NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*MEDTECH

LET*PSYCHOMET*RESPIRATORY THERAPY*CIVIL SERVICE*NAPOLCOM

NCLEX*DHA*HAAD* PROMETRIC* UK-CBT

HANDOUTS
PSYCHIATRIC NURSING
Prepared by: Prof. Archie D. ALviz,
RN, RM, MAN

NURSE CLIENT RELATIONSHIP

- SERIES OF INTERACTION BETWEEN THE NURSE AND THE CLIENT
- GOAL: POSITIVE BEHAVIORAL CHANGE – CHANGE FOR THE BETTER
- BEGINS AT ORIENTATION
- ONLY TOOL AVAILABLE FOR NURSE: SELF (SELF AWARENESS)

Elements of Therapeutic Relationship

T-TRUST
R-RAPPORT
U-UNCONDITIONAL (+) REGARD - ACCEPTANCE
S-SET LIMITS
T-THERAPEUTIC USE OF SELF – THERAPEUTIC COMMUNICATION

THERAPEUTIC BEHAVIOURS:
1. GENUINENESS: SINCERITY AND HONESTY
2. CONCRETENESS: ABILITY TO IDENTIFY CLIENT’S FEELINGS
3. RESPECT: CONSIDERATION OF THE PATIENT AS A UNIQUE BEING

PHASES OF THERAPEUTIC RELATIONSHIP:

1. PRE-INTERACTION/PRE-ORIENTATION
o NO CONTACT WITH CLIENT
o DATA FROM SECONDARY SOURCES (CHARTS, JOURNAL, BOOKS)
o DEVELOP SELF-AWARENESS
2. ORIENTATION/INTERACTION
o ESTABLISH TRUST
o ASSESS CLIENT
o ESTABLISH MUTUAL AGREEMENT
o INFORM ABOUT TERMINATION
3. WORKING
o LONGEST PHASE
o ACHIEVING GOALS, SHARING FACTS
o RESOLVE THE PROBLEM (HIGHLY INDIVIDUALIZED)
4. TERMINATION
o MOVING TOWARDS INDEPENDENCE
o OBSERVE FOR REGRESSIVE BEHAVIOURS

Therapeutic Communication: Elements

1. Sender- the source of message, ENCODER
2. Message- the information transmitted
3. Receiver- recipient of message
4. Feedback- receiver’s response to the message
*BARRIERS: INHIBIT COMMUNICATION PROCESS
 NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*MEDTECH
LET*PSYCHOMET*RESPIRATORY THERAPY*CIVIL SERVICE*NAPOLCOM
NCLEX*DHA*HAAD* PROMETRIC* UK-CBT

THERAPEUTIC COMMUNICATION

NON- VERBAL COMMUNICATION

1. Proxemics- the “physical space” between the sender and receiver (3-6 FT/ONE
ARM AND A HALF)
2. Kinetics- the body movements such as gestures, facial expressions and
mannerisms
3. Touch- intimate physical contact
4. Silence- AGREEING, LISTENING, ENCOURAGE CLIENT TO TALK
5. Paralanguage- “voice quality” (tone, inflection) or how a message is delivered

VERBAL COMMUNICATION

- THEAPEUTIC, APPROPRIATE, SIMPLE, ADAPTIVE, CONCISE AND CREDIBLE

1. Offering self- LET ME SIT HERE WITH YOU FOR 5 MINS (SMART)
2. Active listening- AH HUH, YES, NO
3. Exploring – YES SAID IANA WAS THE BEST, CAN YOU DESCRIBE HER?
4. Broad openings- WHERE WOULD YOU LIKE TO BEGIN?
5. Making observation- I NOTICED YOU HAVE COMBED YOUR HAIR TODAY?
6. Summarizing- IN THE PAST 15 MINS, WE HAVE TALKED ABOUT…
7. Encouraging description of perception- USED IN ILLUSION (W/ STIMULI)/HALLUCINATIONS
(W/O STIMULI- VISUAL, AUDITORY – HAS COMMAND, TACTILE, GUSTATORY (TASTE))
8. Presenting reality
9. SEEKING CLARIFICATION – DO YOU MEAN?
10. Reflecting – LET CLIENT ANSWER, GIVE BACK QUESTION
11. Restating – PT: I AM DOWN, NURSE: ARE YOU DEPRESSED?
12. General leads- GO ON/TELL ME MORE
13. Focusing- LET US LOOK AT IT MORE CLOSELY

NON-THERAPEUTIC COMMUNICATION
- GIVING ADVISE
- TALKING ABOUT SELF
- TELLING THE CLIENT IS WRONG (DISPUTE, ARGUMENT = LOSS OF TRUST)
- FALSE REASSURANCE
- ASKING WHY (DEMANDS AN ANSWER, STIMULATES DEEP SEATED FEELINGS); EXCEPT
SUICIDAL PATIENTS (DIRECT QUESTIONING)

Spheres
ID – PLEASURE, IRRATIONAL – ANTISOCIAL PD
EGO- REALITY BASED (SANITY)
Superego- CONSCIENCE, EGO IDEAL - OCPD
 NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*MEDTECH
LET*PSYCHOMET*RESPIRATORY THERAPY*CIVIL SERVICE*NAPOLCOM
NCLEX*DHA*HAAD* PROMETRIC* UK-CBT

Defense mechanisms
• Repression- UNCONSCIOUSLY FORGETTING (DI SADYA)
• Suppression- CONSCIOUSLY FORGETTING (SADYA)
• Reaction formation- PLASTIC, IBA SINASABI SA TUNAY NA NARARAMDAMAN
• Rationalization- REASONING OUT
• Introjection- BLAMING SELF/SELF REPLICA
• Identification- IDOLIZATION (CERTAIN FEATURES)
• Compensation- WEAK ON ONE ASPECT, STRONG ON ANOTHER ASPECT
• Denial- UNACCEPTANCE OF THE TRUTH
• Displacement- CHANNELING OF ANXIETY TO OTHER PERSON OR THINGS
• Regression- RETURN TO PREVIOUS DEVELOPMENTAL STAGE
• Undoing- RELIEVE GUILT/HUGAS KAMAY
• Conversion- ANXIETY BECOMES PHYSICAL SYMPTOMS
• Intellectualization- REASONING OUT IN A “DETAILED”/ WITH REFERENCES
• Substitution- UNAVAILABLE TO AVAILABLE
• Sublimation- UNACCEPTABLE TO ACCEPTABLE

Crisis
• Maturational or developmental- PREDICTABLE, EXPECTED, NORMAL
• Situational- UNEXPECTED, UNPREDICTABLE
• Adventitious or social- CALAMITIES, ACTS OF GOD, ABUSE, RAPE

Stages of death and dying

DENIAL- SHOCK, DISBELIEF; UNACCEPTANCE OF TRUTH
ANGER- PROJECTION/INTROJECT
BARGAINING- UNREALISTIC OFFERS (BARGAIN)
DEPRESSION- SUICIDAL – PRIORITY: SAFETY
ACCEPTANCE- MOVING FORWARD

MANIFESTATIONS:

Disturbances of Appearance
• Automatism – repeated purposeless behaviors; EX. TWITCHING
• Psychomotor retardation – slowed movements (DEPRESSION)
• Waxy flexibility – maintenance of awkward posture (MOLDED)
• CATATONIA- SAME AS WAXY FLEXIBILITY BUT BUMABALIK SA AWKWARD
POSITION WHEN INAYOS
• Echopraxia – purposeless imitation (MIRROR LIKE)

Disturbances in Communication
• Mutism – MUTE
• Negativism- NO
• Circumstantiality – beating around the bush, with answer
• Tangentiality – do not arrive to the answer
• Stilted language – flowery WORDS
• Flight of ideas- WITH MEANING, SLIGHTLY RELATED
• Loose association- NO MEANING, NOT RELATED
• Perseveration- PERSEVERE, TALK ONE TOPIC ONLY
 NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*MEDTECH
LET*PSYCHOMET*RESPIRATORY THERAPY*CIVIL SERVICE*NAPOLCOM
NCLEX*DHA*HAAD* PROMETRIC* UK-CBT

• Echolalia- PARROT-LIKE IMMITATION

• Palilalia- REPETITION OF STEREOTYPED WORDS/AST SYLLABLE
• Verbigeration- REPETITION OF SAME WORDS ALL OVER AGAIN
• Coprolalia- COPRO: FECES, LALIA: LOGIC/WORDS; TRASHTALKING, CURSE,
BAD WORDS
• Neologism- NEW WORDS
• Blocking – sudden cessation of thought; MENTAL BLOCK
• Word salad- MIXTURE OF UNRELATED WORDS
• Clang association- RHYMING OF WORDS

Disturbances in Perception
• Delusions – FIXED FALSE BELIEFS
• Magical thinking- BELIEVE IN MAGIC
• Paranoia – extreme suspiciousness
• Religiousity – obsession in religious ideas, CULT
• Phobia – irrational fear
• Obsession – persistent thought
• Preoccupation-idea with intense desire
• Compulsion – persistent action
• Thought broadcasting – others know what I am thinking
• Delusions of reference- FEELING TALK OF THE TOWN
• Projection- BLAMING OTHERS

AFFECT:

 INAPPROPRIATE- INCONGRUENT
 BLUNTED- APPROPRIATE EMOTION BUT LITTLE RESPONSE
 RESTRICTED- DISPLAY ONE TYPE OF EXPRESSION
 LABILE MOOD- UNPREDICTABLE
 APATHY- ABSENCE OF EMOTIONS (FLAT AFFECT)
 AMBIVALENCE- TWO OPPOSING FEELINGS, MIXED EMOTIONS
 ANHEDONIA- ABSENCE OF PLEASURE
 EUPHORIA- EXTREME PLEASURE

DELUSIONS OF REFERENCE
PERSECUTORY DELUSIONS
PARANOIA
“POINT OF FOCUS”
DELUSIONS: FIXED FALSE “BELIEFS”
- MAGICAL DELUSIONS
- DELUSIONS OF GRANDEUR
- DELUSIONS OF REFERENCE
 NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*MEDTECH
LET*PSYCHOMET*RESPIRATORY THERAPY*CIVIL SERVICE*NAPOLCOM
NCLEX*DHA*HAAD* PROMETRIC* UK-CBT

STRESS
 STAGE I- ALARM REACTION: DETERMINED THAT THERE IS STRESS
 STAGE II- STAGE OF RESISTANCE: UTILIZE ALL RESOURCES TO SOLVE PROBLEM;
PROBLEM SOLVED
 STAGE III- STAGE OF EXHAUSTION: HAVE UTILIZED ALL RESOURCES BUT PROBLEM
IS NOT SOLVED

ANXIETY (UNKNOWN) VS. FEAR (KNOWN)

Levels of Anxiety
 MILD: LOGICAL, INCREASE CONCENTRATION AND ALERTNESS
o PROBLEM SOLVING APPROACH
 MODERATE: DECREASE ATTENTION SPAN, SELECTIVE INATTENTIVENESS
o RELAXATION TECHNIQUE, DBE, ENCOURAGE VERBALIZATION OF FEELINGS
o MEDICATIONS: ANXIOLYTICS
 SEVERE: LOUD AND RAPID SPEECH, DIFFICULTY OF FOCUSING WITH ASSISTANCE,
DISTORTED PERCEPTION
o REMAIN WITH THE CLIENT – PHYSICAL PRESENCE IS EFFECTIVE IN DECREASING
ANXIETY
 PANIC: SUICIDAL, HYSTERICAL/MUTE, INCOHERENCE
o SAFETY
o DECREASE STIMULI, STAY WITH CLIENT, PAPER BAG (HYPERVENTILATION)

NEUROTRANSMITTERS:
 DOPAMINE- EPI, NOREPI
o EXCITATORY
 SEROTONIN
o INHIBITORY  EXCITATORY
o SYNAPSE (WHERE NEUROTRANSMITTERS EXCHANGE)  SEROTONIN INSIDE
CELLS  INHIBITORY
o SEROTONIN IN SYNAPSE  EXCITATORY
 ANTI-DEPRESSANTS- EXCITATORY
 SELECTIVE SEROTONIN REUPTAKE INHIBITOR- DOES NOT LET SEROTONIN
IN CELLS
 GABA (GAMMA AMINO BUTYRIC ACID)
o BALANCER

Anxiety Related Disorders

 Generalized anxiety disorder (GAD)
- “worry worm”
- no apparent reason
- 6 months
no phobias, panic attacks or OC manifestations
S/sx:
- palpitations
- Headache
- Insomnia
- chest pain
 NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*MEDTECH
LET*PSYCHOMET*RESPIRATORY THERAPY*CIVIL SERVICE*NAPOLCOM
NCLEX*DHA*HAAD* PROMETRIC* UK-CBT

Management:
- assist in problem solving
- teach coping behaviors
- DOC: Benzodiazepines (ANXIOLYTIC)

Panic Disorder
- -recurrent
- -unpredictable
- Panic attacks:
a. Trembling
b. Racing heart (TACYCHARDIA)
c. Chest pain
d. DOB
e. Choking sensations
f. numbness

Management:
- assist in problem solving
- teach coping behaviors
- DOC: Benzodiazepines
- Anti-histamines – if with addiction to Benzo
(PRIMARY EFFECT: ANTI-ALLERGIC, SECONDARY: DEPRESSANT)
- Other meds: Beta Blockers (BLOCKS SNS = RELAXATION, -OLOL), MAOIs, & SSRI

ACUTE STRESS DISORDER

-S/X AFTER 2 DAYS TO 4 WEEKS (1MON)
- SAME S/S AS PANIC DISORDER

MANAGEMENT:
- PROGRESSIVE REVIEW OF TRAUMA (ACCEPTANCE)
- DOC: BENZODIAZEPINES

PTSD
- manifestations more than 4 weeks after acute-stress disorder
- RECURRENT flashbacks of memories and images
- RE-EXPERIENCING OF TRAUMA
- defense mechanism: DISPLACEMENT
- FLASHBACK-recurrent intrusive thoughts

S/sx:
- starts with GENERAL NUMBING to SOMATIC (BODILY) SYMPTOMS:
a. Irritability
b. Aggressiveness
c. Depression
d. Anger
e. Social withdrawal – JOIN IN GROUP THERAPY
 NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*MEDTECH
LET*PSYCHOMET*RESPIRATORY THERAPY*CIVIL SERVICE*NAPOLCOM
NCLEX*DHA*HAAD* PROMETRIC* UK-CBT

Management:
- assist in gaining control over angry impulses (ACCEPTANCE)
- DOC: Benzodiazepines
- Other Meds: Beta blockers, anti-histamines
PHOBIC DISORDER
- PERSISTENT IRRATIONAL FEAR
- FEAR IS UNREASONABLE PROPORTION TO THE ACTUAL DANGER
TYPES:
1. AGORAPHOBIA- FEAR IN OPEN PUBLIC PLACES; STAY NEAR EXIT OR AT HOME
2. SOCIAL PHOBIA- FEAR IN SOCIALIZING
3. SIMPLE PHOBIA- SPECIFIC TYPES
MANAGEMENT:
1. SYSTEMIC DESENSITIZATION- GRADUAL EXPOSURE TO THE FEARED OBJECT
*FLOODING- SUDDEN EXPOSURE  PTSD
2. DBE
3. THOUGHT STOPPING: DIVERSION  RUBBER BAND
4. GUIDED IMAGERY: CONDITIONING

OCD
- OBSESSION: REPETITIVE THOUGHTS
- COMPULSION: REPETITIVE ACTIONS
MANAGEMENT:
1. AVERSION THERAPY: GIVE TIME FRAME; PAIN/PUNISHMENT
2. DOC: SSRI
3. GIVE TIME FOR RITULISTIC BEHAVIOURS UNLESS DANGEROUS
4. ESTABLISH LIMITS
5. DIVERSIONAL ACTIVITIES
NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*MEDTECH
LET*PSYCHOMET*RESPIRATORY THERAPY*CIVIL SERVICE*NAPOLCOM
NCLEX*DHA*HAAD* PROMETRIC* UK-CBT