PSYCHIATRIC NURSING

Nurse-Client Relationship (2 way) 4. Feedback: Receiver’s response

→ Give and Take • Receiver’s response to the message
→ Series of interaction between the nurse and the client
→ GOAL: Positive behavioral change (the patient should ***Barriers: factors that inhibit the communication process
change for the better) • Noise
• Environment
Q1: When does a therapeutic relationship begin? • Mental status
A: Orientation phase • Health status

Q2: The only tool available for the nurse? Non-Verbal Communication Techniques
A: SELF (nurse) -> SELF AWARENESS (You cannot → Proxemics: physical space or physical distance
give what you don’t have) • Not too near because it can invade personal
space
Q3: When is trust established? • Not too far because the patient may feel you are
A: Sharing scared and not sincere
★ Proper physical space: 3-6 ft (one arm and a half)
Elements of Therapeutic Relationship → Kinetics: Body movements (gestures, facial
→ T - rust expressions, mannerisms)
→ R - apport → Touch: intimate physical contact (invasive) NEED A
→ U - nconditional positive regard (Accepting the client CONSENT
for who they are) • Especially when patient had experienced rape,
→ S - et limits (Suicidal patients: reinforce suicidal abuse
precautions) → Silence: agreeing, listening, encourages the patient to
→ T - herapeutic use of self -> THERACOMM talk
→ Paralanguage: voice quality (tone, inflection), how the
Therapeutic Behaviors message is delivered
→ These are the characteristics the nurse should have to
enable to handle the client Verbal Communication
1. Genuineness: sincerity and honesty → Therapeutic in nature
• All things you say are based on reality → Should be therapeutic, appropriate, simple, adaptive,
2. Concreteness: ability to identify one’s feelings concise and credible
• The nurse should be adaptive
3. Respect: consideration of the client as a unique being Therapeutic Communication (Theracomm)
• They have different beliefs though they have the → Offering self: Let me sit here with you for 5 minutes
same condition • Specific:
• Accepting the client for who they are • Measurable
• Attainable
Phases of the Therapeutic Relationship • Realistic
I. Pre interaction/Pre orientation phase • Time Bounded
• no contact with patient → Active Listening: ah, huh, yes, no
• Secondary sources (chart/journals/books) → Exploring: You said Hannah was the best, can you
• SELF AWARENESS describe her?
II. Interaction/Orientation phase → Broad openings: Where would you like to begin?
• Establish TRUST → Making observations: I noticed you have combed your
• Assess the client hair today
• Establish mutual agreement → Summarizing: In the past 15 minutes we have talked
• Informing termination about….
III. Working phase
• Considered as the “Longest Phase” Hallucination (without stimuli) / Illusion (with stimuli)
• Achieving goals and sharing facts → Visual - vision
• Resolve the problem → Auditory - hearing (described as the most dangerous
• A phase that is “Highly individualized” (each type because it can issue a command)
client has its own differences according to → Tactile - feeling
management DEPENDING ON THE NEEDS
OF THE CLIENT) Encouraging description of perception/Acknowledging
IV. Termination phase Presenting Reality
• Moving towards independence
• Trying of the patient is now independent Situation: Patient states, “I am hearing voices..”
• Observe for regressive behaviors → EDP/Acknowledging: Nurse will reply, “What are the
voices telling you?”
Therapeutic Communication → Presenting reality: I know that the voices are
→ A DYNAMIC PROCESS of exchanging information frightening but there are no voices here…
→ It changes depending on the response of the patient → Seeking clarification: Do you mean? Do you say?
→ 2 Techniques: Verbal and Non-Verbal Techniques → Reflecting: Mas makakabuti ba sayo pag iniwan mo
• Used simultaneously for communication to be ang asawa mo? (Letting the client reflect with the
effective guidance but not the opinion of the nurse)
→ Restating: Rephrasing
Elements of Therapeutic Communication
1. Sender: Encoder Situation: Patient states, “I am down”
• The source of message Nurse: You feel depressed?
2. Message: Information → General leads: Go on…
• The information transmitted → Focusing: Let us look at it more closely...
3. Receiver: Decoder
• Recipient of message
Non-Therapeutic Communication → Loose associations: not related, without meaning
Common pitfalls such as: (PHRASES)
→ Giving advise → Perseveration: persevere -> stick with one topic only
• Patient will solve his/her own problem, you will just → Echolalia: parrot-like imitation of speech
guide → Palilalia: stereotyped words/last syllable (nahulog-
→ Talking about self loglogloglog)
→ Telling the client is wrong → Verbigeration: repetition of words or nonsense
→ False reassurance phrases
→ Asking WHY (it demands an answer, makes client → Coprolalia: copro (feces), lalia (logic/speech) -> trash
unrelaxed and uneasy/arouses deep seated feelings) talkers, curse, badwords (more common:
*Except: Suicide (needs direct questioning) Schizophrenia)
→ Neologism: new words
3 Spheres Jargons: they created words and all of them understand
→ ID: Pleasure, Irrational it
• Antisocial personality disorder Example: medical jargons (TID, BID, OD)
→ Ego: Reality based
→ Superego: Conscience, ego ideal Morse code
• Balances the ID SOS (… - - - …) - emergency
• Our part that is idealistic → Blocking: sudden cessation of thought (mental block)
• Obsessive compulsive personality disorder → Word salad: mixture of unrelated words (WORDS)
→ Clang association: rhyming
Defense Mechanisms
1. Repression - unconsciously forgetting (di sadya) Disturbances in Perception
• Have trauma in the past and when asked he/she → Delusions: fixed false beliefs (e.g. “I am the Queen of
cannot remember anything about it England.”) - persecutory, grandeur
2. Suppression - consciously forgetting (sadya) → Magical Thinking: people believe in magic, common in
3. Reaction formation - plastic/plastik/orocan preschoolers
4. Rationalization: reasoning out/making excuses → Paranoia: extreme suspiciousness; could be a
5. Projection: blaming others diagnosis; more general term
6. Introjection: blaming self/exact replica of other people → Religiosity: obsession of religious ideas; point of focus
7. Compensation: weak at one aspect, strong on another is in religion
aspect → Grandiosity: point of focus is himself (e.g. kung gaano
8. Denial: unacceptance of the truth kaganda)
9. Displacement: channeling of anxiety → Phobia: irrational fear; fear is unreasonable (e.g.
10. Regression: Going back to the previous developmental natatakot sa isang baso ng tubig)
stage → Obsession: persistent thoughts
11. Undoing: hugas kamay -> relieve guilt → Compulsion: persistent actions
12. Conversion: anxiety -> physical symptoms → Preoccupation: idea with intense desire; should be
13. Intellectualization: reasoning in a detailed manner satisfied ; much worse
(references) → Thought broadcasting: “others know what I am
14. Substitution: unavailable -> available thinking”; common in people with paranoia
15. Sublimation: unacceptable -> acceptable → Delusions of reference (palaging naiisip)/Ideas of
16. Identification: idolization reference (minsanan lang): talk of the town

3 CRISIS Affect: Expressions

1. Maturational/Developmental: expected/predictable → Inappropriate Affect: incongruence (e.g. may
2. Situational: unexpected/unpredictable namatay, patient laughs)
3. Adventitious/Social: calamities/acts of God/rape → Blunted Affect: correct emotion but little/minimal
response
Stages of Death and Dying → Restricted Affect: displays one type of expression (e.g.
→ Denial/Shock/Disbelief: unacceptance of the truth palagi lang masaya or palagi lang malungkot)
→ Anger: projection (blame others) → Labile Mood: unpredictable emotions or mood; rapid
→ Bargaining: bargain (offer) - unrealistic mood swings; more common in girls; sudden shift (e.g.
→ Depression: suicidal (dangerous) -> SAFETY tumatawa tapos biglang iiyak)
→ Acceptance: moving forward → Apathy: absence of expression; condition; flat affect -
seen in person with apathy
Disturbances in Appearance → Ambivalence: presence of two opposing feelings;
→ Automatisms: repeated purposeless behaviors (from mixed emotions
neurotransmitters) l Ticks (from nerves) → Anhedonia: absence of pleasure
→ Psychomotor retardation: slow movements (more → Euphoria: extreme pleasure
common: Depression)
→ Waxy flexibility: maintenance of an awkward posture Stress: 3 stages
→ Catatonia: maintenance of an awkward posture Stage 1 - Alarm reaction
→ Echopraxia: purposeless imitation (mirror like) → You have determined that there is stress

Disturbances in Communication Stage II - Stage of resistance

→ Mutism: mute → You will utilize all resources to solve the problem
→ Negativism: Patients always say “no” - - - - - - - - Problem Solved - - - - - - - - -
→ Circumstantiality: beating around the bush – with
answer Stage III - Stage of exhaustion
→ Tangentiality: beating around the bush – without → You have utilized all resources but the problem is not
answer solved
→ Stilted language: flowery words; common in males
because they were believed to be poetic Anxiety Vs Fear
→ Flight of ideas: phrases are slightly related, with → Fear - cause is known
meaning • E.g., scared of dogs
→ Anxiety - cause in unknown
• E.g., nervous but I don't know
• Levels of Anxiety
1. Mild
➢ A good anxiety
➢ It increases your logical thinking,
alertness and concentration
➢ Problem solving approach
➢ The best time for a nurse to solve problem
2. Moderate
➢ Decreased attention span
➢ Selective attentiveness (you get only
some information) GABA - Gamma Amino Butyric Acid
➢ Promote relaxation techniques → Balancer
❖ DBE → Imbalance - may cause alter fluctuations of serotonin
❖ Encourage verbalization of feelings to and dopamine resulting in mood disorder = Bipolar
promote comfortness Disorder
❖ You can already give medications → Stress, trauma, physiologic conditions, genetics can
(anxiolytics) so that anxiety would not cause imbalances in GABA
progress into severe or panic attacks
3. Severe Anxiety-related Disorders
➢ Loud and rapid speech, difficulty of 1. Generalized Anxiety Disorder (GAD)
focusing even with attention • “Worry worm” - causes pacing a lot (walking back
➢ Perception is already distorted (don’t and forth)
know what to do/say) • Worries with no apparent reason
➢ Even with instructions patient cannot • Anxiety has experienced within 6 months and
focus above
➢ Nurses should remain with the patient • Should be no phobias (thus, phobic disorder), no
❖ Physical presence is effective in panic attacks (thus, panic disorder) and no OC
decreasing anxiety manifestations (thus OC disorder)
4. Panic • Manifestations
➢ Highest level of anxiety and the most o Palpitations
dangerous ▪ Long standing anxiety disorder can
➢ Suicidal attempts, fixed eyes, contribute to develop heart disease
hysterical/mute ▪ SNS stimulation, heart is always pumping
➢ If patients are suicidal, nurses must causing palpitations
ensure that stimuli is decreased o Headache
❖ Remove the patient from the anxiety- o Insomnia
causing event ▪ Cannot sleep at night
❖ Stay with the client o Chest pain
❖ Patients can hyperventilate so the • Management:
nurse must prepare BROWN PAPER o Assist in problem solving
BAG ▪ The nurse should not solve the problem,
instead assist the patient to solve the
• Manifestations of Anxiety: problem to establish independence
o Teach the client coping behaviors (how to
dougie)
o DOC: Benzodiazepines/Anxiolytics
▪ “pam/lam”: diazepam, alprazolam,
lorazepam, midazolam
▪ Addictive: if with addiction ->
**Moderate: frequent urination ANTIHISTAMINES
 Primary effect: anti-allergic reaction
NEUROTRANSMITTERS:  Secondary effect: sedative
 Needs YELLOW PRESCRIPTION;
Dopamine/Epinephrine/Norepinephrine doctor should be a S2 license holder
→ Excitatory - “nagpapagana”
→ Parkinsons - decreased dopamine in basal ganglia 2. Panic Disorder
(affecting the nerves, muscle movement) causing • Recurrent (pabalik-balik) naol nabalik :>
stuporous posture • Unpredictable
→ Antipsychotics - decreases dopamine, causing • Panic attacks:
pseudo-parkinsonisms o Trembling
o Racing heart (tachycardia) - SNS stimulation
Serotonin o Chest pain
→ Inhibitory - “nagpapatamad” o DOB
→ But can be both inhibitory and excitatory depending on o Choking sensation (kung saan daw naorder
the situation ng chaofan)
→ Synapse (where neurotransmitter exchanges, there o Numbness
are neuron, and cells) • Management:
• Normally serotonin is in the cells, inhibitory in o Assist in problem solving
nature, but when serotonin is in the synapse it o Teach coping behaviors
CHANGES ITS FUNCTION - excitatory o DOC: Benzodiazepines
• Antidepressants - excitatory; balances ▪ Addictive: if with addiction ->
neurotransmitters ANTIHISTAMINES
o SSRI - selective serotonin reuptake inhibitor  Primary effect: anti-allergic reaction
(inhibit the reuptake of serotonin to selective  Secondary effect: sedative
sites)
  Needs YELLOW PRESCRIPTION; 6. Obsessive Compulsive Disorder (OCD)
doctor should be a S2 license holder • Aware, real obsessions and compulsive
○ Other medications: • Obsessive: thoughts
▪ Beta-adrenergic: blocks SNS adrenergic • Compulsions: actions
receptors decreasing anxiety
OCD - anxiety disorder OCPD - personality disorder
▪ MAOI (Monoaminoxidase inhibitors and
SSRIs (Selective serotonin reuptake → Aware → Unaware
inhibitors) - balances the → Real Obsessions → No real
neurotransmitters → Compulsions obsessions/compulsion
→ There is alteration in → perfectionist/rigid/moralistic
3. Acute Stress Disorder neurotransmitter - → More on experiences
• Mabilisan increase in serotonin
• S/SX after 2 days up to 4 weeks (1 month) and dopamine
making them anxious
o Same as panic but the duration is shorter
• Management: • Management:
o Progressive review of the trauma o Aversion therapy: pain/punishment (set limits)
▪ Done by psychologist trauma ▪ If di masunod yung time, there will be a
▪ Provides acceptance to the patient for the punishment
anxiety to be relieved, but when not ▪ Antabuse/Disulfiram: alcoholics
relieved and passes over a month it ▪ This will be effective to OCD because
becomes PTSD they are aware of the condition, so they
o DOC: Benzodiazepines will follow the treatment regimen
o DOC: SSRI
4. Post-Traumatic Stress Disorder ▪ Most therapeutic in response
• S/SX are MORE THAN 4 weeks (>1 month) ▪ Lesser side effects
• Recurrent FLASHBACKS (intrusive thoughts) o Give time for ritualistic behaviors unless
o Rape clients dangerous
o Abused clients ▪ Decrease obsessions and compulsions
o Warshock people thru diversional activities that would make
• Re-experiencing of the trauma them productive
• Defense mechanism: Displacement (pagbabasag o Establish limits
ng picture frames) o Diversional activities
• S/SX: ▪ E.g., washing plates/clothes (catching 2
o General numbing - somatic (bodily) symptoms birds in 1 stone)
o Irritability o SLRC
o Aggressiveness ▪ SL - set limits
o Depression ▪ R - reality
o Anger towards self and others ▪ C - consistency
o Social withdrawal
• Management: Mood Disorders
o Let them join group therapies 1. Bipolar I - fluctuates to mania to major dep
o Assist in gaining control over angry impulses; 2. Bipolar II -
acceptance in his/her situation 3. Manic Disorder
o DOC: 4. Major Depressive Disorder
▪ Benzodiazepines 5. Cyclothymia (bipolar-like disorder) - no extremes
▪ Beta Blockers 6. Dysthymia (minor depressive disorder) - have periods
▪ Antihistamines (especially when there is of dep, no illusion
addiction in benzodiazepines)
But when have suicidal ideas it is considered as major
5. Phobic Disorder depressive disorder
• Persistent irrational fear
• Fear is unreasonable proportion to the actual → Mania - hyperactive but not intact to reality; have
danger illu, delu, hallucinations
• 3 main types: → Hypomania - hyperactive but intact to reality have
1. Agoraphobia: fear of open public places no illu, delu, hallucinations
▪ They always stay near the exit → Hypodepression - depressed but not suicidal; no
▪ Just stays at home suicidal thoughts/ideations
2. Social phobia: fear in socializing, deptly → Major depression - depressed and suicidal
scared
▪ During social anxiety, they become
anxious when there is people
▪ Social phobia can be applied to relatives
but mostly to strangers
3. Simple phobia
▪ Specific types

● Management:
o Systemic desentization: gradual exposure to
the object
▪ Always mauuna
o Flooding: sudden exposure
o Breathing exercises
o Thought stopping: diversional activity -
RUBBER BAND
o Guided Imagery: conditioning mind in thinking
 ▪ Allow them to open the wrappers
Major Depression Bipolar

→ Problem: Over → Problem: Mask of

dependence/loss depression
→ Defense mechanism: → Defense mechanism:
Introjection Reaction Formation
→ S/SX: → S/SX:
• Anhedonia • Hyperactivity
• Psychomotor • Manipulative - they
retardation tend to control
• Negative s/sx other; inattentive
→ Attitude therapy: kind → Attitude therapy: Matter
firmness of fact
→ Activity: • Present reality
• Counting seashells → Activity
(any diversional • Breaking leaves
activity) • Modeling clay
• Writing • Walking - due to
→ Therapy immense amount of
• Group therapy energy (pagurin na
• Non competitive sa umaga, to
→ WOF: Suicide prevent sleep
• Place the client disturbance
near the nurse's patterns)
station → Therapy:
• Open door • Solitary - bawal
• Irregular visits may kasama due to
manipulativeness
• Non-competitive
→ Diet:
• Finger foods: foods
they can eat
without utensils,
they can eat while
doing an activity

Schizophrenia
→ Increased dopamine

3 Main Types
1. Catatonic Schizophrenia
• Abnormal motor behavior
• S/SX
o Catatonia
o Waxy flexibility
o Mutism
o Negativism
• Defense mechanism: Repression
• Nursing Diagnosis: Impaired motor activity
• Management:
o Circulation - needs ROM exercises
o Nutrition - because they are not moving
(spoon feeding/tube feeding is done)
2. Disorganized Schizophrenia
• Bizarre behaviors
• Like taong grasa, umiihi sa kalsada
• S/SX:
o Thought
o Movements
o Speech: neologisms
• Defense mechanisms: Regression
• Nursing Diagnosis: Impaired Social Functioning
• Management:
o ADL assistance
3. Paranoid Schizophrenia
• Extreme suspiciousness/Ideas of reference
• S/SX:
o Delusions
o Hallucinations
o Flight of ideas
• Defense mechanisms: Projection (Paranoid)
• Nursing Diagnosis: Potential injury directed to
self/others (they are hostile, aggressive)
• Management:
o Safety - due to potential injury directed to
self/others
o Nutrition - they feel there are — motives
against them
▪ Give food sealed