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MENTAL HEALTH
⊗ "A state of well-being where a person can realize his or her own abilities to cope with the normal stresses of life and work productively." (WHO) ⊗ A balance in person’s internal life and adaptation to reality. ⊗ A state of well-being in which a person is able to realize his potentials.
Criteria for Mental Health: ⊗ Self-awareness ♦ Ability to: recognize one’s thoughts feelings, asset potentials and weakness. experience genuine feelings as anger, happiness, resentment ♦ Leads to self-acceptance, self-understanding in order to understand others ⊗ Autonomy: ability to function independently and function with others ⊗ Perceptive ability Awareness of stimuli, reality orientation. Orientation to: Time, Place, Person ⊗ Integral capacity: Ability to harmonize psychic forces (id, ego, super ego). ⊗ Self-actuation Ability to adopt to life changes, happy to work with others Satisfaction in every endeavor Genuine cooperation ⊗ Mastery of one’s environment: Awareness of the changes around him
MENTAL HYGIENE
⊗ A science that deals with: Promotive, Preventive, Curative, Rehabilitative aspects of care.
MENTAL DISORDER ⊗ A medically diagnosable illness which results in significant impairment of one's cognitive, affective or relational abilities and is equivalent to mental illness.
MENTAL ILLNESS ⊗ A state in which an individual shows deficit in functioning and is unable to maintain personal relationship. ⊗ A state of imbalance characterized by a disturbance in a person’s thoughts, feelings and behavior ⊗ Factors that increase the risk: Crises, Abuses, Poverty
Criteria for Mental Disorder / Mental Illness: ⊗ Dissatisfaction with: one’s characteristics, abilities and accomplishments one’s place in the world ⊗ Ineffective: interpersonal relationship coping or adaptation to the events in one’s life
PSYCHIATRIC NURSING ⊗ An interpersonal process ⊗ Concerned with all the aspects of care ⊗ Both a Science and an Art Science – uses different theories Art - therapeutic use of self ⊗ Clientele: Individual, family and the community Both mentally healthy and mentally ill
Main tool of the nurse: Therapeutic use of self
Characteristics of a Good Psychiatric Nurse: ⊗ Empathy ⊗ Genuineness ⊗ Congruence ⊗ Unconditional positive regard
THE PSYCHIATRIC SETTING
Admitting a Client in the Psychiatric Setting
Areas to be assessed: ⊗ Health perception ⊗ Orientation ⊗ Metabolic pattern ⊗ Elimination pattern
⊗ Cognitive pattern: Judgment, Insight, Memory ⊗ Activity and exercise pattern ⊗ Thought process ⊗ Sleep-rest pattern
Disturbances in Motor Activity ⊗ Echopraxia - the pathological imitation of posture/action of others ⊗ Waxy flexibility - maintaining the desired position for long periods of time without discomfort ⊗ Akinesia - loss of movement ⊗ Bradykinesia - slowness of all voluntary movement including speech ⊗ Ataxia - loss of coordinated movement ⊗ Automatism - repeated purposeless behavior
Disturbances in Memory ⊗ Confabulation - filling in of memory gaps ⊗ Amnesia - inability to recall past events
- Anterograde - immediate past
- Retrograde - distant past ⊗ Déjà vu - a subjective feeling that an experience which is occurring for the first time has been experienced before ⊗ Jamais vu – a feeling that the familiar does not seem familiar ⊗ Dementia
- gradual deterioration of intellectual functioning
- results in decreased capacity to perform ADL
Other behavioral signs & symptoms ⊗ Agitation – a state of anxiety associated with motor restlessness ⊗ Agnosia - inability to recognize and interpret sensory stimuli ⊗ Akathisia - a feeling of muscular quivering, an urge to move about constantly and an inability to sit still ⊗ Ambivalence - presence of two opposing feelings at the same time ⊗ Delirium - refers to acute change or disturbance in a person's: LOC, cognition, emotion , perception ⊗ Derealization - feeling of strangeness towards the environment ⊗ Dysthymia - persistent state of sadness ⊗ Elation (euphoria)- feeling of expression of excitement ⊗ Mutism – refusal to speak ⊗ Narcolepsy - sleep disorder characterized by frequent irresistible urge to sleep with episodes of cataplexy (sudden loss of muscle power) ⊗ Insomnia – inability to attain enough sleep ⊗ Hypersomnia – excessive sleep ⊗ Parasomnia – abnormal sleep behavior
USE OF APPROPRIATE COMMUNICATION TECHNIQUES
Communication: reciprocal exchange of ideas between or among persons
Modes: ⊗ Verbal - written/spoken ⊗ Non-verbal - posture, tone of voice, facial expression
Types of Non-verbal communication: ⊗ Kinesis
- body movement
- eye contact
- gestures ⊗ Paralanguage
- voice quality
- non-language vocalization (crying, sobbing, moaning) ⊗ Proxemics – law of space relationship ⊗ Touch – physical act ⊗ Cultural artifacts ⊗ Meta communication
- based on role expectations
- hidden meaning of words
Elements:
(Channel)
(Context)
Message
FEEDBACK
Therapeutic Communication: a way of interacting in a purposeful manner to promote the client’s ability to express his / her thoughts and feelings openly.
Essentials for a Therapeutic Communication: ⊗ Genuineness ⊗ Respect ⊗ Empathy ⊗ Attentive listening ⊗ Trust (rapport)
G R^ E^ A^ T
Phase Anxiety Tasks Working / Therapeutic Phase ⊗ it is highly individualized ⊗ more structured than the orientation phase ⊗ the longest and most productive phase ⊗ limit setting must be employed
None (^) ⊗ Major task: identification and resolution of the patient's problems ⊗ planning and implementation Teach Learn Change
Problems: ⊗ Transference the development of an emotional attitude towards the nurse positive or negative ⊗ Counter transference – experienced by the nurse / therapist Termination Phase Patient (^) ⊗ Reinforce and reward change and strength of patient ⊗ Encourage expression of feelings about termination of the relationship ⊗ Summarize the progress ⊗ Terminate the relationship without giving promises
THEORIES OF HUMAN DYNAMICS
Psychosexual Development: Sigmund Freud
Levels of Consciousness and the Psychic Forces
Ego (Reality)
Superego (Moral)
Id (Pleasure)
⊗ Libido - the instinctual drives ⊗ Regression and fixation are common terms in this theory. ⊗ Gave prominence to sexual feelings: defined "sex" as anything that gives gratification
Stages:
Oral Stage (0-2 years) ⊗ The area of gratification is the mouth ⊗ Pleasures: sucking activities like fingers, toes or nipples ⊗ Dissatisfaction: resurface at a later age overeating, smoking, nail-biting
Nursing Implication: ⊗ Provide oral stimulation by giving pacifiers Breastfeeding may provide more stimulation ⊗ Do not discourage thumb sucking
Anal Stage (2-4 years) ⊗ Children's attention is focused on the anal region. ⊗ Pleasure: elimination ⊗ Covers the ideal age for "toilet training" (2 1/2 years) ⊗ 2 concepts: Holding on Letting go
Neurosis
Psychosis
Psychosocial Development Theory: Erik Erikson
⊗ Childhood is very important in personality development. ⊗ Rejected Freud's attempt to describe personality solely on the basis of sexuality believed that social factors greatly affect felt that personality continued to develop beyond five years of age.
Period of Life Primary Person
Positive Resolution Negative Resolution
Infant 0-18 months (Hope)
Trust vs. Mistrust
Maternal person
o Reliance on the caregiver o Development of trust in the environment
o Fear, anxiety and suspicion o Lack of care, both physical & psychological by caretaker leads to mistrust of environment Toddler 18 mos. to 3 years (Willpower)
Autonomy vs. Shame/Doubt
Paternal person
o Sense of self-worth o Assertion of choice and will o Environment encourages independence, leading to sense of pride
o Loss of self-esteem o Sense of external control may produce self-doubt in others
Preschool 3 to 6 years (Purpose)
Initiative vs. Guilt
Family o The ability to learn to initiate activities, to enjoy achievement and competence
o The inability to control newly developed power o Realization of potential failure leads to fear of punishment and guilt
Schooler 6 to 12 yrs. (Competence)
Industry vs. Inferiority
Neighbors/ School
o Learning the value of work o Acquiring skills and tools of technology o Competence helps to order life and make things work
o Repeated frustrations and failures lead to feelings of inadequacy and inferiority that may affect their view of life
Adolescent 12 to 18 yrs, (Fidelity)
Identity vs. Role confusion
Peer group o Experiments with various roles in developing mature individuality
o Pressures and demands may lead to confusion about self
Period of Life
Primary Person
Positive Resolution Negative Resolution
Young Adult 18 to 24 yrs. (Love)
Intimacy vs. Isolation
Partners in friendship
o A commitment to others o Close heterosexual relationship and procreation
o Withdrawal from such intimacy, isolation, self- absorption and alienation from others
Middle Adult 24 to 54 yrs. (Care)
Generativity vs. Self- absorption
Partner o The care and concern for the next generation o Widening interest in work and ideas
o Self-indulgence and resulting psychological impoverishment
Late Adult, 54 yrs. to death, (Wisdom)
Integrity vs. Despair
Mankind o Acceptance of one’s life o Realization of the inevitability of death o Feeling of dignity and meaning of existence
o Disappointment of one’s life and desperate fear of death
Cognitive Development Theory: Jean Piaget
Stages: Sensorimotor (0-2 years) ⊗ Reflex to complex ⊗ Begins to organize visual images and control motor responses ⊗ Coordinates sensory impressions ⊗ Pre-verbal stage
Preoperational Stage (2-7 years) ⊗ Transitional period ⊗ Egocentric and irreversible thinking ⊗ Words become symbols for objects – symbolic thinking ⊗ Formation of ideas of categorization ⊗ Lack of ability to go back and rethink a process or concept. ⊗ Mental image – the symbolic process which are evident in plays ⊗ Construction of verbal schemas – preconcepts
Level Three (Post Conventional Morality)
- The individual recognizes the arbitrariness of social and legal conventions.
- The individual attempts to define moral values that are separate from group norms.
Stage 5
- Behavior recognizes the laws as arbitrary and changeable.
- For aspects of life not governed by laws, right and wrong are personal decisions based on agreement and contracts. Stage 6
- Morality is based on respect for others rather than on personal desires.
- The individual conforms to both social standards and to internalized ideals to avoid self- condemnation rather than to avoid social censure.
Other Theories
Behavioral Model (Ivan Pavlov, John Watson, B. F. Skinner) ⊗ Behavior is:
- a response to a stimulus from the environment
- learned and retained by positive reinforcement
Interpersonal Model (Harry Stack Sullivan) ⊗ Focused on the role of the environment and interpersonal relations as the most significant influences on a individual’s development ⊗ Anxiety is communicated interpersonally
Human Motivational Need Model. (Abraham Maslow) ⊗ Hierarchy of needs in order of importance ⊗ Primary needs (physiologic) need to be met prior to dealing with higher level needs
Psychobiologic Model ⊗ Focus is in mental illness as a biophysical impairment. ⊗ Human behavior is influenced by genetics, biochemical alterations and function of brain and CNS. ⊗ The stress response is a neuroendocrine response
PSYCHOTHERAPY
⊗ A process in which a person enters into a contract to interact with a therapist to relieve symptoms, resolve problems in living and seek personal growth
INDIVIDUAL THERAPY: Is a confidential relationship between client and therapist. ⊗ Hypnotherapy: Involves various methods and techniques to induce a trance state where the patient becomes submissive to instructions ⊗ Humor therapy: Use of humor to facilitate expression of feelings and to enhance interaction ⊗ Psychoanalysis: Focuses on the exploration of the unconscious, to facilitate identification of the patient's defenses
GROUP THERAPY
- minimum number : 3
- Ideal number :8-
Advantages:
- decreases o isolation o dependence
- develops o coping skills o interpersonal learning o opportunities for helping others o ability to listen to other members
⊗ Remotivation Therapy: Promotes expression of feeling through interaction facilitated by discussion of neutral topics
⊗ Family therapy: A method in which family members gain: o insight into the problems o improve communication o improve functioning of individual members as well as the family as a whole. o It focuses on the total family as an interactional system
⊗ Milieu Therapy
- A therapeutic environment is organized to: o encourage and assist the client to control problematic behavior o function within the range of social norms
⊗ Play therapy
- Effective for children suffering from maladjustment or behavior disorder.
- The child is usually placed in a play room
- Purpose - to discover the causes of the child's conflict through observation of his play and to interpret it to the child.
- Implosive therapy o The clients are exposed abruptly to intense forms of anxiety producers, either in imagination or in real life
- Cognitive Behavior therapy o Uses confrontation as a means of helping the clients restructure or rearrange irrational beliefs, maladaptive thinking, perception-, and behaviors. o Used for depression and adjustment difficulties.
- Biofeedback o Teaches the clients to control or change aspects of their internal environment.
- Aversion therapy o Uses unpleasant or noxious stimuli to change inappropriate behavior. o Examples o Antabuse to treat alcoholics
- Assertiveness Training o Clients are encouraged and taught how to appropriately relate to others
- Token-economy: Utilizes the principle of rewarding desired behavior to facilitate change.
ELECTROCONVULSIVE THERAPY (ECT)
- Exact mechanism is unknown
- Requires a consent
Voltage : 70-150 volts Length : .5-2 seconds Frequency : 6-12 treatments Interval : 48 hours Indicator : tonic-clonic seizure
Indications of use:
Contraindications:
- Fever
- Increased ICP
- Cardiac conditions
- TB with history of hemorrhage
- Unhealed fracture
- Retinal detachment
- Pregnancy
- Osteoporosis
Before the procedure:
- Take vital signs
- Diagnostic procedures o X-ray o ECG o EEG
- Drugs given o Atropine sulfate (decrease secretions) o Anectine (Succinylcholine) (relax muscles) o Methohexital Na (Brevital) (anesthetic) During the procedure:
- Observe for tonic-clonic seizure
- Priority: Airway
After the procedure:
- Position
- Check vital signs
- Reorient the client
- Watch out for complications: o Memory loss o Headache o Apnea o Respiratory depression o Fracture
BASIC CONCEPTS ON PSYCHOPHARMACOLOGY
MAJOR TRANQUILIZERS/ ANTIPSYCHOTICS
⊗ Indication: Schizophrenia and Other Psychosis ⊗ Desired effect: control of symptoms ⊗ Best taken after meals ⊗ MOA: Block selected dopamine receptors decrease dopamine reduce symptoms
Types Typical Atypical Examples • Haloperidol
- Mellaril
- Thorazine
- Risperdal
- Seroquel
- Clozaril Disadvantages • EPS
- Treats (+) symptoms only
- Expensive
- Less available
- More agranulocytosis
MINOR TRANQUILIZERS/ ANXIOLYTICS
⊗ Common indication: Anxiety disorders ⊗ Desired Effect: Decreased anxiety, adequate sleep ⊗ Have sedative effects
Examples: (XL VASET) Xanax (Alprazolam) Librium (Chlordiazepoxide ) Valium (Diazepam) Ativan (Lorazepam) Serax (Oxazepam) Esquanile Tranxene (Chlorazepate Dipotassium) Nursing Implications:
- Best taken before meals
- Advise to avoid driving
- Administer it separately with any drug
Anxiolytics +
- Alcohol = severe hypotension / hypersedation
- Another anxiolytic = respiratory depression death
- Other drugs = CNS depression
- Stimulants = less effective
ANTIDEPRESSANTS
Desired effects: increased appetite, adequate sleep
Tricyclic Antidepressants
Examples:
- Imipramine (Tofranil) • Amitriptyline (Elavil)
Nursing Implications: ⊗ Best given after meals ⊗ Effectivity: after 2-3 weeks ⊗ Check the BP, it causes hypotension ⊗ Check the heart rate, it causes cardiac arrythmias ⊗ Monitor I & O ⊗ Monitor for signs of increased IOP
MAO INHIBITORS
Indication: refractory depression
Examples:
- Tranylcypromine (Parnate)
- Phenelzine (Nardil)
- Isocarboxazid (Marplan)
Nursing Implications: ⊗ Best taken after meals ⊗ Report headache; it indicates hypertensive crisis ⊗ Avoid tyramine containing foods like:
- Avocado
- Banana
- Cheddar and aged cheese
- Soysauce
- Preserved foods ⊗ Effectivity: 2-3 weeks ⊗ Monitor the BP ⊗ There should be at least a two-week interval when shifting from one anti- depressant to another
Selective Serotonin Reuptake Inhibitors
- Fluoxetine (Prozac)
- Celatopram (Celexa)
- Sertraline (Zoloft)
- Paroxetine (Paxil)
- Fluvoxamine (Luvox)
Nursing Implications: ⊗ Avoid the use of:
⊗ Monitor PTT, PT ⊗ Never give to pregnant / lactating mothers.
ANTI-MANIC AGENT
Examples:
- Lithium Citrate (Cibalith
- S)
- Lithium Carbonate (Eskalith, Lithane, Lithobid)
PaNaMa
