child by demanding that the child
prepare for a career which the parent would like to do, regardless of the child’s I
nterest and wishes.

13.) Reaction Formation – over compensation or reversal formation.
• Example: Mothers unconsciously do not love their children often over compensates
be becoming overly protective of them.
14.) Sublimation – The substitution of unacceptable instinctual drives into
socially acceptable expressions.
• Example: Excelling in sports to sublimate hostile impulse.
15.) Substitution – Replacement of unattainable therapy or unacceptable
activity into one which is attainable and acceptable therapy
assuring possibility of success. COMPARABLE TO
DISPLACEMENT.
16.) Dissociation – The unconscious separation of painful feelings and
emotions from an acceptable idea, situation or object.
• Example: Sleepwalking (somnambulism), amnesia, fugue.
• A patient recalls that when she was sexually molested as a child, she felt as she
was outside of her body watching what was happening without feeling anything

17.) Undoing – An attempt to replace to a tone to make amends for some undesirable act by
process that attempt to make it appear that the original act was never
committed.
• Example: After spanking his son, a mother bakes his favorite cookies.
18.) Symbolization – An idea of object is used to represent some other idea or object.
• Example: Fetal position.
• A rejected boyfriend rushes into marriage in the rebound.
19.) Displacement – A transfer into another situation of an emotion in a previous situation
where in expression would not have been socially acceptable.
• Example: A husband comes home and yells at his wife after a bad day at work.

20.) Fantasy – Use of imagination or daydreaming
21.) Isolation – the separation of an unacceptable impulse act idea form its memory
origin, there by removing the emotional charge.
• Most commonly seen in obsessive – compulsive neurosis.
• Example: PHOBIA / TABOOS
Phobia – an exaggerated and invariably pathological dread of
some specific type of stimulus or situation.
• Acrophobia – dread of high places
• Agoraphobia – dread of open places
• Algophobia – dread of pain
• Astra(po)phobia – dread of thunder and lightning
• Claustrophobia – dread of closed or confined place
• Coprophobia – dread excreta
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• Hematophobia – dread of sight of blood
• Hydrophobia – dread of water
• Lalophobia or glossophobia – dread of speaking
• Mysophobia – dread of dirt or contamination
• Necrophobia – dread of dead bodies
• Nyctophobia – dread of darkness, night
• Pathophobia or Nosophobia – dread of disease, suffering
• Peccatophobia – dread of sinning
• Phonophobia – dread of speaking aloud
• Photophobia – dread of strong light
• Sitophobia – dread of eating
• Taphophobia – dread of being buried alive
• Thanatophobia – dread of death
• Toxophobia – dread of being poisoned
• Xenophobia – dread of strangers
• Zoophobia – dread of animals

3. Significant Others or Support People
• With anyone who the person fells comfortable trusts and
respects.
• Act as the sounding board, shock absorber of problem of a
person
• Simply listener while one vents various feelings or emotions.
• He or she may interact as the need arises.

4. Personal Strategies.
• Refers with dealing directly with one’s emotions
• How to manage your own problems and stresses
• Alternate ways to reduce stress and enhance their
well being while balancing responsibilities between
work and time spent at home.

ROLES OF THE PSYCHIATRIC
NURSE
• Creator of the Therapeutic Environment
• Technical Nursing Role
• Therapist
• Socializing Agent
• Teacher
• Parent Surrogate

Creator of the Therapeutic Environment
• It is an environment allows the client to:
• Relax
• Feels secure physically and emotionally
• Is not afraid to share thoughts and feelings
• Can be achieved when the people around the client are:
• Honest
• Sincere
• Friendly yet firm
• Nonjudgmental
• There is no cure to mental illness but we can provide
support system, continuous medication, and therapeutic
environment to restore to its optimum capacity.

• Technical Nursing Role
- Refers to our performance to nursing skills and procedure
• Example:
• Checking of vital signs
• Perform treatment procedures
• Administer medications
• Makes physical assessment
• Communication skill- Most important
skill that we need

• Therapist
• Achieved by your performance of your treatment
modalities to the clients.
• The nurse uses the principle of psychotheraphy to help
the client of his behavior, feelings and thoughts.
• Assist the client in finding solutions to his problems.
• The nurse must know to assess thoroughly the level of
readiness of the patient to coordinate in the activity.
Do not ask questions starting with WHY.

• Socializing Agent
• When you allow the patient to participate in group activities.
• Counselor
• Achieved when nurse shows active listening, and giving the client
options, and possible solution to their problems.
• When the nurse assists the patient in identifying stressors that can
cause anxiety and helps client find acceptable outlets of anxiety.

• Teacher
• When nurse gives instruction or educates the client about certain
medications or therapeutic intervention.
• When the nurse teaches the client to learn new skills such as game, song,
dance, step or when the nurse becomes a role model of acceptable behavior.
• Transference –- attribution of feelings to other
person.
• Client to therapist
• Counter transference
• Therapist to patient

• Parent Surrogate
• Acts as parent substitute of the patient
• When the nurse performs functions for the client
originally provided by the mother such as bathing,
dressing, or backrubs.

HISTORICAL PERSPECTIVE OF MENTAL ILLNESS
A.)ANCIENT TIMES
• → sickness indicated displeasure of the gods and in fact was a
punishment for sins and wrong doings.
• → persons with mental disorder were viewed as being either
demonic or divine depending on their behavior.
• Divine – worshipped and adored
• Demonic – ostracized, punished and sometimes
burned.
• → Aristotle attempted to relate mental disorders to physical
disorders and developed his theory that emotions were controlled by
the amount of blood, water and yellow and black bile of the body.
These four (4) substances or humors correspond to emotions of
happiness, calmness, anger, sadness. Imbalance of the four humors
causes mental illness. Treatment is aimed at restoring imbalance
through blood letting, starving or purging.
52

• EARLY CHRISTIAN ERA (1-1000 AD)
• primitive beliefs and superstitious were strong
• diseases are blamed and demon’s and mentally ill are possessed.
• priest preformed exorcisms to rid the persons of evil spirits.
• if failed, incarceration in dungeons, flogging, starving and other brutal
treatment were used.

• RENAISSANCE (1300-1600)
• persons with mental illness were distinguished from
criminals in England
• harmless were allowed wonders the countryside or live in
rural communities.
• “dangerous lunatics” where still thrown in prison, chained
and starved.
• 1547 → Hospital of St. Mary of Bethlehem was official declared as
the first hospital for the insane.
• 1775 → visitors at the institution were charged for a fee for the
privilege of viewing and ridiculing the inmates, who were seen as
animals, less than humans
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B.)PERIOD OF ENLIGHTENMENT AND CREATION OF MENTAL
INSTITUTION
• 1790 → period of enlightenment concerning persons
with mental illness.
• establishment of asylum is credited to Phillippe Pinel in
France and William Tukes in England.
• ASYLUM → a safe refuge or haven offering protection
→ this movement began the moral treatment of
the mentally ill.

• 1802 – 1887 → Dorothea Dix began a crusade to reform the
treatment
of mentally ill in the U.S
• Dix is instrumental in opening 32 state hospitals that offered asylum to the
suffering. She believed that society has obligation to persons who are mentally ill
and promoted adequate shelter, nutritious food and warm clothing.
• The period of enlightenment was short lived.
• within 100 yrs. after the1st Asylum was established state
hospitals were in trouble.
• attendants were accused of abusing clients
• rural location of hospitals were viewed as isolating patients
from family and their homes.
• “insane asylum” took on a negative connotation, rather than
a protective haven.

C.)SIGMUND FREUD and TREATMENT OF MENTAL DISORDERS
• period of scientific study and treatment of mental disorders began
with Sigmund Freud (1856 – 1939)
• Emil Kraepolin (1856 – 1926) began classifying mental disorders
according to their symptoms.
• Eugene Bleuler (1857 – 1939) coined the term “schizophrenia.”
• Freud – challenged the society to look at human beings
objectively and studied the mind and its disorder and their
treatment.

• D.)DEVELOPMENT OF PSYCHOPHARMACOLOGY
• 1950 → development of psychotropic drugs (drugs used to
treatment illness)
• chlorpromazine (Thorazine) – antipsychotic
drug.
• Lithium – antimanic drug
• After 10 yrs:
• Monoamine oxides inhibitor – antidepressants
• Haloperidol (Haldol) – antipsychotic
• Tricyclic Antidepressants
“Drugs reduced agitation, psychotic thinking and
depression improved the condition of the patient.”

E.)HISTORY OF PSYCHIATRIC
NURSING IN THE PHILIPPINES
• The National Center for Mental Health (NCMH) was established
thru Public Works Act 3258.
• It was first known as INSULAR PSYCHOPATIC HOSPITAL,
situated on a hilly piece of land in Barrio Mauway, Mandaluyong,
Rizal and was formally opened on December 17, 1928.
• This hospital was later known as the NATIONAL MENTAL
HOSPITAL
• On November 12, 1986, it was given its present name NATIONAL
CENTER FOR MENTAL HEALTH thru Memorandum Circular
No.48 of the office of the President.

• On January 30, 1987, NCMH was categorized as a Special Research
Training Center and hospital under Department of Health.
• Today, NCMH has an authorized bed capacity of 4,200 and a daily
average of 3,400 in-patients. It sprawls on a 46.7 hectare compound
with a total of 35 Pavilions/ Cottages and 52 Wards.
• The Center has an authorized personnel component of 1,993,
consisting of 116 Doctors, 375 Nurses, 655 Nursing Attendants, 651
Administrative Staff and 196 Medical Ancillary Personnel.
• The NCMH is a special training and research hospital mandated to
render a comprehensive ( preventive, promotive, curative, and
rehabilitative ) range of quality mental health services nationwide.
• It also gives and creates venues for quality mental health education,
training and research geared towards hospital and community mental
health services nationwide.

MENTAL ILLNESS
• Is a complex problem and is unique response
involving an individuals personality as it
interacts with his environment at a time when
he is particularly vulnerable to stress
• The study of the individual’s life experiences
with consideration of genetic physiological
interpersonal and cultural factors is a
reasonable approach.

CAUSES OF MENTAL DISORDERS
1. PREDISPOSING FACTORS
• Conditions in which make the individual susceptible to
precipitating causes and thus more likely to develop
psychosis.
2 PRECIPITATING FACTORS
• exciting cause of psychiatry disorder
• they are highly emotional and critical situations

PREDISPOSING FACTORS
• Inheritance
• Age- adolescence, menopause,
senile periods
• Sex
• Environmental and social
factors:
• financial depression
• war
• family relationships
• environmental factors
• family organization – broken
homes
• Family Health Environment
• Family
Attitudes/practices/values
• Social class differences
• differences between the poor
and the rich/ develop
Inferiority Complex
• Family control patterns
• authoritarian
• lax
• ambivalent
• overly permessive
• Family Placement and roles
• oldest - youngest
• prettiest - ugliest
• Segregations sororities
• Social change (forced
retirement)
• Cultural conflicts.

PRECIPITATING FACTOR
Physical Precipitating causes:
• Infection
• Fever
• Exhaustion
• Intoxicants - narcotics,
alcohol, bromides,
barbiturates
Benzedrine
• Organic conditions
• Trauma
Psychic Precipitating Causes
• dynamic motivating and
damaging causes of mental
illness not easily identified or
understood (emotions)
• strong emotions
• conflicts between conscious
and unconscious drives
• disappointment
• rejection
• deprivation
• marital difficulties
• failure in one’s ambition
• inferiorities
• economic reverses

NURSING PROCESS
• A systematic process or a six – step problem solving approach to
nursing that also serves as an organizational framework for
the practice of nursing.
• It sets the practice of nursing in motion and serves as a monitor
of quality nursing care.

1. ASSESSMENT – the collection of data about a person,
family, or group by the methods of observing, examining,
and interviewing.
TWO TYPES OF DATA
• Subjective data
• obtained from the client, family members, or significant others
• provide information spontaneously during direct questioning or
during health history
• involves interpretations of information by the nurse
• Objective data
• information obtained verbally from the client, as well as the
results of:
• Inspection
• Palpation
• Percussion
• Auscultation

3 KINDS OF ASSESSMENT
1. Comprehensive assessment
• includes all the dimensions of a person
• completed in collaboration with other health care professionals
• includes data related to the clients biological, cultural, spiritual, and social needs
Physical examination
• performed to rule out any physiologic causes of disorders such as anxiety, depression, or
dementia
2. Focused assessment
• the collection of specific data regarding a particular problem as determined by the
client, a family member, or a crisis situation
Example: suicide attempt
3. Screening assessment
• includes the use of a specific screening instrument to evaluate data regarding a
particular problem.

ASSESSMENT DATA COLLECTION
• discussion of the data collected by the nurse during a
comprehensive assessment conducted in the psychiatric
setting.

DATA TO BE ASSESSED
• Appearance
• Affect, or Emotional State
• Behavior, Attitude, and Coping Patterns
• Communication and Social Skills
• Content of Thought
• Orientation
• Memory
• Intellectual Ability
• Insight Regarding Illness or Condition
• Spirituality
• Sexuality
• Neurovegetative Changes

1. Appearance
• physical characteristics, apparent age, peculiarity of dress,
cleanliness, and use of cosmetics
Facial Expression – is a manner of non verbal communication in which
emotions, feelings and moods are related.
2. Affect or Emotional State –
Affect and emotion are commonly used interchangeably
• Affect – the outward manifestation of a person’s feelings, tone, or
mood.
• As a nurse you should assess congruently the
language and the facial expression
• Relationship between the thought and process is of particularly
significance
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3. Behavior, Attitude, and Coping Patterns
Factors for assessment:
• Exhibit strange, threatening, suicidal, self – injuries, or violent
behavior.
• Evidence of any unusual mannerism or motor activity such as
grimacing, tremors, tics, impaired gait, psychomotor retardation
or agitation.
• Appear friendly, embarrasses, evasive, fearful. Resentful, angry,
negativistic, or impulsive.
• Behavior overactive or underactive.
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4. Communication and Social Skills
• the manner in which the client talks enables us to appreciate
difficulties with his thought processes
• It is desirable to obtain a verbatim sample of the stream of
speech to illustrate psychopathologic disturbances.
con’t

• Factors to be considered:
• They speak coherently
• The rate of speech slow, retarded, or rapid
• Clients whisper or speak softly, or do they speak loudly or
shout.
• There is delay in answers or responses, or so clients break
off their conversation in the middle of a sentence and refuse
to talk further.
• They repeat certain words and phrases over and over
con’t

• Make up new words that have no meaning to others.
• Their language obscene
• Their conversation jump from one topic to another
• They stutter, lisp, or regress in their speech
• They inhibit any unusually personality traits or
characteristics that may interfere with their ability to
socialize with others or adapt to hospitalization
• What cultural group or groups do they identify.

• Impaired Communication -
Following terminology is commonly used:
• Blocking – sudden stoppage in the spontaneous flow or
stream of thinking or speaking for no
apparent external or environmental reason.
• Circumstantiality – the person gives much unnecessary
detail that delays meeting a goal or stating a point.
• commonly found in clients with manic disorder and clients with some
cognitive impairment disorders
• Individuals who use substances may also exhibit this pattern of speech.
• Flight of Ideas – over productivity of talk and verbal
skipping from one idea to another. The ideas
are fragmentary, although talk is continuous.

Perseveration – is the persistent, repetitive expression of a single
idea in response to various questions.
Verbigeration – describes the meaningless repetition of
incoherent words or sentences.
Neologism – a new word or combination of several words coined or
self – invented by a person and not readily understood by
others
Mutism – refers to the refusal to speak even though the person may
give indications of being aware of the environment.
- occur from conscious or unconscious reasons.

5. Content of Thought
• alterations in thought processes frequently sees in the psychiatric
clinical setting.
• Can be related to a functional emotional disorder or to an organic
condition.
A. Delusions
B. Hallucinations
C. Depersonalization
D. Obsessions
E. Compulsions

A. Delusions – fixed false beliefs not true to fact and
not ordinarily accepted by other members of the
person’s culture.
- they cannot be corrected by an appeal to the
reason of the person experiencing them

TYPES OF DELUSION
1. Delusions of reference or persecution - The client believes that he or
she is the object of environmental ttention or is being singled out
for
harassment.
2. Delusion of alien control - The client believes his or her feelings,
thoughts, impulses, or actions are controlled by an external source.
3. Nihilistic delusion - The client denies reality or existence of self, part of
self, or some external object.
4. Delusion of self- deprecation - The client feels unworthy, ugly, or sinful

5. Delusion of grandeur - A client experiences exaggerated ideas of her or
his importance or identity.
6. Somatic delusions - The client entertains false beliefs pertaining to body
image or body function.
7. Delusion of self – accusation - False feeling of remorse or guilt.
8. Delusion of Infidelity- pathologic feeling of jealousy that his partner is
unfaithful
9. Paranoid Delusion - false feeling of over suspiciousness

10. Thought control delusions
a. thought insertion - somebody inserted thought in
his mind
b. thought withdrawal - somebody look to withdraw
his thought
c. thought broadcasting - reacts, interact quickly
and believes that everybody
can read his mind.

B. HALLUCINATIONS
- sensory perceptions that occur in the
absence of an actual external stimulus.
TYPES OF HALLUCINATIONS
1. Auditory hallucination- hears
2. Visual hallucination - seeing objects
3.Olfactory hallucination - smells
4.Gustatory hallucination - taste
5. Tactile hallucination - feels movement

C. DEPERSONALIZATION
• feeling of unreality or strangeness concerning self, the
environment or both.
- these people may feel they are “going crazy”
- causes include:
a. prolonged stress
b. psychological fatigue
c. substance abuse

D. OBSESSIONS
- insistent thoughts, recognized as arising from
the self, usually regarded by the client as
absurd and relatively meaningless, yet
persistent despite his or her endeavors to be
rid of them

E. COMPULSION
- insistent, repetitive, intrusive, and unwanted
urges to perform an act contrary to one’s
ordinary wishes or standards.

6. ORIENTATION
- ability to grasp the significance of
their environment, an existing
situation, or the clearness of
conscious
processes.

LEVELS OF CONSCIOUSNESS
1. Confusion- disorientation to person, place, or time, characterized by
bewilderment and complexity
2. Clouding of consciousness- Disturbance in perception of thought
that is slight to moderate in degree, usually
owing to |
physical or chemical factors producing functional
impairment of the cerebrum.
3. Stupor- a state in which the client does not react to or is unaware of the
surroundings.- the client may be motionless and mute, but
conscious.
4. Delirium- Confusion accompanied by altered or fluctuating
consciousness.- disturbance in emotion, thought, and
perception is moderate to severe.Ex. Infections, toxic
states,
head trauma
5. Coma- Loss of consciousness

7. MEMORY
- the ability to recall past experiences.
• Recent Memory – ability to recall events in the immediate past and up
to 2 weeks previously.
- loss of memory may be seen in clients with dementia,
delirium, or depression.
• Long-term Memory – is the ability to recall remote past experiences
such as place of birth, names, of school attended,
occupational history, etc.
- loss of memory is due to a physiologic disorder
resulting in brain dysfunction.

Memory defects may result from:
• lack of attention
• difficulty with recall
• or any combination of these factors
3 Disorders of Memory:
1. Hypermnesia – abnormally pronounced memory
2. Amnesia - loss of memory
3. Paramnesia – falsification of memory

8. Intellectual Ability
• ability to use facts comprehensively
9. Insight Regarding Illness or Condition
• Insight – self understanding, or the extent of one’s understanding about
the origin, nature, and mechanisms of one’s attitudes and behavior
• Insightful clients are able to identify strengths and weaknesses that may
affect their response to treatment.
10. Spirituality
• by learning to take a spiritual history and understand a client’s beliefs,
values, and religious culture
• nurses become better equipped to evaluate whether these beliefs and
values are helping or hindering the

11. Sexuality
• express any concerns regarding sexual identity, activity, and function.
• Age and sex of the clinician may affect the response given.
12. Neurovegetative Changes
• the client changes in psychophysiologic functions such as:
• sleep patterns
• eating patterns
• energy levels
• sexual functioning
• bowel functioning
• usually complain of insomia or hypersomia, loss of appetite or increased
appetite, loss of energy, decreased libido, and constipation, which are all
signs of neurovegetative changes.

Sleep Pattern
• Insomnia – a symptom that have many different causes, and it
occurs
often in clients with psychiatric disorders.
• Acute or primary insomnia – often caused by emotional or physical
discomfort such as chronic stress, hyperarousal, poor
sleep hygiene, environmental noise, or jet lag.it is not
due to the physiological effects of a substance or a
general medical condition.
• Secondary insomnia – related to a psychiatric disorder such as
depression, anxiety, or schizophrenia; general medical
or
neurologic disorders; pain; or substance abuse.

DOCUMENTATION OF ASSESSMENT DATA
Criteria for the documentation:
• Objective – the nurse documents what the client says and
does by stating facts and quoting the client’s
conversation.
• Descriptive – the nurse describes the client’s appearance,
behavior and conversation as seen as heard.
• Complete – Documentation of examinations, treatments,
medications, therapies, nursing interventions,
and
the client’s reaction to each should be made on
the client’s chart.
• what should be done by the client.
• Samples of the clients writing should be preserved.

• Legible – with the use of acceptable abbreviations only and
no erasures.
- correct grammar and spelling are important, and
complete sentences should be used.
• Dated – important to note the day and the time of each entry.
• Logical – presented in logical sequence.
• Signed – should be signed by the person making the entry.

NURSING DIAGNOSIS
• Is a statement of an existing problem or potential health
problem that a nurse is both competent and licensed to
treat.
• Clinical judgment about individual, family, or community
responses to actual or potential health problems/ life
processes.
• Provides basis for selection of nursing interventions to
achieve outcomes for which the nurse is accountable.
• Psychiatric nurse analyzes the assessment data before
determining a nursing diagnosis.

PSYCHIATRIC- MENTAL HEALTH NURSING
(PMHN) DIAGNOSTIC SYSTEM
-organized 8 human response process:
• activity
• cognition
• ecological
• emotional
• interpersonal
• perception
• physiologic
• evaluation

• Cue’s – are facts collected during the assessment process.
• Inferences – are judgments that the nurse makes about the cue’s
• Actual Nursing Diagnosis – based on clinical judgment of the nurse on
review of validated data.
• Risk Nursing Diagnosis – is based on clinical judgment of the client’s
degree of vulnerability to the development of a specific
problem.
• Wellness nursing diagnosis – is based on clinical judgment about an
individual, group, or community transitioning from a
specific
level to higher level of wellness.
• Syndrome Nursing Diagnosis – cluster of actual or high risk diagnoses that
are predicted to be present because of a certain event or
situation.

FACTORS OF NURSING DIAGNOSIS
• Validating data – valid data can be assumed to be factual and
true.
• Validation of data may occur by:
• Rechecking data collected
• Asking someone to analyze the data
• Comparing subjective and objective data
• Asking the client to verify the data
• To determine if a sufficient number of cues are present to confirm
a nursing diagnosis, the nurse should consult a list of defining
characteristics for the diagnosis suspected.
• Nursing diagnosis should not be written in terms of cues,
inference, goals, patient needs, or nursing needs.
• Nursing diagnostic statements should not be stated or written to
encourage negative responses by healthcare providers, the client,
or the family.

OUTCOME IDENTIFICATION
• Expected outcomes are measurable client – oriented that are realistic in
relation to the client’s present and potential capabilities.
• Involve the other member of the health care team formulate the
outcomes.
• Nurse and multidisciplinary team members understand the problems
identified by the client and the outcomes the client hopes to achieve.
• con’t.

• Expected outcomes serve as a record of change in the client’s health status.
• Outcomes are measurable client – oriented goals are both short term and
long term; they should be clearly stated by the nurse and should describe
the expected end result of care.
• Outcomes are consequences of a treatment or an intervention.
• Outcome statement should be directly related to the nursing diagnosis.

PLANNING
• To guide therapeutic intervention and achieve expected outcomes.
• Is individualized, identifies priorities of care, identifies effective
interventions, and includes client education to achieve the stated
outcomes.
• The responsibilities of psychiatric nurse, client, and multidisciplinary
team members are indicated.
• Documentation of the plan of care should allow access to it by team
member and modification of the plan as necessary.
• Priority setting considers the urgency of the problem or need and its
impact on the client.
• Maslow’s hierarchy of needs usually the guide for problem solving
during formulation of plan care.

• General principles to remember when writing care plans:
• Individualize or personalize the plan of care according to the nursing
diagnosis or problem list
• Use simple, understandable language to communicate information
about the client’s care
• Be specific when stating nursing action.
• Prioritize nursing care
• State short and long term goals.
• Indicate the responsible party for each client intervention.

IMPLEMENTATION
• Uses of various skills to implement the plan care
• Implement of care based on:
• nursing theory
• establish trust with the client
• promotes the client’s strengths
• sets mutual goals with the client to promote wellness.

• Intervention used by the nurses in clinical setting:
• Counseling interventions to help the client improve or
regain coping abilities.
• Maintenance of a therapeutic environment or milieu
• Structured interventions to foster self-care and mental and
physical well-being.
• Psychobiologic interventions to restore the client’s health
and prevent future disability.
• Health education
• Case management
• Interventions to promote mental health and prevent mental
illness.

Additional intervention used by clinical nurse specialist:
• Individual, group, and child therapy
• Pharmacologic agent prescription
• Consultation with other health care providers

EVALUATION
• Focuses on the client’s status, progress toward goal
achievement, and ongoing reevaluation of the care plan.
• Four possible outcome may occur:
• The client may respond favorably or as expected to nursing
interventions.
• Short term goals may be met but long term goals may remain
unmet.
• The client may be unable to meet or achieve any goals.
• New problems or needs maybe identified
• All members of the multidisciplinary treatment team, as well as the
client, should be encouraged to provide feedback regarding the
effectiveness of the plan of care.
• As a result of evaluation process, the care plan is maintained,
modified or totally revised.
106

STANDARD OF CARE
• Standard I. Assessment
- collects client health data.
• Standard II. Diagnosis
-analyses the assessment data in determining diagnosis.
• Standard III. Outcome Identification
- identifies expected outcomes individualized to the client.
• Standard IV. Planning
-develops a plan of care that is negotiated among the
client, nurse, family, and health care team and
prescribes
evidence-based interventions to attain expected
outcomes.
• Standard V. Implementation
- implements the interventions identified in the plan of
care.
Standard Va. Counseling:
- uses counseling interventions to assist clients in
improving or regaining their previous coping abilities,
fostering mental health, and preventing mental illness
and disability

Standard Vb. Milieu therapy:
- provides, structures, and maintains a therapeutic
environment in collaboration with the client and other
health care providers.
Standard Vc. Promotion of Self Care Activities :
- structures interventions around the client’s activities of
daily
living to foster self-care and mental and physical well-
being.
Standard Vd. Psychobiologic Interventions:
- uses knowledge of psychobiologic interventions and
applies clinical skills to restore the client’s health and
prevent future disability.
Standard Ve. Health Teaching
- through health teaching, assist clients in achieving
satisfying, productive, and healthy patterns of living.

Standard Vf. Case Management
- provides case management to coordinate
comprehensive health services and ensure
continuity of care.
StandardVg. – Health Promotion and Health Maintenance:
- employs strategies and interventions to promote and
maintain health and prevent mental illness.
• Standard VI. Evaluation

UNIT II: DEVELOPMENT OF THE PERSON
• Personality → refers to the aggregate of the physical and mental
qualities
of the individual as these interact in characteristic
fashion
with his environment.
→ expressed through behavior. It is the sum total of one’s
behavior
→ it is complex, dynamic and unique.
• Factors that influence Personality
a.) Heredity
b.) Environment
c.) Training

Theories of Personality
• 1.) Psychoanalytic Theory
Sigmund Freud – the father of psychoanalysis who
stresses that early childhood
experiences is important in the
development of personality
• Personality Component
a.) Id – reflects basic or innate desires such as pleasure – seeking
behavior, aggression and sexual impulses.
→ seeks instant gratification, causes impulsive,
unthinking
behavior and has no regard for rules or social
convention.
→ “pleasure principle”
→ developed during infancy.

b.) Superego → reflects on moral and ethical concepts, values and
parental and socials expectations
→ the “conscience”
→ the “censoring force of the self”
→ developed during preschool age
c.) Ego → the balancing or mediating force between the id and
superego.
→ represent mature and adaptive behavior that allows
person to function successfully
→ the integrator of personality
→ operates on reality principle
→ developed during toddlerhood
Strict Superego – leads to rigid, compulsive, unhappy
person.
Weak or Defective Superego – leads to antisocial behavior,
hostility, anxiety or guilt.

• 2.) Interpersonal Theory (Harry S. Sullivan)
a.) Infancy
- Self-concept is developed
- Mothering role is achieved by perception of the child
as “Good me” if not “Bad me”.
- If satisfaction and security of the child is achieved, he
views himself as a worth while individual; but if an
infant severely deprived, he develops “Not me”
attitude.
Type of play: Solitary Play
• BY: ROMMEL LUIS C. ISRAEL III 113

• 3 PERSONIFICATION OF THE SELF
1.) “Good me” – results from experiences of approval and
tenderness and is associated with
good
feeling and about the self.
2.) “Bad me” – results from experiences resulting from high
anxiety situations and are associated with
feelings of shame, guilt and low self-
esteem.
3.) “Not me” – develops in reaction to overwhelming anxiety
arising from situations that provoked
feeling
of horror or dread.

• b.) Toddlerhood
- Emphasized the sense of POWER the child feels
as
he attempts to control himself and others.
BEHAVIORAL TRAITS:
• 1.) Toddlers are headstrong and negativistic (their favorite word is
“No”).
• 2.) Toddlers are naturally active, mobile and curious which make
them vulnerable to accident.
• 3.) Temper tantrums are common.
• 4.) Type of play: Parallel Play

• c.) Pre-schooler
- Known as Later Childhood
- Characterized by: Consensual Validation – there is
the
use of language which can be
consensually validated by others.
BAHAVIORAL TRAITS
1.) Love to watch adults and imitate their behaviors.
2.) They are very creative and curious (Their favorite word is
“WHY”).
3.) They love to tell “lies”, to brag and boast in order to impress
others.
4.) They are very imaginative; imaginary playmates are common.
5.) They love offensive language.
6.) Question about sex should be answered honestly at the level of
their understanding.
7.) Type of play: Associative Or Cooperative Play

• d.) Schooler
1.) Juvenile Era: (6 – 10 years old)
• 1.a. The child turn away from his parents as being the most
significant people in his life and looks to peers of the
same sex to fill the functions of providing him sense of
security and companionship.
• 1.b. Period of gang loyalties
• 1.c. Child acquire the very important interpersonal tools:
• Ability to complete
• Ability to compromise
2.) Preadolescence (11 – 12 years old)
• 2.a. Child develop the ability to experience intimacy.
• 2.b. Chum Relationship – an intense love relationship with a
particular person of the same sex whom the child perceives to
be very similar to himself.
•

• e.) Adolescence (12 – 18 years old)
1.) Known as the Early Adolescence.
2.) Establish relationship with the opposite sex.
3.) Adolescence experiences already sexual urges
termed by Sullivan as LUST.
4.) Development of heterosexual relationship.
• f.) Young of Early Adulthood (20 -40 years old)
1.) Known as Late Adolescence.
2.) There is incorporation of INTIMACY (which
developed during pre-adolescence with a chum)
and LUST (which developed in early adolescence)
in heterosexual relationship.

• f.) Young of Early Adulthood (20 -40 years old)
1.) Known as Late Adolescence.
2.) There is incorporation of INTIMACY (which
developed
during pre-adolescence with a chum) and LUST
(which developed in early adolescence) in
heterosexual relationship.
→ humans are essential social being
→ human personality determined in the context of social interactions
with other human beings.
→ early life experiences with parents, especially the mother,
influence an individual development throughout life.
119

• 3.) Behavioristic Theory
→ behavior can be changed by a system of reward and punishment.
→ derived form the works of Ivan Pavlov, John Watson and B.F.
Skinner.
→ concerned only with observable behavior not with intra psychic or
interpersonal processes or the personality itself.
→ all behavior are responses to a stimulus or stimuli from the
environment.
→ there are consequences that results from behavior broadly speaking
reward and punishments
→ behavior that are rewarded with reinforces tend to recur.
• POSITIVE REINFORCERS that follow a behavior increase the livelihood
that the m
behavior will recur.
• NEGATIVE REINFORCERS that are removed after a behavior increases
the

• 4.) Cognitive Theory (Jean Piaget)
• →Piaget believed that an individual has a genetically predetermined
intellectual or cognitive potential that develops according to the
quality of child’s interaction with the environment
• GENETIC EPISTEMOLOGY – the study of the nature of thought,
especially the development of thinking.
• SCHEMA – an innate knowledge structure which initially enable the
person to behave an interact with the environment.
• COGNITVE DEVELOPMENT – the development of the ability to
think,
remember and solve problems.

2 PROCESSES OF COGNITIVE DEVELOPMENT
1.) Assimilation – incorporation of a new knowledge to
the existing knowledge.
2.) Accommodation – modification of the existing body
of knowledge in a person based on the
newly acquired knowledge. The existing
body of knowledge maybe changed
refined a reinforced.

FOUR PERIODS OF COGNITVE DEVELOPMENT
1.) Sensorimotor – “Assimilation vs. Accommodation”
(0 – 2 years old )
a.) Cognitive Development
a.1. Assimilation – the process by which an individual
acquires information or knowledge or by which
experiences are integrated into an existing scheme.
a.2 Accommodation – process of creating a new scheme by
modifying an existing scheme after an individual’s
interaction with the environment.
b.) This is a period based primarily on immediate experience through the sense.
c.) Infant begins to display behavior which Piaget calls Primary Circular
Reaction.
d.) At this time, the child also achieves Object Performances (the awareness that is
independent of his own action and perception).

2) Pre – Operational Thought (2 – 6 years old)
• Stage I: Pre-conceptual Thought (2 – 4) years old)
- characterized by Egocentricity expressed in
relating everything to himself
• Stage II: Perceptual Intuitive ( 4 – 6 years old)
- characterized by: reason can be given for belief and
reactions but still considered pre-logical and termed as pre-
operational intuitive behavior.
Jean Piaget described thinking of children as:
1. Egocentric – thoughts are primarily centered to
themselves
2. Irreversible – inability to go back and rethink a
process or concept or to conserve
such process or concept
124

3.) Concrete Operation (7 -11 years old)
Not egocentric – able to understand cause and effect in
concrete situation but cannot yet reason
hypothetically.
• Major Events :
a.) Conservation – refers to the retention of the same properties even if they
are
arranged differently or reshaped.
b.) Reversibility – refers to completion of certain operation in the reverse order
and ending up the same.
• Development proceeds from Pre-Logical to Logical Concrete thought.
• Deals with visible concrete objects and relationship.
• Increase intellectual and conceptual development.
• Accommodation is developed – modifies ideas to fit reality. Believes
that animate and remote inanimate objectives (sun, moon) have life.
• Intellectual development proceeds and relations and can handle numbers.
125

4.) Formal Operation (11 – 15 years old)
- Employs logical reasoning
- Development proceed from Logical Concrete to
Logical
- Solution to all kinds of categories of problem.
- Abstract thinking is fully utilized.
- Develops capacity to use hypothetic reasoning and
considers all possible solutions problem. Believe that
only plants, animal and people have life.
- Logical, mathematical and scientific reasoning
are completed

STAGES OF GROWTH AND DEVELOPMENT
a.) Psychosexual Development (Sigmund Freud)
I. Oral Phase (1 – 1 ½ yrs old)
• Mouth ─ erogenous zone; area of satisfaction and pleasure.
• Period of complete dependence.
• Greatest need security
II. Anal Phase (1 ½ ─ 3 yrs old)
• Anus – site of tension and sensual gratification
• Primary source of pleasure is elimination or retention.
• Critical period of toilet training and urination.
• Greatest need – Power
• First experience with discipline and authorities.
• Retention and expulsion (forcing out) are experienced as pleasurable
especially because these functions come under the child’s control. Child uses
this new skill to pleasure or annoy parenting adult.
• Bowel control : 18 months
• Daytime Bladder Control: 2 ½ yrs. old
• Nighttime Bladder Control: 3 yrs.

III. Phallic Stage (3 – 6 yrs old)
• Genital Region – erogenous zone; the primary source of pleasure.
• Indicative Behaviors
a.) Masturbation
b.) Fantasy
c.) Play activities, experimentation with peers and questioning of adults
about sexual topics.
• Girls develop penis envy
• Girls: Elektra Complex
• Boys: Oedipal Complex
• Because of the desire to posses parent of the opposite sex, the child
develops guilt feelings and fear of punishments by parent of the
same sex (castration complex)
• Imitation of parent of the same sex or internalization of the traits.

IV. Latency (6 – 12 yrs old)
• Stage of development marked by expanding peer
relationship.
• Libido is channeled into school, home, organization activities,
and hobbies relationship with peers.
• Time for increased intellectual activity.
• Significant other are the school and neighbors.
V. Genital Phase – Puberty
• Child becomes sexually nature
• Libido is centered again to the genital area
• Characterized as establishment of relationship with the
opposite sex

b.) Psychosocial Theory (Erik Erikson)
1.) Infancy : Trust vs. Mistrust
• Task: Development of trust in oneself, other people, the environment and
meaningfulness of existence.
• Trust: When needs are meet consistently by mother or primary caregiver.
The child will be able to relate well with others, share and has optimism
and hope in life.
• Mistrust: If needs are not met, child develops mistrust, hostility,
suspiciousness, engages in excessive testing behaviors later in life, fears
affection and becomes withdrawn.
2.) Early Childhood: Autonomy vs. Shame and Doubt
• Task: The need to establish a differentiation between the self and its own will
and pressure from the outside influence.
• Autonomy: Support and encourage the child to explore the environment
• Supportive and consistent toilet training leads to development of self
confidence that he can control himself and the environment.
• Shame and Doubt: If the mother rejects child’s attempt to explore the
environment and the parents’ lack of confidence to the abilities of the child.
Child becomes insecure and learns to become ashamed of himself.
130

• 3.) Initiative vs. Guilt
• Major Task: Accomplishment proper sex rule identification resulting to
resolution of Oedipus complex. Failure leads to improper sex rule
identity.
• Initiative to explore and reach security outside the home could lead to
guilt.
• The sense of “badness” may develop which could restrict initiative.
• Child is ready to learn quickly and to mature and to cooperate
successfully with others.
• Frequent Asking Is Initiative
• Social Skill: Cooperative Play
•
• 4.) Industry vs. Inferiority
• Major Tasks: Acquisition of competence
• Child is halfway outside the family world. This is the active period of
socialization.
• Child works with others and produce thing which should be recognized
to prevent inferiority.
• Peer – most important person. The child learns to win recognition by
finishing tasks to completion, producing things, solving problems
131

Con’t. Early Childhood
• Social Skill – Parallel play
• Anal needs are of primary importance
• Father emerges as the important figure
• Development of muscular maturation. This sets the scene of two simultaneous
sets of social modalities – “holding on or letting go”
• Primary need: Power
• It is the obsessive-compulsive phase of development
Strong Shame and Doubt will result to:
• Rebelliousness
• Stubbornness or compliance
• Compulsiveness like being meticulous and perfectionist
• Cleanliness
• Jealousy
• Over compensatory control
132

3.) Preschool : Initiative vs. Guilt(Development of Conscience)
• Major Task: Accomplishment proper sex rule identification resulting to
resolution of Oedipus complex. Failure leads to improper sex rule identity.
• Initiative to explore and reach security outside the home could lead to
guilt.
• The sense of “badness” may develop which could restrict initiative.
• Child is ready to learn quickly and to mature and to cooperate successfully
with others.
• Frequent Asking Is Initiative
• Social Skill: Cooperative Play
• 4.) School Age: Industry vs. Inferiority
• Major Tasks: Acquisition of competence
• Child is halfway outside the family and world. This is the active period of
socialization.
• Child works with others and produce thing which should be recognized to
prevent inferiority.
• Peer – most important person. The child learns to win recognition by
finishing tasks to completion, producing things, solving problems

5.) Puberty : Identity vs. Role Diffusion
• Major Tasks: Acquisition of fidelity.
• Rapid physical development advent of sexual maturity precipitate.
• Search for self identity, period of rapid physiologic or psychologic
revolution. Emancipation from family, heterosexual relationship, develops
ideology and philosophy of life; highest incidence of Schizophrenia
Diffusion – the sense of one’s own identity or diffusion of identity
because of attempt to be too many person.
6.) Young Adulthood : Intimacy vs. Isolation
• Task: Establishment of friendship and eventually a satisfying marriage.
Characteristic:
• Human closeness and sexual fulfillment.
• Forms mutually regulating work procreation and recreation.
• Arrives at working philosophy of life.
• Tolerant.
• Has a mastered environment.

7.) Mid- Adulthood : Generativity vs. Self – Absorption and
Stagnation
• Major Tasks:Acquisition of ability to care.
• Generativity ─ is reflected in the individual establishments and guiding
the next
generation. The person is productive and creative in both career
and family. There is willingness to assume responsibility for
others.
8.) Older Adult : Integrity vs. Despair
• Integrity - is achieved when the individual accepts responsibility for what his life
has been and finds it has worth.
Characteristics:
• Wisdom is achieved.
135

III. THE INTERACTING NURSE-PATIENT
RELATIONSHIP
Communication - refers to the reciprocal exchange of ideas,
beliefs, attitude or feelings between or among persons.
A. Mode of Communications
1. Verbal – the transmission of message using the spoken
or
written language.
2. Non – verbal – actions or behaviors that communicate a
message without speaking.
• Facial expressions Body language
• Posture Hand gestures
• Manner of dress Proxemics

• GENERAL PRINCIPLES
1. Non- verbal communication is multi-channeled.
2. Non- verbal communication is relatively spontaneous.
3. Non- verbal communication is relatively ambiguous.
4. Non– verbal communication may contradict verbal messages.
5. Non- verbal communication is very culture bound.
RELATED TERMS:
• Kinesics – the study of communication through body language.
• Proxemics – the study of people’s use of interpersonal space.
• Personal Space – is a zone of space surrounding a person that is felt to “belong” to that
person.
• Territoriality – the marking off and defending of certain areas as their own.
• Paralanguage – refers to how something is said rather than what is said.

INTERPERSONAL DISTANCE ZONES:
1. Public Distance – (12 ft and beyond); for actors total strangers, important
officials.
2. Social Distance – (4-12 ft); for social gatherings, friends and work situations.
3. Personal Distance – (18 inches – 4 ft); close friends.
4. Intimate Distance – (0 – 18 inches); parents and children, lovers, husband and
wife.
COMPONENTS OF COMMUNICATION
1. Sender – source of information
2. Message – information being transmitted.
3. Channel – mode of communication
4. Receiver – recipient of communication
5. Feedback – return response
6. Context – the setting of communication
138

• THERAPEUTIC NURSE-PATIENT RELATIONSHIP
Definitions:
• Nurse-Patient Relationship – results from a series of interaction
between a nurse and a patient/ client over a period of time, with the
nurse focusing on the needs and problem of the person/family/group
while using the scientific knowledge and specific skills of the
nursing profession.
• Therapeutic Nurse-Patient Relationship – a mutual learning
experience and a corrective emotional experience for the patient; the
nurse uses herself and specified clinical technique in working with
the patient to bring about behavioral change.

Goals of the Therapeutic Nurse-Patient
Relationship:
1. Self-realization, self-acceptance and increased
genuine self-respect.
2. Clean sense of personal identity and an
improved level of personal integration.
3. An ability to form intimate,interdependent,
interpersonal relationship with a capacity to
give and receive love.
4. Improve functioning and increased ability to
satisfy needs and achieve realistic personal
goals.

Characteristics of Therapeutic Nurse-Patient
Relationship:
1. Listening – perceiving the patient’s message in the cognitive and
affective domains.
2. Warmth – feeling of cordiality and affection.
3. Genuineness – being oneself and not acting out a role; being open &
truthful.
4. Attentiveness – demonstrating a concentration of time and/or
attention on the patient.
5. Empathy – understanding the patient’s feelings; viewing the world
as the patient does.
6. Positive Regard – accepting the patient as he is; non-judgmental.
7. Humor – ability to see the “funniness” of a situation to be amused by
one’s own imperfection, to see the funny side of the otherwise
serious situation.
8. Consistency – maintaining the same basic attitude toward the
client, so that he derives security from being able to predict her
behavior.
141

Response of Patients and Nurse in the NPR:
Resistance – patient’s attempt to remain unaware of
anxiety-producing aspects within herself.
Transference – the experiencing of feelings, drives,
attitudes, fantasies, and defenses toward a person in
the present that do not befit that person but rather are
a repetition of reactions originating with significant
others during early childhood, unconsciously displaced
onto figures in the present.
Counter-transference – involves feelings of the nurse
(positive or negative) toward the patient, such as
special concern, sexual attraction, anger, impatience or
resentment.

Considerations in Setting Limits for Patients:
1. The most general consideration is that the nurse cannot be completely
permissive or completely restrictive.
2. The nurse should take into account the patient’s degree of comfort and
feeling of being respected which may result from limits set on his
behavior.
3. The nurse should also take into account the consequences of the limits set
on his behavior.
4. The nurse should also consider her own feelings and attitudes in restricting
a patient.
5. The effect of limit setting on a relationship of the nurse and patient.
6. The extent to which the nurse will be able to maintain the limits set for the
patient.
7. The time at which a limit is set and the nurse’s attitude in setting it.

Indications or Signs of a Non-Therapeutic/Distorted Involvement
Distorted Involvement - the nurse uses the patient primarily for her own emotional needs and purposes.
1. Excessive worry over the patient.
2. Feeling of intense hatred for him.
3. Preoccupations with him to the exclusion of other patients or being constantly “overcome with
pity” for him.
4. Being possessively attached to a patient that she resents to anyone’s relationship with or
interest in him.
5. Feeling that no one else can nurse him as well as she can.
6. Being frequently upset when the patient is upset or when “things don’t go right” for him.
7. Unable to accept anyone’s point of view concerning activities with the patient.
8. Joke or tease in harsh belittling manner.

• The nurse – Patient Interaction
- A single encounter engaged in by particular
setting for the purpose of facilitating the
patient’s recovery through the utilization
of the nurse’s special knowledge and skills,
professional not social and is directed
toward moving patients from maladaptive
behavior

PHASES OF THE NURSE
PATIENT INTERACTION
1. Pre-orientation Phase
• Begins when the nurse is assigned to a patient
• Phase of NPR in which the patient is excluded as an active
participant
• Nurse feels certain degree of anxiety
• Includes all of what the nurse thinks and does before interacting with
the patient
• *Major task of the nurse: to develop self-awareness
Other tasks:
• Data gathering, planning for first interaction

JOHARI’S WINDOW
Known to
others
Not known to
others
Known to self Not known to self
Public self
I
Semi-public self
II
Private self
III
Area of the
Unknown
IV

2. Orientation phase. The purpose of the
orientation phase is to become acquainted; gain rapport;
demonstrate genuine caring and understanding; and established
trust. The orientation phase usually last from 2 to 10 sessions, but
with some patients can take many months.
*Major task of the nurse: To develop a mutually acceptable contract
Other tasks
• Determine why the patient sought help
• Establish rapport, develop trust, assessment
• Ways to Build trust and security (first level of an interpersonal experience):
• Be confident- follow contract, keep appointments.
• Allow patient to be responsible for contract.
• Convey honesty.
• Show and caring and interest.
• When patient is unable to control behavior, nurse set limits and/or provide
appropriate alternatives outlets.
148

• Discuss the contract: dates, times, and place of meetings;
duration of each meetings; purpose of meetings; role of both
patient and nurse; use information obtained; arrangements
for notifying patient/ nurse if unable to keep appointment.
• Facilitate the patient’s ability to verbalize his or her
problem.
• Be aware of themes:
• Content (what the patient is saying).
• Process (how the patient interacts).
• Mood (hopeless, anxious).
• Interaction (did the patient ignore you, was he or she submissive, did
he or she dominate conversation

• Observation and assess the patient’s strengths and positive aspects of his or her
personality. Include the patient in identification of his or her own attributes.
• Identify patients’ problems, nursing diagnosis, outcome criteria, and nursing
interventions; formulate nursing care plan.
Patient Responses to Orientation Phase
• May willing engage in the therapeutic relationship.
• May test you and the limits of the relationship:
• May be late for meetings
• May end meeting early.
• May play nurse (you) against the staff.
• May not remember your name or appointment time:
• Put information on a card and give this to patient.
• Reinforce contract in early meetings and restate limits if necessary.
• May attempt to shock:
• May use profane words.
• May share an experience that patient feels will shock or frighten you.
• May use bizarre behavior.
• May focus on nurse in an attempt to see if nurse is competent. Focus on patient.
150

3. Working phase. This phase begins when the patient assumes
responsibility to uphold the limits of the relationship. Focus is on
the “here and now”. The purpose of the working phase is not to
bring about positive changes in the patient’s behavior.
• Set priorities when determining patient needs:
• Preserve life and safety: is patient suicidal, not eating,
smoking in bed while medicated, acting out behavior harmful
to others?
• Modify behavior that is unacceptable to others: such as e.g.,
acting out of hostile verbalization, bizarre behavior,
withdrawal, poor hygiene, and inadequate social skills.
• Identify with patients those behaviors he or she is willing to
change; set realistic goals. Make goal testable and attainable
for successful experiences. This will increase sense of self
worth and help patient accept need for growth.

… Working Phase
- It is highly individualized.
- More structured that the orientation phase
- The longest and the most productive phase of the NPR.
- Limit setting is employed
- *Major Task of the Nurse: Identification and resolution of
the patients problems.
- Other Tasks: Planning and Implementation

Patient Response to Working Phase
• May use less testing, less focusing in nurse, fewer attempts to
shock nurse.
• May remember anticipate appointment with nurse.
• May use more description and clarification to facilitate
understanding; wants you to know how he/she feels.
• May be more responsive in interaction.
• May improve appearance.
• May bring up topic he/she wished to discuss.
• May confide more confidential materials. The working phase is
painful for patient, and is reached when change occurs as
problems are analyzed and discussed by patient and nurse.
153

4. Termination phase.
The purpose of this phase is to dissolve the
relationship and assure the patient that he or she
can be independent in some or all of his or her
functioning.
- Ideally the termination phase should begin during
orientation phase. The more independent and
involved relationship required longer time for
termination. Termination usually occurs if the
patient
has improved sufficiently for the relationship to
end, but it may occur if as patient is transferred or
you
as a nurse leave the agency.

… Termination Phase
- It is a gradual weaning process.
- it is a mutual agreement.
- It involves feelings of anxiety, fear and loss.
- it should be recognized in the orientation phase.
-* Major Task of the Nurse: To assist the client to review what he has
learned
and transfer his learning to his relationship with others.
- Other task: Evaluation
WHEN TO TERMINATE:
- When goals have been met/ accomplished.
- When the patient is emotionally stable.
- When the patient exhibit greater independence.
- When the patient is able to cope with separation anxiety, fear and loss.
155

Methods of decreasing the involvement:
• Space your contracts farther apart (not usually necessary in the
student clinical experience).
• Reduce the usual length of time you spend with patient.
• Change the emotional tone of the interactions by:
• Not responding to or following up clues that led to new areas to
investigate.
• Focusing on the future – oriented material.
• Some patient may want to work up to the last meeting; use your
judgment.
What to discuss with patient about termination
• Help patient to discuss his/her feelings about it.
• Have patient talk about gains he/she has made. (Include negative
aspects of sessions also)
• Share with the patient the growth you in him/her.
• Express benefits you have gained fore the experience.
• Express your feelings regarding leaving patient.
• Never give patient your address or telephone number.
156

Patient Responses to Termination
• May deny separation.
• May deny significance of relationship and/or termination
• May express anger or hostility (overtly or covertly). Anger openly express to nurse, may be a natural and healthy response
to events. Patient feels secure enough to show anger. Nurse responses to above in accepting, neutral manner.
• May display marker change in attitude toward nurse/therapist; may make critical remarks about nurse or be hostile
because of pending break of emotional ties. If the nurse doesn’t understand the reason for the patient’s reaction, he/she
may react with anger or defensiveness and block the termination process.
• May display a type of grief reactions. It takes time to get over the loss, which is why it is important to start the
termination process early.
• May feel the rejected and experience increased negative self-concept.
• May terminate relationship prematurely.
• May regress to exhibition of old symptoms.
• May request premature discharge.
• May make suicide attempt.
• May be accepting but may still express regret or fell momentary resentment. This is healthy response. Make a clean
break or you may hinder the patient realization that relationship often must and do, terminate.
157

THERAPEUTIC NURSING PROCESS
The nurse promotes goal-directed activities that help to alleviate the discomfort of the client by
promoting growth and satisfying interpersonal relationships.
Characteristics: - Goal directed
- Understanding, empathic
- Concreteness
- Honest, open communication
- Acceptance; nonjudgmental attitude
ORIENTATION PHASE
(Teach them!)
WORKING PHASE
(Provide therapeutic experience)
TERMINATION PHASE
(Take Pride!)
Trust and Rapport
Environment (Therapeutic)
Assess client’s strength and
weaknesses
Contract (Therapeutic)
Help communicate
Promote Positive self concept
Realistic goal setting
Organize support system
Verbalize feelings (encourage)
Implement action plan
Develop positive coping behaviors
Evaluate the results of plan of action
Promote self care
Recognize increasing anxiety
Increase independence
Demonstrate emotional stability
Environmental support

DIFFERENTIATING SOCIALAND THERAPEUTIC
RELATIONSHIP
Focus of therapeutic relationship is in helping
clients (RELEASE)
Reinforces self-worth
Enhance self-concepts and confidence
Learn coping strategies
Examine relationship
Achieve Growth
Solve Problems
Extinguish (let go) of unwanted behavior
Differentiation SOCIAL INTERACTION THERAPEUTIC RELATIONSHIP
Characteristics Personal and intimate Personal but NOT intimate
Goal Doing favor for mutual benefit Promoting functional use of one’s latent
inner resources
Termination Not defined Defined in the beginning
Identification May not occur By client with help of the nurse
Resources used Variety during interaction Specialized professional skills for
intervention

THERAPEUTIC
COMMUNICATION
TECHNIQUES

Technique Description/Definition Example
Offering self The nurse offers to stay with the client and
either talk or just sit quietly.
“Let me sit with you for 15 minutes and read a
story.”
“I’d like to eat lunch with you.”
“Let’s walk to the cafeteria together.”
Providing broad
opening
The nurse invites the client to select a topic “Where would you like to begin.”
“Talk more about…”
“What would you like to tell me about yourself?”
“Tell me what’s been in your mind?”
I’m interested in hearing about issues of concern to
you.”
Making an
observation
The nurse acknowledges that something or
someone exists or has changed in some way.
“You appear anxious. I notice that you have been
coming to lunch with the group.”
“You have drawn a picture>”
“That’s a new hairstyle, isn’t it?”
“I noticed on the chart that today is your birthday.”
Suggesting
collaboration
The nurse makes an offer to work together
with the client.
“Let’s try to figure this out together.”
“Let’s talk and see if we can work together to
understand this.”
“Perhaps we can discuss this and see what offended
you.”
Providing silence The nurse allows the verbal conversation to
stop to provide a time for quiet contemplation
of what has been discuss, formulation of
thoughts about how to proceed, or for
intension reduction.
(Silence)

Accepting
messages
The nurse acknowledges that he or she has
heard and understood what he client has said.
“Yes”
“Okay”
Nodding “Uh hmmm.”
(Smiling) “Um-hmm.”
(Nodding) “I hear what you’re saying.”
“I understanding.”
Providing general
leads
The nurse provides brief interjections that let
the client know that he or she is on the right
track and should continue.
“Go on…”
“Talk more about…”
“Then what?”
Please go on.”
“And…?”
Exploring The nurse asks the client to describe
something in more detail or to discuss more
fully.
“You said you liked Carl best. Can you tell me
about Carl?”
“Your said you get more satisfaction out of helping
out at the flower shop. I’d like to hear more about
that.”
“These dreams you mentioned. What are they like?”
“What seems to be the problem?”
“Tell me more about…”
Focusing The nurse selects one topic for exploration
from among several possible topics presented
by the client.
“Give an example of what you mean.”
“Let’s look at this more closely.”
“You said you hate all your brothers. Tell me about
Carlo first.”
“You’ve briefly mentioned three different suicide
attempts. For now, I’d like to focus on just what was
going on with you at the time of the first attempt.”
“Let’s return to the last point you made and talk
more about that.”
162

Asking for
clarification
The nurse lets the client know that what was
said was unclear. If necessary, the nurse asks
for clarification or provides input regarding
how to make the message clearer.
“I’m not sure that I understand what you’re saying.”
“Do you mean…?”
“I didn’t understand what you meant then. Can you
say that in different words?”
“Let me repeat back to you what I think I heard you
say.”
Restating The nurse paraphrases what the client has said.
This paraphrased message may be fed back to
the client in the form of a statement or a
question to provide the client the opportunity
and clarify further.
Child: “Ugh! That’s poo poo!”
Nurse: “The medecine tastes pretty bad, huh?”
Adolescent: “I called Ralph on the big white
porcelain telephone.”
Nurse: “You vomited.”
Adult: “I’m down.”
Nurse: “You feel depressed?”
Seeking
consensual
validation
The nurse attempts to verify with the client that
a certain term means the same thing to both
parties.
“You want ‘moo moo’? Does ‘moo moo’ mean
milk?”
“When you say your brother is crazy, does the word
crazy mean ‘kind of wild’?”
“Tell me if we both understand the word the same
way.”
Placing events in
time or sequence
The nurse asks the client to explain more about
when an event occurred (placing the event in
time) or to explain the sequence of a series of
events.
“Were you frightened before or after the movie?”
“Tell me what went on before the fight broke out
the gym?”

RESPONSE EXAMPLE
1. False reassurance “Don’t worry; you will be better in few weeks.”
“Don’t worry; I had an operation just it; it was a snap.”
2. Giving advise “What you should do is…”
“If I were you, I would do…”
3. Rejecting “I don’t it when you…”
“Please, don’t ever talk about…”
4. Belittling “Everybody feels the way.”
“Why, shouldn’t feel that way.”
5. Probing “Tell me more about your relationship other men.”
6. Overloading “Hi, I am Joann, your student nurse. How old are you? What brought you to
the hospital? How many children you have? Do you want to fill out your menu
right now?”
7. Under loading “Not giving enough information so that the meaning is clear; withholding
information.”
8. Clichés “Gee, the weather is beautiful outside.”

ALPHABET OF THERAPEUTIC COMMUNICATION
• Accepting Opening
• Broad opening Present reality
• Clarifying Questions not answerable
not yes or no
• Demonstrate unconditional positive regard Reflecting
• Exploring Sharing of observation
• Focusing Trust
• General leads Using silence
• Here and now behavior Validating
• Informing What is said and more
important than why it is said
• Jargon, figure of speech Explore alternatives rather than answer of solution
• Keep respect You are interested to listen
• Master active listening Zest up-show interest
• Never advise
NONTHERPEUTIC COMMUNICATION
• ● False reassurance; ● Probing;
• ● Giving advise; ● Overloading;
• ● Rejecting; belittling; ● Underloading

Best responses are those that:
● Encourages client to express more fully
● Reflects or re-states what the client has earlier said
● Reflects the feelings that are identified and encourage
expression of these feelings
● Encourage hope (never with false assurance)
● Clarifies client’s statement
● Acknowledges client’s non verbal behavior
● Uses silence but expresses being there
● Informs
● Clarifies and validates
Never:
● Give response that belittles, negates or devalue
● Advice or show approval or disapproval
● Ask for explanation or “why”
● Avoid
● Be defensive
Remember to:
● Focus on client
● Accept client as s/he is
● Be honest and consistent
● Attempt to establish good relationship (rapport)
● Allow client then family to make decision
● Answer according to nursing action
● Do not provide response that implies that the
client is unworthy
● Select the most comprehensive (global) answer
● Focus on the feeling of client
166

PSYCHOSOCIAL ASSESSMENT
•PSYCHIATRIC HISTORY – To identify patterns of functioning that are as well as patterns that create problems in the client’s everyday life.
• A. General history of client ● Obtain general demographic information
• ● Pertinent personal history
• ● Previous mental health hospitalization
• B. Components of psychiatric history ● Presenting symptoms
• ● Family history
• ● Personal profile
MENTAL STATUS EXAMINATION
A. General appearance attitude and
behavior.
● Description: posture, gait, activity, facial expression, mannerisms
● Disturbances include deviations of activity, distortions in mobility (waxy flexibility or dyskinesia),
uncooperativeness, and changes in personal hygiene.
B. Characteristics talks and stream
of thought.
● Descriptors: emphasis on form, rather than content of client’s verbal communication: loudness, flow,
speed, quality, logic, level of coherence.
● Disturbances include the following patterns:
▪ Mutism – extreme form of negativism
▪ Circumstantialitiy – “ beating around the bush”
▪ Perseveration – repetition of a single word or phrase over and over
▪ Flight of ideas – rapid transition from one topic to another, without completing the original
thought (common in manic)
▪ Blocking – sudden cessation of thought
▪ Echolalia – repeating exactly what is heard
▪ Neologism – inventing words only he understands
▪ Verbigeration –
▪ Pressured speech -

C. Content of thought. ● Descriptors: what is central theme? How does client view himself ( self-concept)? Is
suicidal of homicidal ideation present? If so, what is potential lethality?
● Disturbance include:
● special preoccupations and experiences such as
▪ Hallucinations – sensory perceptions that have no external stimuli
▪ Illusions – misperception of an external stimuli
▪ Delusions – false belief
▪ Depersonalization – subjective sense of feeling unreal, strange, unfamiliar or
emotional numb
▪ Obsessions – maladaptive persistent patterns of thought, images or feelings that
generate anxiety
▪ Compulsions – maladaptive urges to act on impulse (ritualistic behaviors)
▪ Preoccupations – recurrent thought or center of particular idea or thought with an
intense emotional component
▪ Phobias – “ irrational fear”
▪ fantasies and daydreams.
D. Emotional state ● Descriptors: clients report of subjective feeling (mood or affect) and examiners
observation of client’s pervasive of dominant state.
● Disturbances include deviations such as
▪ elation ▪ incongruence, and
▪ depression ▪ disassociation.
▪ apathy
E. Sensorium and intellect ● Determine degree of client’s awareness and level of intellectual functioning, general
ability to grasp information and calculate; abstract thinking; memory (recall of remote
past and recent experiences, retention and recall of immediate impressions; and reasoning
and judgment).
● Disturbances of
▪ orientation in terms of time, place, person and self ▪ memory
▪ retention ▪ attention
▪ information ▪ judgment
168

ANXIETY
Definition:
• A diffused unpleasant uneasiness, apprehension, or fearfulness
stemming from anticipated danger. The source of which is
unidentifiable.
Characteristics
• It is the basic element of behavior.
• Serves as a signal which alerts an individual to defensive action to
handle exhibition.
• Necessary for one’s survival.
• It is an emotion and a subjective experience of the individual.
• It is an energy and as such cannot be observed directly. It can only be
inferred from the person’s behavior.
• Emotion without a specific object.
• It is provoked by the unknown. It therefore precedes all new
experiences like entering school, moving to new places, starting a
new job, etc.
• It is communicated personally.
169

Precipitating Factors to Anxiety
Two Categories:
• Threat to biological integrity – refers to the disturbance in homeostasis
i. e., temperature control, vasomotor stability, etc.
• Threat to self – esteem – refers to the threat to the tendency of an
individual toward maintaining established views of self and the values
and patterns of behavior he uses to resist changes in self – view.
• Sense of helplessness
• Sense of isolation (alienation)
• Sense of insecurity (Threat to identity)
Behavior Response to Anxiety
• Anger
• Defensive behavior
• Irritation
• Complaining
• Crying
• Denial
• Withdrawal
• Forgetfulness
• Quarreling
170

PSYCHIATRIC NURSING

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