Chapter OneFoundations of Psychiatric Mental Health NursingMental Health The WHO defines health as a state of complete physical, mental, and social wellness, not merely the absence of disease or infirmity.

Mental health is influenced by individual factors, including biologic makeup, autonomy, and independence, self-esteem, capacity for growth, vitality, ability to find meaning in life, resilience or hardiness, sense of belonging, reality orientation, and coping or stress management abilities; by interpersonal factors, including effective communication, helping others, intimacy, and maintaining a balance of separateness and connectedness; and by social/cultural factors, including sense of community, access to resources, intolerance of violence, support of diversity among people, mastery of the environment, and a positive yet realistic view of the world

Mental Illness The APA (2000) defines a mental disorder as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.

Deviant behavior does not necessarily indicate a mental disorder.

Diagnostic and statistical manual of mental disorders The DSM-IV-TR is a taxonomy published by the APA. The DSM-IV-TR describes all mental disorders, outlining specific criteria for each based on clinical experience and research.

The DSM-IV-TR has 3 purposes: To provide standardized nomenclature and language for all mental health professionals. To present defining characteristics or symptoms that differentiates specific diagnoses. To assist in identifying the underlying causes of disorders.

A multiaxial classification system that involves assessment on several axes, or domains of information, allows the practitioner to identify all the factors that relate to a persons condition. Axis I is for identifying all major psychiatric disorders except MR and personality disorders. Examples include depression and schizophrenia. Axis II is for reporting mental retardation and personality disorders as well as prominent maladaptive personality features and defense mechanisms. Axis III is for reporting current medical conditions that are potentially relevant to understanding or maintaining the persons mental disorder as well as medical conditions that might contribute to understanding the person. Axis IV is for reporting psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of mental disorders. Included are problems with the primary support group, the social environment, education, occupation, housing, economics, access to health care, and the legal system. Axis V presents a Global Assessment of Functioning which rates the persons overall psychological functioning on a scale of 0 to 100. This represents the clinicians assessment of the persons current level of functioning. All clients admitted to a hospital or psychiatric treatment will have a multiaxis diagnosis from the DSM-IV-TR.

Self-awareness issues Self-awareness is the process by which the nurse gains recognition of his or her own feelings, beliefs, and attitudes.

It is an ART because the essential tool used is the Self. A psychiatric nurse should be a role model, a change agent and employ the Therapeutic Use of the Self (TUS) which is the ability to use ones person consciously and with full awareness so as to establish relatedness and to structure nursing interventions, ability to use self deliberately and intentionally therapeutically A nurse should develop Self-awareness which according to Taylor, is the ability to experience genuine feelings of joy, anger and resentment as well as beliefsExample: A male nurse had a fight with his wife. He controlled his feelings, went to work and assigned to 3 patients on physical restraints. One patient while being fed, spewed his food on the male nurse. The latter reacted by kicking the patient resulting to rupture of bladder. As a consequence, he was relieved of his job.

To demonstrate self awareness: if only the nurse was truthful to himself, he could ask his supervisor to assign him elsewhere doing difficult duties because he cant handle the stressful job due to his personal problem.

CBQ #1: What is the most difficult part in the therapeutic nurse-patient relationship?a. to remain professional at all timesb. to establish trust-patient resistance due to experiencec. to exhibit empathyd. self awarenessAnswer: D, self awareness

CBQ #2: Factor that strains therapeutic nurse-patient relationship?Answer: Counter transference-you see one person in another person CBQ #3: Client went to assaultive behavior, what should the nurse do?a. Call restraining team- practice in NCMHb. Call doctor- answer as MDc. Give neuroleptics- ideal answerd. Self awareness- local board answerAnswer: D, according to Keltner, give the client the right to receive the least restrictive environment

3 Scopes of Psychiatric Nursing Practice:1. Caring for psychologically ill client in general hospital or medical center Psychiatric nursing also have specialty areas such as adult and child Psychiatric nursing liaison is employed in medical centers to handle the psycho-social concern of psychologically ill clients Role of the nurse is as a facilitator bringing out the clients fears and anxieties

2. Community Mental Health Nursing (CMHN) The application of the principles of psychiatric care in communities & groups of people History of CMHN: Mental Health Nursing started, where big mental institutions provide custodial care (physical care such as feeding and bathing only) of the clients. This resulted to develop Social Breakdown Syndrome, a complication of mental illness (CBQ) wherein clients remained apathetic. Apathyis a complete absence of feelings or state of indifference in situations where in a normal person can elicit responses.

3. Caring for the Mental Health Consumers in a psychiatric institution

3 Levels of Prevention in CMH Centers: (CBQ)Level of PreventionClientsAspect of Care

PrimaryWella. Promotion of M. H.b. Prevention of M.I.c. Crisis Intervention

SecondarySicka. Case Findingb. Institute Immediate Treatment

TertiaryRecovereda. Follow upb. Prevent further complicationsc. Job placement

CBQ #1: Which of the following aspects of care specifically focus on primary care?a. promotion of mental healthb. prevention of illnessc. crisis interventiond. teaching sex education among adolescent & old peopleAnswer: D, all are correct but this is more specific

CBQ #2: To institute immediate treatment is this?a. Primary careb. Secondary carec. Tertiary careAnswer: B, secondary care because patient is already sick

PRIMARY Level of Prevention

A. Promotion of Mental Health (MH):According to WHO, the Definition of Mental Health:1. It is the ability to maintain an emotional well being 2. It is the ability to handle normal stresses of life3. It is the ability to see self as others do and must fit in the society or culture where one belongs or lives

6 Concepts/Criteria of Positive Mental Health (according to Marie Jahoda):1. Knowledge of Self ability to recognize and use God given talents/potentials and positive points (assets) & accepting negative points (liabilities) turning it into something positive healthy or normal narcissism is seen in infants & become pathologic if you reach adolescent years mentally healthy person will strive to avoid his liabilities through enhanced self-awareness by giving an opportunity to do the JOHARI Window by Joe Luft and Harry Ingham

4 Quadrants of Life or 4 Windows of LifeI. Public Self Known to self and othersII. Blind Spot Bad breath area because unknown to self but known to others Take the risk It brings anxiety to know the truth

III. Private Self Secrets, masks, pretences & hypocrisy Known to self but unknown to othersIV. Unconscious Unknown to self and others

Principles involved in the use of JOHARI Window to enhance self awareness:a. Change in any quadrant affects all the rest of the quadrantsb. Bigger the Q III, poor communication/interpersonal relationships How to improve Johari Window?1) Go into self disclosure by opening up to a friend2) Feedback mechanism by constructive criticism c. Bigger the Q I, good communication/interpersonal relationships

CBQ: Can a nurse be self revealing?Answer: Yes, as long as it has a professional objective, refocus with empathy done only for 30 minutes

5 Levels of Communication in Johari Window:a. Clich (meaningless phrase)b. Gossipc. Ideas and judgment-trying to keep knowledgeable to compensate what is lacking like confidenced. Feelings-suppress feelings but never dies & come later as..e. Guts-you should take the risk of blurting deep darkest secret

2. Perceptive Ability is awareness of our environmentExample: A normal mentally well person who feels cold will get a blanket but a psychotic person is oblivious of the climate

3. Integrative Ability is the ability to harmonize the 3 Psychic Forces of Sigmund Freud: a. IDacts on pleasure, without morals, cant wait & impulsiveb. EGO-acts on reality principle, the one deciding, can wait, can satisfy the needs of ID and restrictions of SEc. SUPEREGOacts on moral principle and the good conscienceMentally HealthyStrong IDStrong Superego(Balanced)(Antisocial PD)(Depression)

4. Autonomous Behavior is the ability to decide wisely5. Desirous growth, development and self actualization is the ability to reach for the highest Example: Graduating, passing the licensure examinations and going to further studies6. Mastery of ones environment is the ability to adjust and adapt how you do anything is how you do everything

Roles of a Psychiatric Nurse:1. Mothering supervision of feeding & grooming that entails touching the client, so the nurse should be assessed first orchestrating the clinical activities in the area Example: Schizophrenia/Paranoid-mothering is CI, they may react violently Anti-social PD-mothering is CI, they have been smothered by too much mothering before, everything was given to them & they didnt experience any disappointments & frustrations2. Teacher Example: Nurse teaches a manic client to wear make-up/clothes properly3. Technician know the scientific principle behind nursing procedure develop systematic ways of doing nursing jobs Example: Nurse explains to client the importance of turning head to one side after a tonic clonic convulsion during ECT to prevent aspiration pneumonia4. Socializing Agent 2 Types:a. Active socializing role-initiating social gatherings, presentations & dancing activitiesb. Passive socializing role-staying with mute patients5. Counselor providing outlet for patients anxieties & hostilities nurse should avoid giving advices, suggestions & opinions nurse should assess the clients level of anxietyMild-therapeutic; motivates an individualModerate-give activitiesSevere-invite client into brisk walkingPanic-nurse should stay put only & presence gives assurance to the client6. Creator of Therapeutic Environment to produce a warm, homelike accepting atmosphere

3 Essential Skills of a Psychiatric Nurse:1. Communication2. Observation: to take notice of something which another person might missa. Appearance-observe patient from head to foot, look at the eyes first (window of the soul)Example: Depressed client-sad facial expression, droopy posture, downcast eyes, slow movement=prevent suicideb. BehaviorExample: Manic client-too happy, arms crossed & face sideways Paranoid-refuse to eat because of suspiciousness Depressed-refuse to eat because of feeling of worthlessnessc. Conversation-the manner the patient talksExample: Bipolar-client with pressured speech Depressed-monosyllabic Schizophrenia-incomprehensible responses3. Recording & Reporting Official account of things done Avoid psychiatric terms, it should be per patients verbatim Charting Aides:a. Quotation marks-used to quote the exact verbatim of the clientExample: may boses, papatayin ko silab. Parenthesis-used to validate words preceding the parenthesisExample: sino sila? (ang mister ko at babae nya)c. Short dashes-used to validate words which were mumbled by the clientExample: may boses..ingat silad. Long dashes-used to complete an incomplete statementExample: masakit-----meaning the client didnt say anything else

Communication defined as an exchange of my world of meaning with your world of meaning is the reciprocal or mutual exchange of ideas, feelings, values, beliefs, information & attitudes between 2 persons or among a group of persons clarify or validate first the clients feelings & expression before drawing a conclusion According to Davis, context (CBQ) is the physical setting or constraints where communication took place

Types of Communication:1. Verbal-the transmission of a message using spoken or written word2. Non-verbal actions or behaviors that communicate a message without speaking listen to what the other person is not saying more reliable of true feelings because less conscious reflective of ones attitude

Subtypes of Non-verbal communication:a. Kinesis-the study of communication through body movement or body language; Kinesics-is a science of understanding body movement 3 Forms of Kinesis:1) Facial expression-the eyes & the corner of the mouth are 2 areas of the face that are least susceptible to controlExamples: Bipolar, manic-sizing upSchizophrenia-evasiveWorried-knitted forehead

2) Eye contactDimming of lights-looking at a stranger with an 8 feet distance and subsequently averting of our eyes as a sign of respect to the stranger (Hall) _________________________________________________________________________________________________PRELIMSCare Of Clients with Maladaptive Patterns of Behavior

Examples:Prepared By: Ms. April Anne D. Balanon Page 9 of 9 GreywolfRed

Paranoid-poor eye contactSchizophrenia-empty looksManic-super happy but eyes have no glowDepressed-sad looks, drooping eyes

3) Gestures: Examples a) Thumb pointing to the pocket-unconsciously telling you to look at his bulging penisb) Repetitive movement-according to Freud, doing repetitively is sexual in naturec) Semi-reclining position with crossed legs & both hands placed at nape-superiorityd) Drawing pointed & straight object-phallic personalitye) Hands on top of lap-ready to talk or discussf) Crossed arms & legs-defensiveg) Hands on pocket-ready to fighth) Applying lipstick in front of others-to look at my kissable lips

b. Proxemics is the study of peoples use of interpersonal space is the law of space relationship or spatial relationship (CBQ)

2 Forms of Proxemics:1) Territoriality is the marking off & defending of certain areas as their own permanent space that we prevent from intrusion2) Personal Space is a zone of space surrounding a person that is felt to belong to that person temporary space that we prevent from intrusion Interpersonal Distance Zones:a) Intimate=6-8 inches as in parents, children, loversb) Personal=1.5-3 feet as in close friends; according to Hall, comfort zone is the arms lengthc) Business=4-12 feet as in gatherings, friends & work situations Persecutory Stance-exhibited by persons who were subjected to persecution (sarcasm or ridicule) by their loved onesd) Public=12 feet and beyond as in concerts & public performances; CBQ: Paranoid clients-nearest distance is 4 feet

c. Paralanguage refers to how something is said rather than what is said false language or beyond the language itself (CBQ)2 Forms:1) Voice quality-tone of voice2) Non language vocalization-crying, sobbing

d. Touch-physical act & not always sexual in nature; according to Keltner, touch clients with warning

3. Symbolical-sending flowers to loved ones as an expression of love

Therapeutic Communication Definition: The process in which the nurse consciously utilizes the principles of communication in a goal directed professional framework According to Kaplan, it involves active listening while understanding the client providing insight (awareness as to ones mental condition) & clarification (encourage the expression of feelings accurately) Therapeutic communication techniques has to have: respect, warmth, genuineness and empathy (entering into the life situation of the person or the objective understanding of how patients feel or how they see their situation)

4 Important Aspects of Therapeutic Communication:1. Active Listening attentiveness to the client in a physical & psychological manner paying close attention to verbal & non-verbal communication5 Aspects of Physical Attending according to Kozier:a. Face to face contact with the client-face client squarelyb. Maintain eye contactc. Lean forward toward the client shows interestd. Relatively relaxed positione. Open posture CBQ: The nurse must not interact with crossed arms & legs to the client because it decreases or loses attention on part of nurse & experiences the same feeling or situation from the client

2. Understanding impart to the client that you understood them by showing empathy (CBQ)-entering into the life situation of client by perceiving his current situation or problem or putting oneself into the clients shoe avoid sympathy because it tends to push client into feelings of hopelessness & worthlessness; it has 2 elements: pity & condolence-nurse becomes subjective & emotional (introjection), so if nurse experienced nape pain, shes unconsciously absorbing the feelings of the client

3. Insight is the awareness to ones mental condition the aim of the nurse is for the client to realize that he has a problem, thus the nurse should be truthful, compassionate & trustworthy

4. Clarification asking client to restate, elaborate or give examples of ideas or feeling encourage client to express feelings more accurately, elaborately & specifically

Avoid the following Non Therapeutic Techniques:

Dont worry statements it gives client false reassurances it belittles his feelings expressed or connotes that feelings are non valid Example: Nurse-You dont need to worryWhy questions Dont use why as a universal rule because it seeks explanation or reasons that are subjective, conclusive, judgmental & threatening involving the client to thinking process wherein the client is already preoccupied with hallucinations & delusions Any question that puts the client to the defensive side Example: Nurse-What made you think about that? Except for this CBQ: Scenario-Patient is standing in front of the window, Nurse asked-Why are you standing in front of the window?Answer: Nurse uses the nursing process of assessment-SEAS S-afety needs of client E-ncourage to express feelings A-ssist in solving problems S-olving problems=never solve problems for the client, nurse should assist only to avoid parasitic relationshipExploratory statements (How) Avoid deep probing question by using how at a minimum level the psychiatrist can use how & why because their role is to determine the reason behind the clients feeling the nurse role is to allow the expression of clients feelingsAuthoritarian remarks emphasizing the rules & regulations in the clinical area according to Kaplan, forget the real/actual world of nursing, when answering the board exam so stick with the ideal (Ivory tower of nursing), go back to the references Example: Nurse-Im sorry that smoking is not allowed but I understand that its difficult.Nurse focus statement blocks the clients opportunity to express feelings by grabbing the limelight from the client Example: Client is telling the nurse about his problems then the nurse relates similar problems of her ownClose-ended questions questions answerable by yes or no these questions can be used only during the orientation phase because the nurse is gathering the demographic data of client or when assessing the safety needsAgreement with the client indicating accord with the client important to know the psychopathology of hallucinations & delusionsa. its the client defensive coping mechanism against overwhelming anxiety, desires & inner conflicts which emanated from a loss, danger or threatb. these desires are serviceable or important to the clientc. these desires are projected thoughts of the client (this is what they want in real)Disagreeing with the client opposing the clients ideas Example: Nurse-Thats not true..youre wrongDefending Attempting to protect someone or something from verbal attack Example: Nurse-This hospital has a fine reputationGiving advice Telling the client what to do Example: Nurse-I think what you should do is or What dont youParroting

Therapeutic Communication Techniques:1. Reflecting verbalizing stated or implied clients feelings encourage to listen to ones feelings first, repeat what the client said but turn his statement from declarative to interrogatory Example: Client-Maam, hes breaking up with me. Nurse-Hes breaking up with you? What do you feel about this break up?

2. Presenting reality or giving correct information reporting events as they really are offering a view of what is real & what is not without arguing with the client Example: Client-ikaw! Ikaw yung nasa panaginip ko, papatayin mo ako!. Nurse-Im the nurse of the clinical area.

3. Empathy entering into the life situation of the person objective understanding of how patient feel or how they see their situation Example: Nurse-I understand how you feel today.

4. Voice out doubts Expressing uncertainty about the reality of clients perception & conclusions Example: Nurse-I think that is very unusual.

5. Open-ended questions allowing client to tell his story without constraints Example: Nurse-How can I help you

6. Confrontation (CBQ) focuses the clients attention on the resistance by heightening his awareness & inviting an explanation Example: Client-This is the only time that I have peace of mind, now that we are divorced (but client is crying) Nurse-You said that..but I see that youre crying.

7. Suggesting collaboration (CBQ) offering to work with client toward a goal making arrangement/agreement with the client Example: Nurse-Perhaps you & I can determine the source of your anxiety

8. Encouraging comparison asking client to verbalize similarities, differences & perceptions Example: Nurse-Was your experience similar to what had happened when you were 7 years old?

9. Formulating a plan of action (CBQ) Example: Nurse-Next time you hear voices ordering you to kill, what will you do?

10. Giving recognition (CBQ) Example: Nurse-Ive noticed you have combed your hair today.

11. Making observation commenting on what the nurse perceives Example: Nurse-Ive noticed that you are pacing the floor, you seem upset.

12. Role playing Example: Nurse-What will you tell me if I were your boss?

13. Focusing directing flow of interaction by pursuing a topic until its meaning is clear Example: Nurse-You were telling..

14. Paraphrasing restating the content of message Example: Client-Maam, hes coming back Nurse-You mean that youre going to live together again

15. Offering general leads promotes freedom of response Example: Nurse-Where would you like to begin?

16. Summarizing pulling together the salient points of an interaction reviewing main points & conclusions Example: Nurse-For the last 30 minutes, we have been discussing.

17. Validation checking perception of clients verbalizations, remarks, feelings & plans Example: Client-Something will happen soon, my husband & I are going to see each other soonNurse-What you mean by saying that? Tell me about it