NOTES VI - PSYCHIATRIC NURSING PART 1

NOTES VI - PSYCHIATRIC NURSING PART 1

Introduction

•MENTAL HEALTH – balance in a persons internal life and adaptation to reality

•Mental ILL Health – state of imbalance characterized by a disturbance in a persons thoughts, feelings and behavior

Psychiatric nursing

•interpersonal process whereby the professional nurse practitioner ,through the therapeutic use of self (art) and nursing theories (science), assist clients to achieve psychosocial well being.

•Core : interpersonal process

Related Terms

•Mental hygiene

–measures to promote mental health , prevent mental illness and suffering and facilitate rehabilitation

–Main tool: therapeutic use of self

–It requires self-awareness

•Methods to increase self-awareness:

–Introspection

–Discussion

–Experience

–Role play

•Assessment (psychosocial processes )

–Appearance , behavior or mood

–Speech , thought content and thought process

–Sensorium

–Insight and judgment

–Family relationships and work habits

–Level of growth and development

Common Behavioral Signs and Symptoms

Disturbances in perception

•Illusion

–misinterpretation of an actual external stimuli

•Hallucinations

–false sensory perception in the absence of external stimuli

Disturbances in thinking and speech

•neologism – coining of words that people do not understand

•Circumstantiality – over inclusion of inappropriate thoughts and details

•Word salad – incoherent mixture of words and phrases with no logical sequence

•Verbigeration – meaningless repetition of words and phrases

•Perseveration – persistence of a response to a previous question

•Echolalia – pathological repetition of words of others

•Aphasia – speech difficulty and disturbance

–Expressive , receptive  or global

•Flight of ideas- shifting of one topic from one subject to another in a somewhat related way

•Looseness of association-incoherent illogical flow of thoughts (unrelated way)

•Clang association – sound of word gives direction to the flow of thought

•Delusion – persistent false belief, rigidly held

–Delusions of grandeur: special /important in a way

–Persecutory: threatened

–Ideas of reference: situation/events involve them

–Somatic: body reacting in a particular way

–Jealous: thinking that their partner is unfaithful

–Erotomanic: person, usually of high status, is in love with the client

–Religious: illogical ideas about God and religion exhibited by extreme or extraneous behavior

–Mixed: combination of above without a predominant theme

•Magical thinking – primitive thought process thoughts alone can change events

•Autistic thinking – regressive thought process; subjective interpretations not validated with objective reality

•Dereism – unorganized thinking

Disturbances of affect

•Inappropriate – disharmony between the stimuli and the emotional reaction

•Blunted affect – severe reduction in emotional reaction

•Flat affect – absence or near absence of emotional reaction

•Apathy – dulled emotional tone

•Depersonalization – feeling of strangeness from one’s self

•Derealization – feeling of strangeness towards  environment

•Agnosia – lack of sensory stimuli integration

Disturbances in motor activity

•Echopraxia – imitation of posture of others

•Waxy flexibility – maintaining position for a long period of time

•Ataxia – loss of balance

•Akathesia – extreme restlessness

•Dystonia- uncoordinated spastic movements of the body

•Tardive dyskinesia – involuntary twitching or muscle movements

•Apraxia – involuntary unpurposeful movements

Disturbances in memory

•Confabulation – filling of memory gaps

•Déjà vu – something unfamiliar seems familiar

•Jamais vu- something familiar seems unfamiliar

•Amnesia – memory loss (inability to recall past events)

–Retrograde-distant past

–Anterograde – immediate past

–Anomia – lack of memory of items      

Dynamics of Human Behavior

•Behavior – the way an individual reacts to a certain stimulus

•Conflict – situation arising from the presence of two opposing drives

•Need - organismic condition that requires a certain activity

Dynamics of Human Behavior

•Personality

–totality of emotional and behavioral traits that characterize the person in day to day living under ordinary conditions; it is relatively stable and predictable.

FORMATION OF PERSONALITY

•TEMPERAMENT

–biological-genetic template that interacts with our environment.

–a set of in-built dispositions we are born with

–mostly unalterable

–our nature.

•CHARACTER

–the outcome of the process of socialization, the acts and imprints of our environment and nurture on our psyche during the formative years (0-6 years and in adolescence).

–the set of all acquired characteristics we posses, often judged in a cultural-social context.

•Sometimes the interplay of all these factors results in an abnormal personality

THEORIES OF PERSONALITY DEVELOPMENT

Freud’s
PSYCHOSEXUAL THEORY

•Libido – inner drive

•Parts of body –focus of gratification

•Unsuccessful resolution - fixation

•Structures of personality

–Id: pleasure principle-instinct

–Ego: controls action and perception –reality principle

–Superego: moral behavior - conscience

•0-18 m0s ;oral – mouth – trust and discriminating

•18 mos. – 3 years ; anal – bowels – holding on or letting go

–Negativism and toilet training age

• 3 -6 years phallic ; genitals –exploration and discovery ( inc. sexual tension)

–Gender identification and genital awareness

–Oedipus and Electra complex

–Castration anxiety and penis envy

•6-12 years – latency (quiet stage) sexual energy diverted to play. Institution of superego: control of instinctual impulses

•12 – young adult – genital ; reawakening of sexual drives –relationships

–Sexual maturation

–Sexual identity ,ability to love and work

Eric Erickson’s
PSYCHOSOCIAL THEORY

•0-12mos

•1-3y  

•3-6                     

•6-12                  

•12-18                

•18-25                

•25-60                

•60 and above

•TRUST vs. MISTRUST

•AUTONOMY vs. SHAME & DOUBT

•INDUSTRY vs. INFERIORITY

•INITIATIVE vs. GUILT

•IDENTITY vs. IDENTITY CONFUSION

•INTIMACY vs. ISOLATION

•EGO INTEGRITY vs. STAGNATION

•GENERATIVITY vs. DESPAIR

INFANCY

•CONSISTENT MATERNAL –CHILD INTERACTION – TRUST

•INNER FEELING OF SELF WORTH

•HOPE

TODDLER

•ALLOW EXPLORATION

•PROVIDE FOR SAFETY

•“NO, NO” – NEGATIVISM

•OFFER CHOICES / REVERSE PSYCHOLOGY

•TOILET TRAINING – 18 MOS.-BOWEL

–DAYTIME BLADDER: 2 yo

–NIGHTIME BLADDER: 3 yo

•REWARD W/ PRAISE AND AFFECTION

•INDEPENDENCE

PRE-SCHOOL

•PROVIDE PLAY MATERIALS

•SATISFY CURIOSITY

•TEACH AND REINFORCE(HYGIENE,SOCIAL BEHAVIOR)

•SIBLING RIVALRY

•WILLPOWER

SCHOOL AGE

•HOW TO DO THINGS WELL-SUPPORT EFFORTS

•CHUMS AND HOBBIES

•NEEDS TO EXCEL/ACCOMPLISH

•NEED FOR PRIVACY AND PEER INTERACTION

•COMPETENCE

ADOLESCENCE

•MAKE DECISION,EMANCIPATION FROM PARENTS

•BODY IMAGE CHANGES

•NEED TO CONFORM BUT KEEP INDIVIDUALITY

•SELF - AWARENESS

YOUNG ADULT

•COMMITMENT AND FIDELITY

•RESPONSIBILITY

•ACHIEVEMENT OF INDEPENDENCE

MIDDLE ADULTHOOD

•SUPPORT-PERIOD OF ROLE TRANSITIONS

•MIDLIFE CRISIS

•ADJUSTMENT AND COMPROMISE

•MOST PRODUCTIVE AND CREATIVE

•ALTRUISM

LATE ADULTHOOD

•SELF ACCEPTANCE

•SELF WORTH

•WISDOM

Jean Piaget’s
COGNITIVE THEORY

0-2 SENSORIMOTOR

•REFLEXES

•IMITATIVE REPETITIVE BEHAVIOR

•SENSE OF OBJECT PERMANENCE AND SELF SEPARATE FROM ENVT.

•TRIAL AND ERROR RESULTS IN PROBLEM SOLVING

2-7Y  PRE-OPERATIONAL

•SELF-CENTERED,EGOCENTRIC

•CANNOT CONCEPTUALIZE OTHER’S VIEW

•ANIMISTIC THINKING

•IMAGINARY PLAYMATE – SYMBOLIC MENTAL REPRESENTATION – CREATIVITY

•2-4 PRE-CONCEPTUAL (PRE-LOGICAL)

•4-7 INTUITIVE (UNDERSTANDING OF ROLES)

7-12Y CONCRETE OPERATIONAL

•LOGICAL CONCRETE THOUGHT

•INDUCTIVE REASONING (SPECIFIC TO GENERAL)

•CAN RELATE, PROBLEM SOLVING ABILITY

•REASONING AND SELF-REGULATION

12-ABOVE: FORMAL OPERATIONAL THOUGHT

•Abstract thinking

•Separation of fantasy and fact

•Reality oriented

•Deductive reasoning

•Apply scientific method

Havighurst’s
DEVELOPMENTAL TASKS

•Baby to early childhood

–Right from wrong and Conscience

•Late childhood

–Physical skills, wholesome attitude, social roles

–Conscience morality and values

–Fundamental skills in academics

–Personal independence

•Adolescence

–Sexual social roles

–Relationships

–Independence and ideology

•Early adulthood

–Career

–Selecting a mate

–Finding Civic or social responsibility

•Middle age

–Achieving  Civic or social responsibility

–Adjusting to changes

–Satisfactory career performance

–Adjusting to aging parents

–Adjusting to parental roles

•Old age

–Adjusting to changes

–Establishing satisfactory living arrangements and affiliations

Kohlberg’s
 MORAL DEVELOPMENT/ THINKING/ JUDGEMENT

•PRE-CONVENTIONAL (0-6)

–PUNISHMENT AND OBEDIENCE

–OBEDIENCE TO RULES TO AVOID PUNISHMENT

•CONVENTIONAL ( 6-12 )

–MUTUAL INTERPERSONAL EXPECTATIONS,RELATIONSHIPS AND CONFORMITY

–SOCIAL SYSTEM AND CONSCIENCE MAINTENANCE

–BEING GOOD IS IMPORTANT SELF RESPECT OR CONSCIENCE

•POST –CONVENTIONAL (12 – 18 Y)

–PRIOR RIGHT OR SOCIAL CONTRACT

–UNIVERSAL ETHICAL PRINCIPLE

–ABIDE FOR COMMON GOOD

–RATIONAL PERSON-VALIDITY OF PRINCIPLES-AND BECOME COMMITTED TO THEM

–INNER CONTROL OF BEHAVIOR UNDERSTANDING THE EQUALITY OF HUMAN RIGHTS AND DIGNITY OF HUMAN BEINGS AS INDIVIDUALS

Harry Stack Sullivan’s
INTERPERSONAL THEORY

INFANCY

•NEED FOR SECURITY-INFANT LEARNS TO RELY ON OTHERS TO GRATIFY NEEDS AND SATISFY WISHES, DEVELOPS A SENSE OF BASIC TRUST, SECURITY AND SELF WORTH WHEN THIS OCCURS

TODDLERHOOD / EARLY CHILDHOOD

•CHILD LEARNS TO COMMUNICATE NEEDS THROUGH USE OF WORDS AND ACCEPTANCE OF DELAYED GRATIFICATION AND INTERFERENCE OF WISH FULFILLMENT

PRE-SCHOOL

•DEVELOPMENT OF BODY IMAGE AND SELF-PERCEPTION

•ORGANIZES AND USES EXPERIENCES IN TERMS OF APPROVAL AND DISAPPROVAL RECEIVED

•BEGINS USING SELCTIVE INATTENTION AND DISASSOCIATES THOSE EXPERIENCES THAT CAUSE PHYSICAL OR EMOTIONAL DISCOMFORT AND PAIN

SCHOOL AGE

•THE PERIOD OF LEARNING TO FORM SATISFYING RELATIONSHIPS WITH PEERS-USES COMPETITION,COMPROMISE AND COOPERATION

•THE PRE-ADOLESCENT LEARNS TO RELATE TO PEERS OF THE SAME SEX

ADOLESCENCE

•LEARNS INDEPENDENCE AND HOW TO ESTABLISH SATISFACTORY RELATIONSHIPS WITH MEMBERS OF THE OPPOSITE SEX

YOUNG ADULTHOOD

•BECOMES ECONOMICALLY, INTELLECTUALLY AND EMOTIONALLY SELF SUFICIENT

LATER ADULTHOOD

•LEARNS TO BE INTERDEPENDENT AND ASSUMES RESPONSIBILITY FOR OTHERS

SENESCENCE

•DEVELOPS AN ACCEPTANCE OF RESPONSIBILITY FOR WHAT LIFE IS AND WAS AND OF ITS PLACE IN THE FLOW OF HISTORY

TREATMENT MODALITIES

REMOTIVATION THERAPY

•TREATMENT MODALITY THAT PROMOTES EXPRESSION OF FEELINGS THROUGH INTERACTION FACILITATED BY DISCUSSION OF NEUTRAL TOPICS

• STEPS :

                climate of acceptance

                creating bridge to reality

                sharing the world we live in

                appreciation of works of the world

                climate of appreciation

MUSIC THERAPY

•Involves use of music to facilitate expression of feelings, relaxation and outlet of tension

PLAY THERAPY

•enables patient to experience intense emotion in a safe environment with the use of play

•children express themselves more easily in play. revealing as reflection of child’s situation in the family

•provide toys and materials – facilitate interaction – observe and help child resolve problems through play

Group therapy

•Treatment modality involving three or more patients with a therapist to relieve emotional difficulties, increase self – esteem, develop insight , LEARN NEW ADAPTIVE WAYS TO COPE WITH STRESS and improve behavior with others

•IDEAL 8 – 10 MEMBERS

MILIEU THERAPY

•Consists of treatment by means of controlled modification of the patient’s environment to facilitate positive behavioral change

•Increase patient’s

–Awareness of feelings

–Sense of responsibility and

–Help return to community

•clients plan social and group interaction

•token programs , open wards and self medication are done

FAMILY THERAPY

•A METHOD OF PSYCHOTHERAPY WHICH FOCUSES ON THE TOTAL FAMILY AS AN INTERACTIONAL SYSTEM

•PROBLEM IS A FAMILY PROBLEM

•focus on sick members behavior as source of trouble / symptom serve a function for the family

•members develop sense of identity

•points out function of the sick member for the rest of the family

PSYCHOANALYTIC

•focuses on the exploration of the unconscious, to facilitate identification of the patients defenses

•ANXIETY RESULTS BETWEEN CONFLICTS OF ID AND EGO

•Becomes aware of unconscious thoughts and feelings to understand anxiety and defenses

HYPNOTHERAPY

•Various methods and techniques to induce a trance state where patient becomes submissive to instructions

BEHAVIOR MODIFICATION

•Application of learning principles in order to change maladaptive behavior

•Believes that psychological problems are a result of learning

•Everything learned can be unlearned

BEHAVIOR MODIFICATION

•OPERANT CONDITIONING

–Use of rewards to reinforce positive behavior

–Perceived and self-reinforcement becomes more important than external reinforcement

•DESENSITIZATION

–Slow adjustment or exposure to feared objects (phobias)

–Periodic exposure until undesirable behavior disappears or lessens

AVERSION THERAPY

•An example of behavior modification

•Painful stimulus is introduced to bring about an avoidance of another stimulus

•End view: behavioral change

OTHER THERAPIES

•HUMOR THERAPY

–To facilitate expression and enhance interaction

•ACTIVITY THERAPY

–Group interaction while working on a task together

BIOLOGICAL/ MEDICAL THEORY

•EMOTIONAL PROBLEM IS AN ILLNESS

•cause may be inherited or chemical in origin

•FOCUS OF TREATMENT IS MEDICATIONS AND ECT

BIOLOGICAL THERAPY

•ELECTROCONVULSIVE THERAPY

–Artificial induction of a grand mal seizure by passing a controlled electrical current through electrodes applied to one or both temples

–mechanism of action – unclear

–voltage: 70 – 150 volts

–Duration: 0.5 – 2.0 seconds

–6 to 12 treatments

–intervals of 48 hours

•indicators of effectiveness – occurrence of generalized tonic – clonic seizures

•indications – depression , mania and catatonic schizophrenia

•s/e: confusion, disorientation, short -term memory loss, seizure (30-60 sec)

•NPO prior

•Contraindications

–Fever, pregnancy

–Inc ICP, fracture

–retinal detachment

–TB with hemoptysis

–cardiac d/o

•consent needed

•Reorient after, supportive care

•medications given :

–Atropine sulfate: decrease secretions

–Succinylcholine (Anectine): promote muscle relaxation

–Methohexital Sodium ( Brevital ): serves as an anesthetic agent

•common complications:

–loss of memory

–headache

–apnea

–fracture

respiratory depression