Psychiatric Nursing- Foundations

Psychiatric Nursing The Heart of the Nursing Profession

Outline of Psychiatric Nursing  Fundamental Concepts of Psychiatric nursing

The Definition of Psychiatric Nursing  The Scope of Psychiatric Nursing Practice  Self-Awareness  Theoretical Framework 

Freud  Erikson  Piaget  Sullivan 

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Outline of Psychiatric Nursing  The Therapeutic Nursing  

Relationship The Therapeutic Communication Modalities of Psychiatric Care Psychiatric Settings- Therapeutic Environment  Overview of Psychotherapytherapeutic modalities  Psychopharmacology  Psychiatric Diagnostic Tests 

Outline of Psychiatric Nursing  The Psychiatric Nursing Process Psychiatric Assessment: History and PE  Diagnostic Examination  Psychiatric Nursing Diagnosis  Nursing Planning  Nursing Implementation  Nursing Evaluation 

Outline of Psychiatric Nursing  Client Responses to illness Anxiety and Crisis  Anger  Hostility  Depression  Abuse  Violence  Suicide  Grief and Loss 

Outline of Psychiatric Nursing Psychiatric Disorders: Adult 2. 3. 4. 5. 6. 7. 8.

Anxiety and Anxiety Disorders Schizophrenia Mood disorders Personality Disorders Eating Disorders Substance abuse Somatoform disorders

Outline of Psychiatric Nursing Psychiatric Disorders: Children and 2. 3. 4. 5.

adolescents Autism ADHD Mental Retardation Other disorders

Outline of Psychiatric Nursing Psychiatric Disorders: Others 2. 3.

Dementia Delirium

Ready Colleagues? BY: Prof Joan A. Ocampo

Nature of Psychiatric Nursing

Let us first review terms related to Psychiatric Nursing

Nature of Psychiatric Nursing Mental Health A state of emotional, psychological and social wellness evidenced by satisfying interpersonal relationships, effective behavior and coping, positive self-concept and emotional stability (Videbeck)  lifelong process of successful adaptation to a changing internal and external environments 

Nature of Psychiatric Nursing Mental Disorder A clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress, increased risk of suffering, death, disability and loss of freedom (Videbeck)  Loss of ability to respond to environment in ways that are in accord with oneself and society 

Mentally Healthy Person     

Accepts himself Perceives reality Mastery of self and environment Autonomy Unifying, integrated outlook in life

Nature of Psychiatric Nursing The DSM-TR IV 

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A taxonomy that describes all mental disorders, outlining specific diagnostic criteria for each based on clinical experience and research Clinicians utilize this to diagnose psychiatric disorders Purpose of DSM-TR: 1. 2. 3.

Standard nomenclature Defining characteristics Underlying cause of disorders

Nature of Psychiatric Nursing The DSM-TR IV : Multi Axis Classification AXIS I- Major Psychiatric Disorders AXIS II- Mental Retardation and Personality Disorders AXIS III- Current Medical Condition AXIS IV- Psychosocial and Environmental Problems AXIS V- Global Assessment of

Nature of Psychiatric Nursing Historical People Worth Mentioning 2. Aristotle- the Humors 3. Freud- -Psychosexual theory 4. Kraeplin- symptomatic classification of mental disorders 5. Bleuler- coined “schizophrenia”

Nature of Psychiatric Nursing Psychiatric Nursing in the Philippines  GO and NGOs  Mental health programs

Nature of Psychiatric Nursing Psychiatric Nursing in the Philippines Mental Health= State of well being, where a person can realize his potential Mental Ill Health= disturbance of thought, feelings and behavior Mental Disorder= medically diagnosable illness Mental Hygiene= Science which deals with measures employed to promote mental health

Nature of Psychiatric Nursing Scope of Nursing Practice  Individual, family and community  Healthy and ill person

Nature of Psychiatric Nursing Self Awareness  The process by which the nurse gains recognition of his/her own feelings, beliefs and attitudes (Videbeck)  Initial nursing activity to do before practicing psychiatric nursing

Nature of Psychiatric Nursing Self Awareness  This is accomplish through reflection, spending time deliberately focusing on how one feels and what one values or believes

Theoretical Foundations 

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Mental health-Psychiatric treatment integrates concepts and strategies from theories. Theoretical Models are used as guides for treatments These theories attempt to explain human behavior, health and mental illness

Theoretical Foundations 

Theoretical frameworks allow the systematic organization of knowledge  guide data collection  provide explanations for assessed behaviors  guide care plan development  provides rationales for interventions and  determine evaluation criteria  Guide research by providing assumptions to be tested. 

Theoretical Foundations PsychosexualPsychoanalytical Theory Psychosocial Theory Cognitive Theory

Sigmund FREUD

Interpersonal Theory Moral Theory

Harry Stack Sullivan KOHLBERG

Spiritual Theory

FOWLER

Erik ERIKSON Jean PIAGET

Theoretical Foundations Behavioral Theories Humanistic Theories Psychobiology theory

Pavlov and Skinner Maslow and Carl Rogers Neuroanatomy and physiology

Theories of Personality development      

Freud’s Psychoanalytic theory Erikson’s Psychosocial theory Sullivan’s interpersonal theory Piaget’s Cognitive theory Fowler’s Spiritual theory Kohlberg’s Moral theory

Psychosexual/Psychoanal ytical 

This theory supports the notion that EVERY human behavior is caused and can be explained

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Freud believes that “repressed” sexual urges, desires, impulses or drives motivated much human behavior

Psychosexual/Psychoanal ytical 2.

3.

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Components of Personality ID- part of a person that reflects BASIC or innate DESIRES, INSTINCT and SURVIVAL impulses EGO- represents the REALITY aspect SUPER-EGO- part that reflects MORALITY and ethical concepts, and values

Psychosexual/Psychoanal ytical Personality Stages and Functional Awareness 2. Conscious – perceptions, thoughts and emotion that exist in the person’s awareness 3. Pre-conscious/SubconsciousThoughts and emotions not currently in awareness but can be recalled with effort 4. Unconscious- thoughts, drives and emotions totally a person is

Psychosexual/Psychoanal ytical According to this theory, much of our behavior is motivated by our SUBCONSCIOUS thoughts or feelings

Psychosexual/Psychoanal ytical Five Stages of psychosexual development 2. Oral 3. Anal 4. Phallic or Oedipal 5. Latency 6. Genital

Psychosexual/Psychoanal ytical Phase Oral Anal Phalli c Laten cy Genit al

Age 0-18 months 1½-3 years 3- 5 years 6- 12 years 12 & above

Focus Site of gratification: Mouth Site of gratification: Anus Site of gratification: Genitals Site of gratification: (School Activities) Site of gratification: Genitals

Psychosexual/Psychoanal ytical Phase Oral Anal Phalli c Laten cy Genit al

Age 0-18 months 1½-3 years 3- 5 years 6- 12 years 12 & above

Focus Major task: Weaning Major task: Toilet training Major task: Oedipal & Electra complex Major task : School activities Major task: Sexual intimacy

Psychosexual model (Freud) 1. Oral a. 0-18 months b. Pleasure and gratification through mouth c. Behaviors: dependency, eating, crying, biting d. Distinguishes between self and mother e. Develops body image, aggressive drives

Psychosexual model (Freud) 2. Anal a. 18 months - 3 years b. Pleasure through elimination or retention of feces c. Behaviors: control of holding on or letting go d. Develops concept of power, punishment, ambivalence, concern with cleanliness or being dirty

Psychosexual model (Freud) 3. Phallic/Oedipal a. 3 - 6 years b. Pleasure through genitals c. Behaviors: touching of genitals, erotic attachment to parent of opposite sex d. Develops fear of punishment by parent of same sex, guilt, sexual identity

Psychosexual model (Freud) 4. Latency a. 6 - 12 years b. Energy used to gain new skills in social relationships and knowledge c. Behaviors: sense of industry and mastery d. Learns control over aggressive, destructive impulses

Psychosexual model (Freud) 5. Genital a. 12 - 20 years b. Sexual pleasure through genitals c. Behaviors: becomes independent of parents, responsible for self d. Develops sexual identity, ability to love and work

Psychosexual/Psychoanal ytical Ego Defense Mechanisms

Unconscious Ego defense mechanism 

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These are PSYCHOLOGIC adaptive mechanisms Mental mechanisms that develop as the personality attempts to DEFEND itself, establishes compromises among conflicting impulses and allays inner tensions

Unconscious Ego defense mechanism 

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The unconscious mind working to protect the person from anxiety Releases tension

Ego Defense Mechanisms 

Compensation

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Denial

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Covering up weaknesses by emphasizing a more desirable trait

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Attempt to ignore unacceptable realities by refusing to

Ego Defense Mechanisms 

Displacement

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Identification

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Discharging emotional reactions from one object to a LESS threatening object/person

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Imitation of someone feared or respected

Ego Defense Mechanisms 

Intellectualizatio n

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Introjection

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Use of rational explanations that remove from the event any personal significance and feelings

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Acceptance of other’s norms as oneself

Ego Defense Mechanisms 

Minimization

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Projection

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Not acknowledging the significance of one’s behavior

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Blame is attached to others or to environment for unacceptable thoughts, mistakes, etc

Ego Defense Mechanisms 

Rationalization

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Reaction Formation

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JUSTIFICATION of certain BEHAVIORS by faulty logic/reasons

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Acting OPPOSITELY to the way they feel

Ego Defense Mechanisms 

Regression

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Repression

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Resorting to an earlier, more comfortable level of functioning that is less demanding

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Unconscious mechanism of keeping threatening desires or thoughts from

Ego Defense Mechanisms 

Sublimation

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Substitution

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Re-channeling of aggressive energies into socially acceptable activities

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Replacement of a highly valued object by a LESS valuable or acceptable and

Ego Defense Mechanisms 

Undoing

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Actions or words designed to cancel some disapproved thoughts, impulses , or acts in which the person relieves GUILT by making reparation

Psychosexual/Psychoanal ytical Transference and Countertransference  TRANSFERENCE is the clients feeling toward nurse arising from unconscious experiences with early significant others  COUNTER TRANSFERENCE is the nurse’s feelings toward the patient arising also form previous experiences

Psychosexual/Psychoanal ytical The Freudian View of Mental Illness  All behavior has meaning  Mental illness and manifestations are caused by unconscious INTERNAL conflict arising from unresolved issues in early childhood  Ego defenses are utilized to relieve inner tension

Psychosocial Theory 

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Theory that focuses on developmental task, focuses on EGO as this develops from social interaction The developmental tasks are sequential and depend on prior successful mastery An individual who fails to “master” the task at appropriate age may return to work on

Psychosocial Theory Use of the theory in Nursing  Assessment can be done focusing on the psychosocial development at specific age  Appropriate interventions can be selected based on task  Nurses can promote healthy behaviors and encourages hope that re-learning is possible

Erikson’s Psychosocial theory        

Trust versus mistrust Autonomy versus shame and doubt Initiative versus guilt Industry versus inferiority Identity versus role confusion Intimacy versus isolation Generativity versus stagnation Ego integrity versus despair

Psychosocial Model (Erikson) 1. Trust vs mistrust a. 0 - 18 months b. Learn to trust others and self vs withdrawal, estrangement

2. Autonomy vs shame and doubt a. 18 months - 3 years b. Learn self-control and the degree to which one has control over the environment vs compulsive

Psychosocial Model (Erikson) 3. Initiative vs guilt a. 3 - 5 years b. Learn to influence environment, evaluate own behavior vs fear of doing wrong, lack of selfconfidence, over restricting actions

4. Industry vs inferiority a. 6 - 12 years b. Creative; develop sense of competency vs sense of inadequacy

Psychosocial Model (Erikson) 5. Identity vs role confusion a. 12 - 20 years b. Develop sense of self; preparation, planning for adult roles vs doubts relating to sexual identity, occupational career

6. Intimacy vs isolation a. 18 - 25 years b. Develop intimate relationship with another; commitment to career vs

Psychosocial Model (Erikson) 7. Generativity vs stagnation a. 21 - 45 years b. Productive; use of energies to guide next generation vs lack of interests, concern with own needs

8. Integrity vs despair a. 45 years to end of life b. Relationships extended, belief that own life has been worthwhile vs lack of meaning of one’s life, fear of

Interpersonal theory 

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This concept focuses on interaction between an individual and his environment Personality is shaped through “interaction” with significant others We internalize approval or disapproval form our parents

Interpersonal theory Personality has three SELFSYSTEM 1. “Good Me” develops in response to behaviors receiving approval by parents/SO 2. “Bad Me” develops in response to behaviors receiving disapproval by parents/SO 3. “Not Me” develops in response to behaviors generating extreme

Interpersonal theory Mental Health is Viewed as: 2. Related to conflict or problematic interpersonal relationships 3. Past relationships, inappropriate communication and current relationship crisis are etiologic factors of mental illness

Interpersonal theory Treatment of Mental illness:  Focuses on anxiety and its causes  Therapeutic relationship with client that is active and participative  Feelings and emotions are verbalized by the clients to modify problematic relationships

Interpersonal theory Usefulness in Nursing  Nurse and client can participate in and contribute to the relationship that is therapeutic  This relationship can be used as a corrective interpersonal experience  Anxiety management

Interpersonal Model (Sullivan) 1. Infancy a. 0 - 18 months b. Others will satisfy needs

2. Childhood a. 18 months - 6 years b. Learn to delay need gratification

3. Juvenile a. 6 - 9 years b. Learn to relate to peers

Interpersonal Model (Sullivan)

4. Preadolescence

a. 9—12 years b. Learn to relate to friends of same sex

5. Early adolescence

a. 12—14 years b. Learn independence and how to relate to opposite sex

6. Late adolescence

a. 14—21 years b. Develop intimate relationship with

Cognitive Theory 

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This theory focuses on the inborn development of thinking ability from infancy to adulthood A person is born with a tendency to organize and to adapt to their environment Mental illness is not directly discussed

Cognitive Theory Usefulness of Cognitive theory in Nursing 2. This provides an understanding how an individual think and communicate. Nurse can provide intervention accordingly 3. Nursing interventions should be congruent to the agespecific cognitive level 4. Teaching strategies are

Piaget  

Sensori-motor (birth to 2 ) Pre-operational (2-7) Preoperational preconceptual (2-4)  Preoperational intuitive (4-7) 

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Concrete operational (7-12) Formal operational (12 to adulthood)

Cognitive Theory (Piaget) A. 0 - 2 years: sensorimotor -reflexes, repetition of acts B. 2 - 4 years: preoperational/preconceptual -no cause and effect reasoning; egocentrism; use of symbols; magical thinking C. 4 - 7 years: intuitive/preoperational

Cognitive Theory (Piaget) D. 7 - 11 years: concrete operations - uses memory to learn - aware of reversibility E. 11 - 15 years: formal operations -reality, abstract thought -can deal with the past, present and future

Behavioral Theory 

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This concept describes a person’s function in terms of identified BEHAVIORS People learn to be who they are Behavior can be observed, described and recorded Behavior is subject to reward or punishment Behavior can be modified by changing environment

Behavioral Theory 

The Classical Conditioning by Pavlov Learning can occur when a stimulus is paired with an unconditioned response  Conditioned responses happens when stimulus is present  Acquisition – gain of learned response  Extinction – loss of learned response 

Behavioral Theory 

The Operant Conditioning by Skinner Rewards and punishments are utilized  Positive reinforcement- rewards  Negative reinforcement Positive punishment  Negative punishment- withdrawing reward 

Behavioral Theory Mental Illness is viewed as:  Mal-adaptive BEHAVIORS are learned through classical and operant conditioning  Mal-adaptive behaviors can be changed by altering environment

Behavioral Theory Application to Nursing 2. The nurse assess both adaptive and ,al-adaptive behaviors 3. The nurse and client collaborate in identifying behaviors that need to change 4. Behavioral modification techniques are utilized by the nurse in the treatment of mental illness

Humanistic theory 

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Human nature is positive and growth centered and existence involves search for meaning and truth Maslow’s theory of Needs are organized in a hierarchy

Humanistic theory Mental illness in this framework 2. The failure to develop one’s FULL potential leads to poor coping 3. Lack of self awareness and unmet needs interfere with feelings of security 4. Fundamental human anxiety is fear of death which leads to existential anxiety

Humanistic theory Application of the theory to Nursing 2. NCR is based on positive regard, respect and empathy 3. Nurses assess the spiritual aspects of the client including religion, love and relationships 4. Through reflective listening and emphatic responses, the nurse helps the client gain selfunderstanding

KOHLBERG’S STAGES OF MORAL DEVELOPMENT

PRECONVENTIONAL LEVEL 

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Stage 1 Age 23 Description:  Punishment or obedience (heteronomous morality)  A child does the right things because a parent tells him or her to avoid punishment

PRECONVENTIONAL LEVEL 

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Stage 2 Age : 4-7 Description:  Individualism  Child carries out actions to satisfy own needs rather than society’s. The child does something for another if that person does something for him in return

CONVENTIONAL LEVEL level 2 

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Stage 3 Age : 7-10 Description:  Orientation to interpersonal relations of mutuality  A child follows rules because of a need to be a good person in own eyes and in the eyes of others

CONVENTIONAL LEVEL level 2 

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Stage 4 Age : 10-12 Description:  Maintenance of social order, fixed rules and authority  Child follows rules of authority figures as well as parents to keep the system working

POSTCONVENTIONAL LEVEL level 3 

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Stage 5 Age :older than 12 Description:  social contract, utilitarian law making perspective  child follows standards of society for the good of all people

POSTCONVENTIONAL LEVEL level 3 

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Stage 6 Age :older than 12 Descriptions:  universal ethical principle orientation  child follows internalized standards of conduct

Therapeutic Relationships 

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This is a nurse-client interaction that is directed toward enhancing the client’s well-being (Isaacs) A relationship established between a health care professional and a client for the purpose of assisting the client to solve his problems

Therapeutic Relationships 

The nurse- patient relationship is characterized by a helping process The nurse and client work together for his benefit  The nurse uses herself therapeutically and this is achieved by self-awareness 

Therapeutic Relationships 

The nurse- patient relationship Respect the client and vale as individual  Holistic care  Maintain appropriate limits  Covey empathy not sympathy  Maintain honest and therapeutic communication  Encourage expression of feelings 

Therapeutic Relationships ELEMENTS OF THE THERAPEUTIC RELATIONSHIP  Contract  Boundaries  Confidentiality  Therapeutic Behaviors

Therapeutic Relationships ELEMENTS OF THE THERAPEUTIC RELATIONSHIP Therapeutic Behaviors 3. Genuineness = sincerity and honesty 4. Concreteness= ability to identify client’s feelings 5. Respect= shown through consideration of patient as unique being

Therapeutic Relationships 2. 3. 4. 5.

PHASES OF THE THERAPEUTIC RELATIONSHIP Pre-Interaction- Pre-orientation Orientation- Interaction Working Termination

Therapeutic Relationships Phase Nursing Activities Pre-interaction InteractionOrientation Working Termination

Nurse obtains data from secondary sources Nurse establishes trust, assess client, establishes mutual agreement Nurse assists the client to meet goals and resolve problems Nurse and client express feelings about termination, observes regressive behaviors

Orientation       

Establishment of goals, rules, boundaries etc.. Rapport is built Identify expectations Trust is gained Assessment is done Goals are defined Contract is made

Working/Exploration/Identif ication  

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Problems are identified Solutions are explored, applied and evaluated Nurse assists the client to develop coping skills, positive self concept and independence Promote insight and the use of adaptive coping mechanisms

Termination/Resolution 

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Nurse terminates the relationship based on mutually agreed goals when these are already achieved Focus of this stage is growth that has occurred Client may become anxious and reacts Nurses must help patient resolve the anxiety and ends the

Therapeutic Communication 

Therapeutic communication Dynamic process of exchanging information  Composed of verbal and non-verbal techniques that the nurse uses to focus on the client’s needs 

Therapeutic Relationships Therapeutic communication : ELEMENTS 2. Sender- the source of message 3. Message- the information transmitted 4. Receiver- recipient of message 5. Feedback- receiver’s response to the message

Therapeutic Relationships NON VERBAL COMMUNICATION 2. Proxemics- the physical space between the sender and receiver 3. Kinetics- the body movements such as gestures, facial expressions and mannerisms 4. Touch- intimate physical contact

Therapeutic Relationships NON VERBAL COMMUNICATION 4. Silence 5. Paralanguage- voice quality (tone, inflection) or how a message is delivered

Therapeutic Relationships VERBAL COMMUNICATION  Use of therapeutic communication techniques  Effective communication should be therapeutic, appropriate, simple, adaptive, concise and credible

Therapeutic Communication Open ended questions Focus on FEEELINGS State behaviors observed Reflect, restate, rephrase Neutral responses

Therapeutic Communication Offering self

I am here to help you

Active listening

Eye to eye contact

Exploring

Tell me more about…,. What do you want to talk about You seemed depressed

Broad Openings Making observation

Therapeutic Communication Summarizing Voicing doubt Encouraging description of perception Presenting reality

Seeking clarification

A few minutes ago, we were talking about.. Then… I find it hard to believe What are these voices telling you The sound is produced by the car No one is in the room I am not sure of what you mean

Therapeutic Communication Verbalizing the implied

Are you saying you want to kill yourself?

Reflecting

Do you think you should?

Restating

P: I cant sleep at night N: You cant sleep at night ? then…. GO on…

General leads Focusing

Hmm….you were saying…. Lets talk more about what you think of your problems

Non-therapeutic communication  

These are blocks to communication Usually, these are the common pitfalls of communicating nontherapeutically: Giving advise  Talking about self  Telling client is wrong  False reassurance  Cliché’  Asking ‘Why’ 

Non-therapeutic communication Making judgment

You are wrong

False reassurance

It’s going to be alright

Invalidation

I cannot talk now, I’m busy I am the best nurse to care for you P: I’m afraid of the surgery N: Ho many children do have If Iyou were you, I will

Focusing on self Changing the subject

Giving advice

Non-therapeutic communication Agreeing Disapproving Defending Requesting explanation Cliché Belittling feelings

Yes I think you are right I don’t want you to do that This hospital is the best “why” There is the sun after the rain P: I’m so depressed today N: everyone feels sad

Proxemics INTIMATE= PERSONAL=

Distances Touching to 1 ½ ft 1 ½ to 4 ft

SOCIAL=

4 to 12 ft

PUBLIC=

12 to 15 ft

Psychiatric Nursing Process  

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Applies to all clients Utilizes unique process for psychological assessment Similar to other types of nursing process approaches

Psychiatric Nursing Process Nursing ASSESSMENT Nursing History Physical Examination including the Neurological examination Laboratory Examination 

Psychiatric Nursing Process 

Nursing ASSESSMENT Refers to the scientific process of identifying a patient’s psychosocial problems, strengths an concerns  Interview is done to acquires broad information about a client 

Psychiatric Nursing Process 

MENTAL STATUS ASSESSMENT Level of consciousness  General appearance  Behavior  Speech  Mood and affect  Judgment  Memory  insight 

Psychiatric Nursing Process 

MENTAL STATUS ASSESSMENT Observation of mood and affect  Assessment of thought, sensorium and intelligence  Speech and content  Assess developmental status and family-cultural-spiritual background 

Psychiatric Nursing Process 

MENTAL STATUS ASSESSMENT Emotional status  Cognitive assessment  Socio-cultural assessment 

Psychiatric Nursing Process 

Physical Examination 

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Observation for key signs

Diagnostic Tests CT, MRI, PET, EEG  Laboratory tests= CBC, Electrolytes, Drug levels 

Psychiatric Nursing Process 

Other diagnostic tests Beck depression inventory  Minnesota multiphasic personality inventory  Draw-a person test  Sentence completion test  Thematic aperception test 

Psychiatric Nursing Process 

Nursing Diagnoses Anxiety  Ineffective coping- individual, family  Fatigue  Fear  Sleep pattern disturbance  Altered thought process  Etcetera 

Psychiatric Nursing Process  

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Nursing Objectives Short term goals are set for immediate problems, feasible and within client's capabilities Long term goals are related to discharge planning and prevention of recurrence of symptoms

Psychiatric Nursing Process 

Nursing Objectives: The client will: Participate in treatment program  Becomes oriented to three spheres and exhibit reality-based behaviors  Recognize reasons for behavior  Maintain self-care activities 

Psychiatric Nursing Process 

Nursing Interventions Use of therapeutic communication  Therapeutic Groups  Psychotherapy: Family, Milieu, Behavioral modification, Crisis intervention, Psychopharmacology  Electroconvulsive therapy 

Psychiatric Nursing Process 

Nursing Evaluation Determine if goals are met by collecting data and comparing them to baseline  Clients’ behavior should demonstrate optimal orientation to reality and interaction with others appropriately 

Treatment Modalities 1. 2. 3. 4. 5. 6. 7.

Therapeutic Environment- Milieu Therapeutic Groups Crisis intervention Family therapy Behavioral modification Cognitive therapy Psychotherapy

Therapeutic environment 

Research has documented that the environment in which the mentally ill person is treated is a major factor in enhancing or impeding the therapeutic effects of other treatment modalities

Therapeutic environment Characteristics of a Therapeutic environment 2. The clients’ physical needs are met 3. The client is respected 4. Decision making authority is clearly defined 5. Client is protected from injury (self and others)

Therapeutic environment Characteristics of a Therapeutic environment 5. Clients are allowed freedom of choice commensurate to his ability to decide 6. Nursing Personnel remain constant and assignments are stable 7. Emphasis is placed on social interaction between clients and

Therapeutic Modalities Milieu therapy 

Total environment has an effect on the person’s behavior- physical, emotional, relationships

Purposes of therapy 3. Improve client’s behavior 4. Involve client in decision making 5. Increase autonomy and communication 6. Set structure of unit and

Therapeutic Modalities Milieu therapy  The surrounding is made positive to effect behavioral changes in the prescribed directions  Goals of milieu therapy: to help patient develop sense of selfesteem, personal growth, improve ability to relate to others and return to the community better prepared

Therapeutic modalities Milieu therapy 

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The nurse involves the client in decision making The nurse promotes the involvement of staff in care Social skills are developed and sense of community is fostered

Therapeutic Groups A treatment approach in which the entire milieu is used as treatment  This includes the physical environment and the others clients 

Therapeutic Groups Group Therapy  Involves meaningful interaction between members of a group as they relate their personal experiences to each other  The main objective is for each group member to examine his own behavior and relationship. The group can influence to change his behavior and relationships

Therapeutic Groups 

Groups of clients meet with one or more therapists to work together to solve client problems

Therapeutic Groups 

Purposes To increase self-awareness  To improve interpersonal relationships  To make changes in behavior  To enhancing group teaching and learning 

Therapeutic Groups 

Structure of the Therapeutic Group One leader chosen by the group  Members  Size is usually 10  Physical arrangement  Time and place of meeting 

Therapeutic Groups Phases of group development 2. Beginning phase 

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Middle phase 

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Info given, anxiety heightened Confrontation, cohesiveness, trust and self-reliance

Termination phase  

Goals of the group are achieved Individuals leave the group when work is done

Therapeutic modalities CRISIS  A disturbance caused by a precipitating event such as perceived loss, a threat of loss or a challenge that is perceived as a threat to self.

Therapeutic modalities CRISIS Can be classified as to maturational crisis, situational crisis or adventitious crisis Maturational= role changes  Situational= loss of job, death  Adventitious= fires, earthquakes and floods  In a crisis, the person’s usual methods of coping are 

Therapeutic Modalities 

Characteristics of Crisis: It is sudden  It is short term may last for 4-6 weeks  Individualized  The person becomes dependent and overwhelmed 

Therapeutic Modalities Factors that can produce crisis  1. Hazardous EVENTS  2. Threat to the individual’s equilibrium  3. Inadequate coping skills

Therapeutic Modalities 

There are four PHASES of Crisis (DIDA) Denial  Increased Tension- when the person knows the existence of crisis and still continues ADL  Disorganization= pre-occupied and unable to perform function  Attempts to Reorganize= by 

Therapeutic Modalities CRISIS INTERVENTION A technique of helping the person go through the crisis  To mobilize his resources  To help him deal with the here and now  A five step problem solving technique designed to promote a more adaptive outcome including improved abilities to cope with future crises 

Therapeutic modalities Goal of Crisis intervention: help the patient go back to his state of optimum level of functioning  IDENTIFY the problem- A solution is not possible unless the problem be identified.  LIST alternatives- all possible solutions to the problem need to be listed.  CHOOSE from among the alternativeseach options is carefully considered, and the alternative chosen is usually highly individualized, based on priorities and values of the person  IMPLEMENT the plan- the alternative is put into action. The nurse may need to support and encourage patient to take action  EVALUATE the outcome- the effectiveness

Therapeutic modalities Family therapy  An approach in which the therapist focuses on the behavior of the entire family as a system instead of focusing on the pathology of one member

Therapeutic modalities Family therapy  

Focuses on the client as a ‘family” Involvement of family members

Purposes of family therapy 3. Improve relationships among family members 4. Promote family functions 5. Resolve family problems 6. Help family find ways to cope with problems

Therapeutic modalities Family therapy  Problems are identified by each family members and each discusses his/her involvement in the problem  Members discuss how problems affect them and they explore how to solve them

Therapeutic Modalities Family therapy  The nurse functions to assess the family interactions, makes observations and encourages expression of feelings  Helping the family resolve the problem is the goal

Therapeutic Modalities Behavioral Modification 

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Therapy to change the unacceptable behavior to acceptable The nurse determines the unacceptable behaviors and she identifies adaptive behaviors Punishment is given to unacceptable behavior Reward is given to acceptable behavior

Therapeutic Modalities Behavioral Modification  Other Behavioral therapies 1. Self-control therapy 2. Aversion therapy 3. Desensitization 4. Modeling 5. Operant conditioning

Therapeutic Modalities Cognitive therapy  An active, directive, timelimited approach  Therapeutic techniques are used to identify reality testing  The nurse helps the patient think and act more realistically and adaptively about his problems

Therapeutic Modalities Play therapy 

Therapy with children in which they are helped to express themselves or their behavior through play

Therapeutic Modality: Psychotherapy 

A method of treating mental illness in which verbal and expressive techniques are used to help the person resolve inner conflict and modify behaviors

Therapeutic Modality: Psychotherapy 1. 2. 3. 4. 5. 6.

Psychoanalysis Client centered therapy Rational emotive therapy Gestalt therapy Reality therapy Transactional analysis

Therapeutic Modality: Psychotherapy 1.

Psychoanalysis 



THE therapist obtains information about the past and present experiences that have repressed in the person’s subconscious mind By learning the source of the problem, the problems can be brought to the conscious where the therapist helps the individual dealt with them

Therapeutic Modality: Psychotherapy 2. Client Centered therapy  





The therapist work with one client Accepting, non-judgmental environment aimed at reducing the anxiety and reducing negative defenses The patient is encouraged to express his feelings and increase self-awareness When the person is aware of what he feels, he can work on improving

Therapeutic Modality: Psychotherapy 3. Rational-Emotive therapy 





This is based in the assumption that a person’s behavior is due to his own thinking Problems arise as the person believes about eh events The therapy aims to change the person’s belief system

Therapeutic Modality: Psychotherapy 4. Gestalt Therapy 





The mind receives experiences as a whole When the experience is complete, the problem will arise The goal of the therapy is to help patients complete the experience through awareness

Therapeutic Modality: Psychotherapy 5. Transactional Analysis  

A group therapy method Helps people “analyze” their transaction or interaction with others and guides them to the conclusion: I’m OK you are OK

Responses to Illness    

Stress Anxiety Crisis Anger and hostility

Importance of studying stress 

It provides a way of understanding the person as a holistic being



Nurses must also learn to cope with stress in their work and life as they are subjected to the demands of their career.

Stress and Adaptation 

STRESS  A condition in which the person responds to changes in the normal balanced state  Selye: non specific response of the body to any kind of demand made upon it 

Any event – environmental / internal demands or both tax or exceed the adaptive resources of an

Stress and Adaptation 

STRESSOR 



Any event or stimulus that causes an individual to experience stress

They may neither positive or negative, but they have positive or negative effects  Internal

Stressor (illness, hormonal change, fear)  External Stressor (loud noise, cold temperature)  Developmental Stressor  Situational Stressor

Stress and Adaptation  COPING-

a problem solving process that the person uses to manage the stresses or events with which he/she is presented.

Stress and Adaptation  ADAPTATION-

the process by which human system modifies itself to conform to the environment. It is a change that results from response to stress.

Stress and Adaptation SOURCES OF STRESS 2. Internal 3. External 4. Developmental 5. Situational

Stress Characteristics It is a universal phenomenon.  It is an individual experience.  It provides stimulus for growth and change.  It affects all dimension of life.  It is not a nervous energy. 

Effects of Stress on the Body 









Physical- affects physiologic homeostasis Emotional- affects feeling towards self Intellectual- influences perception and problem solving abilities Social – can alter relationships with others Spiritual- affects one’s beliefs and values

Effects of Stress on the Body 

  



Metabolic Disorders  Hyper/hypothyroi dism  Diabetes Cancer Accident proneness Skin disorders  Eczema  Pruritus  Urticaria  Psoriasis Respiratory disorders  Asthma  Hay fever  Tuberculosis





 

CVD  Coronary artery disease  Essential hypertension  CHF GIT disorders  Constipation  Diarrhea  Duodenal ulcer  Anorexia nervosa  Obesity  Ulcerative colitis Menstrual irregularities Musculoskeletal disorders  RA 

GENERAL THEORETICAL FRAMEWORKS FOR UNDERSTANDING STRESS Stress can be defined differently by the three models  STIMULUS  RESPONSE  TRANSACTION

Stress and Adaptation 2.

Models of Stress STIMULUS based models

4.

RESPONSE based models

6.

TRANSACTION based models

Stress as a Stimulus 



When viewed as a stimulus, stress is defined as an event or set of events causing a disrupted response (Lyon and Werner, 1987) Life events or circumstances causing

Stress as a Stimulus 

 



Holmes and Rahe 1967: They studied the relationship between specific life changes such as divorce or death, and the subsequent onset of illness. Focus: disturbing events within the environment Advantage: the scale identifies events stressful for most people Disadvantage: does not provide individual differences in perception and response to

Stress as a Transaction Views the person and environment in a dynamic, reciprocal and interactive relationships (Lazarus, 1966 )  Mental and physiologic (adaptive and affective) responses to stress 

Stress as a Transaction 

The transactional stress theory includes cognitive, affective, and adaptive responses from person and environment interaction. The person responds to perceived environmental changes by coping mechanisms.



Transactional theory of stress emphasizes that people & groups differ in their sensitivity & vulnerability to certain types of

Stress as a Transaction 







Includes mental & psychologic components or responses as part of his concept of stress takes into account cognitive processes that intervene between the encounter & the reaction encompasses a set of cognitive, affective & adaptive (coping) responses that arise out of personenvironment transactions. Cognitive appraisal: evaluative process determines why & to what

Stress As a Response 





Disruptions caused by harmful stimulus or stressors Specifies particular response or pattern of responses that may indicate a stressor Selye (1976): developed models of stress, that defines stress as a non-specific response of the body to any demand made on it

Stress As a Response  



Focus: reactions of the BODY Selye used the term “stressor’ as the stimulus or agents that evokes a stress response in the person . A stressor may be anything that places a demand on the person for change or adaptation.

Stress As a Response Hans Selye (1976) “ non-specific response of the body to any kind of demand made upon it He called it “non-specific” because the body goes through a number of biochemical changes and readjustments without regard to the nature of the stress producing agents.  Any type of stressor may produce the same responses in 

Stress As a Response 

Advantage : response to stress is purely physiologic; determines physiological response to stress



Disadvantage: does not consider individual differences in response pattern

Stress as a response SELYE proposed two Stress adaptation responses 2. General Adaptation Syndrome 3. Local Adaptation Syndrome

General Adaptation Syndrome 





Physiologic responses of the whole body to stressors Involves the Autonomic Nervous System, and Endocrine System Occurs with the release of adaptive hormones and subsequent changes in the WHOLE body

General Adaptation Syndrome

Three stages adaptation to stress for both GAS/LAS: Stressor

Alarm reaction Shock phase Epinephrine

Cortisone

Normal state

Stages of resistance

Stages of exhaustion

Rest

Countershock Phase

Death

General Adaptation Syndrome I. ALARM REACTION  Initial reaction of the body; “ fight OR flight” responses  Mobilizing of the defense mechanisms of the body and mind to cope with stressors.  SHOCK PHASE- the autonomic nervous system reacts; release of Epinephrine and Cortisol  COUNTERSHOCK PHASE- reversal of the changes produced in the shock

General Adaptation Syndrome

II. STAGE OF RESISTANCE:  The BODY stabilizes, hormonal levels return to normal, heart rate, blood pressure and cardiac output return to normal 2 things may occur:  Either the person successfully adapts to the stressors and returns to normal, thus resolving and repairing body damage; or  The stressor remains present, and adaptation fails (ex. Long-term terminal illness, mental illness, and

General Adaptation Syndrome III. STAGE OF EXHAUSTION:  Occurs when the body can no longer resist stress and body energy is depleted.  The body’s energy level is compromised and adaptation diminishes.  Body may not be able to defend self that may end to death.

General Adaptation Syndrome Stage 1 ALARM REACTION Enlargement of adrenal cortex Enlargement of lymphatic system Increase in hormone levels Stage 2 RESISTANCE PHASE Shrinkage of adrenal gland to normal size Lymph nodes closer to normal size Hormone levels sustained Stage 3 EXHAUSTION PHASE Rest or death Increase in hormone levels Depletion of adaptive hormones

Stress and Adaptation A-R-E ALARM: sympathetic system is mobilized! RESISTANCE: adaptation takes place EXHAUSTION: adaptation cannot be maintained

GAS Hypothalamus Anterior Pituitary Gland Adrenal Gland Adrenal Cortex Adrenal medulla

Adrenal gland

Adrenal Gland

Adrenal Gland

Hormonal Changes Adrenal Cortex 

MINERALOCORTICOIDS



Aldosterone  Na+ retention  WATER retention  Protein anabolism GLUCOCORTICOIDS  Cortisol  (Anti-inflammatory)  Protein catabolism  Gluconeogenesis

Adrenal Medulla







NOREPINEPHRINE  Peripheral vasoconstriction  Decreased blood to kidney  Increased renin (angiotensin) EPINEPHRINE  Tachycardia  Increased myocardial activity  Increased Bronchial dilatation  Increased Blood

Local Adaptation Syndrome 



 

Localized responses to stress Ex. Wound healing, blood clotting, vision, response to pressure Adaptive: a stressor is necessary to stimulate it Short- term Restorative: assist in homeostasis

Local Adaptation Syndrome Reflex Pain response:  Localized response of the CNS to pain  Adaptive response and protects tissue from further damage  Involves a sensory receptor, a sensory serve to the spinal cord, a connector neuron, motor nerve, effector’s muscles. Example: unconscious removal of hand from a hot surface, sneezing, etc. Inflammatory Response:  Stimulated by trauma or infection, thus preventing it to spread; also promotes healing

FACTORS INFLUENCING RESPONSE TO STRESS      

Age, Sex Nature of Stressors Physiological functioning Personality Behavioral Characteristics Level of personal control Availability of support system  Feelings of competence  Cognitive appraisal, Economic Status 

The MANIFESTATIONS OF STRESS INDICATORS OF STRESS  Physiologic  Psychological  Cognitive  Verbal-Motor

Physiological Indicators   

      

Dilated pupils Diaphoresis Tachycardia, tachypnea, HYPERTENSION, increased blood flow to the muscles Increased blood clotting Bronchodilation Skin pallor Water retention, Sodium retention Oliguria Dry mouth, decrease peristalsis Hyperglycemia

Remember these Physiologic Manifestations of Stress 

Pupils dilate to increase visual perception when serious threats to the body arise



Sweat production (diaphoresis) increases to control elevated body heat due to increased metabolism

Remember these Physiologic Manifestations of Stress 

Heart rate or pulse rate increases to transport nutrients & byproducts of metabolism more effectively



Skin becomes pale (Pallor) because of constriction of peripheral blood vessels to shunt blood to the vital organs.

Remember these Physiologic Manifestations of Stress 

BP increases due to vasoconstriction of vessels in blood reservoir (skin, kidneys, lungs), due to secretion of renin, Angiotensin I and II



Increased rate/depth of respiration with dilation of bronchioles, promoting hyperventilation and increased oxygen uptake

Remember these Physiologic Manifestations of Stress 

Mouth may become dry, urine output may decrease. The peristalsis of the intestines decreases leading to constipation



For serious threats, there is improved mental alertness

Remember these Physiologic Manifestations of Stress 

Increased muscle tension to prepare for rapid motor activity/defense



Increased blood sugar (glucocorticoids & gluconeogenesis) to supply energy source to the body.

Psychological indicators  This

includes anxiety, fear, anger, depression and unconscious ego defense mechanisms

Anxiety A

state of mental uneasiness, apprehension, or helplessness, related to anticipated unidentified stress

 Occurs

in the Conscious, subconscious, or unconscious levels

Levels of Anxiety 4 Levels of Anxiety:  Mild  Moderate  Severe  Panic

Levels of Anxiety 

Mild- increased alertness, motivation and attentiveness



Moderate- perception narrowed, selective inattention and physical discomfort

Levels of Anxiety 

Severe- behaviors become automatic, details are not seen, senses are drastically reduced, very narrow focus on specific details, impaired learning ability.



Panic- overwhelmed, unable to function or to communicate, with possible bodily harm to self and others, loss of strong displeasure

Anxiety

CATEGOR Y

MILD

ANXIETY MODERAT E

SEVER E

PANIC

Difficult to understa nd Easily distracte Tachycar d dia,

Trembling unpredicta ble response

Percepti Increas on and ed attention arousal

Narrowe Inability Distorted d focus to focus perceptio n

Communication

Increase d questioni ng

Voice tremors Focus on particular object

VS changes

NONE

Slight Increase

Palpitation , choking, Hyperven chest pain tilation

Fear 



It is a mild to severe feeling of apprehension about some perceived threat. The Object of fear may or may not be based on reality.

Anxiety versus fear ANXIETY

FEAR

State of mental Emotion of apprehension uneasiness Source may not be Source is identifiable identifiable Related to the future Related to the present Vague

Definite

Result of psychological or emotional conflict

Result of discrete physical or psychological entity, definite and concrete events

Anger 



Subjective feeling of strong displeasure It is an emotional state consisting of subjective feeling of animosity or strong displeasure

Other terms related Anger Hostility = marked by overt antagonism & harmful or destructive behavior  Aggression = unprovoked attack or a hostile, injurious, or destructive action or outlook  Violence = exertion of physical force to injure or 

Depression  An

extreme feeling of sadness, despair, dejection, lack of worth or emptiness

Depression Emotional Symptoms:   

Tiredness emptiness numbness

Behavioral signs:  



Physical signs     

loss of appetite weight loss constipation headache dizziness



  

irritability inability to concentrate difficulty making decision loss of sexual desire crying sleep disturbance social withdrawal

COGNITIVE MANIFESTATIONS 

Thinking responses that include problem solving, prayer, structuring, self control, suppression and fantasy



Thinking responses of the individual toward stress

COGNITIVE MANIFESTATIONS 

PROBLEM SOLVING: Use of specific steps to arrive at a solution



STRUCTURING: manipulation of a situation so that threatening events do not occur

COGNITIVE MANIFESTATIONS 

SELF CONTROL / DISCIPLINE: assuming a sense of being in control or in charge of whatever situation



SUPPRESSION: willfully putting a thought / feeling out of one’s mind

COGNITIVE MANIFESTATIONS 

FANTASY / DAYDREAMING: “ make believe” or imagination of unfulfilled wishes as fulfilled



PRAYER: identification, description of the problem, suggestion of solution, then reaching out for help or support to the supreme being

VERBAL / MOTOR MANIFESTATIONS 

First hand responses to stress

VERBAL / MOTOR MANIFESTATIONS 

CRYING: feelings of pain, joy, sadness are released



VERBAL ABUSE: release mechanism toward non living objects, and stress producing events



LAUGHING: anxiety reducing response that leads to constructive problem solving

VERBAL / MOTOR MANIFESTATIONS 

SCREAMING: response to fear or intense frustration and anger



HITTING AND KICKING: spontaneous response to physical threats or frustrations



HOLDING AND TOUCHING: responses to joyful, painful or sad events

FACTORS INFLUENCING STRESS DEPEND ON THE  Nature of the stressor  Perception of the stressor  Number of simultaneous stressor  Duration of exposure to the stressor  Experiences with a comparable stressor  Age of the individual  Support people

Personality Types TYPE A 



impatient, competitive, aggressive, and insecure, always in a hurry, inability to relax Prone to cardiovascular illness.

Personality Types TYPE B  more relaxed, unhurried, able to enjoy both work and play without guilt

Personality Types TYPE C:  “coping personality” experiences considerable stress but learns to cope with it (challenge, commitment,& control) , uses personality characteristics to cope with stress Coping Characteristics of Type C:  Challenge  Commitment 

COPING 





A problem solving process or strategy that the person uses to manage the out-of-ordinary events or situations with which he/she is presented. Successfully dealing with problems A cognitive and behavioral effort to manage specific external and internal demands that are

Coping related terms 





Coping strategy- is a coping mechanism, way of responding to problems Problem focused coping- efforts to improve a situation by making changes Emotion focused coping- includes thoughts and actions that relieve emotional stress

Coping related terms 







Long term coping- involves constructive and realistic changes Short term coping- involves stress reduction to tolerable levels temporarily Adaptive coping- helps person deal effectively with stress Maladaptive coping- results in unnecessary distress for the person and stressful events

MODES OF ADAPTATION 1. Physiologic mode (biologic adaptation) 

Occurs in response to increased or altered demands placed on the body & results in compensatory physical changes.

2. Psychological Mode 

Involves a change in attitude & behavior toward emotionally stressful situations. (Ex. Stopping smoking)

3. Socio-cultural Mode 

Changing persons behavior in

CHARACTERISTICS OF ADAPTIVE RESPONSES  



  

All attempts to maintain homeostasis Whole body or total organism response Have limits (Physiologic, Psychologic/Social) Requires time Varies from person to person Maybe inadequate or excessive (infection/allergy

MANIFESTATIONS OF ALTERED COPING  Addictive

behaviors  Physical illness  Anxiety and depression  Violent behaviors

Applying the Nursing Process     

A D P I E

Assessment It is important that the nurse have an understanding of the methods or strategies used by the patient so that nursing care can be appropriately individualized. 1. Utilize the Nursing History  Subjective data- such as the functional pattern, risk pattern and dysfunctional pattern. 2. Physical Examination – centered on the changes in the ANS and NES. Objective data- Physical assessment, Diagnostic tests and procedures

Diagnoses Utilize those accepted by NANDA 2. Anxiety 7. Fear 3. Caregiver role strain 8. Impaired adjustment 4. Compromised family coping 9. Ineffective coping 5. Decisional conflict 10. Ineffective Denial 6. Defensive coping 11. Post-trauma Syn 7. Disabled Family coping 12. Relocation

Planning The goals for the patient with ineffective individual coping need to be individualized, taking into consideration the patient’s history, areas of risk, evidence of dysfunction and related objective data.  There are four important guidelines to be followed in choosing nursing goals. The nurse must choose goals geared :  



To eliminate as many stressors as possible To teach about the effects of stress to the body

Planning Overall client goals are the following:  To decrease or resolve anxiety  To increase ability to manage or cope with stress  To improve role performance Examples of Patient Goals are: After ___hours/days: 1. The patient will identify sources of stress in his/her life 2. The patient will identify usual personal coping strategies for stressful situations 3. The patient will define the effect of

Implementation 







Once the diagnosis is made, the nurse can intervene independently and collaboratively to help restore function The nurse can assist the patient in recognizing signs and symptoms of stress, identifying the sources of distress, and choosing an appropriate course of action. The nurses can assist the patient in finding techniques that are most effective. The nurse also has significant role in identifying people at risk for

Implementation There are essentially three ways to manage Stress:  Eliminate the causes/sources of stress  Produce a relaxation response in the body  Suggest a change in lifestyle, if possible

Implementation Stress reduction techniques:  Proper nutrition  Regular exercise, physical activity & recreation  Meditation, Breathing exercises, creative imagery, YOGA  Communication, time management, expression of feeling, talking it out, organizing time  Biofeedback  Therapeutic touch

Implementation 1. 2. 3. 4. 5. 6. 7. 8.

Minimize anxiety Mediate anger Massage Progressive relaxation Guided imagery Biofeedback Therapeutic touch CRISIS INTERVENTION

Implementation Minimize anxiety  Support the client and the family  Orient the client to the hospital or agency.  Give the client in a hospital some way of maintaining identity.  Provide information when the client has insufficient information.  Repeat information when the client has difficulty remembering.  Encourage the client to participate in the plan of care.  Give the client the time to express feelings and thoughts.

Implementation Mediating Anger  Responses that reduce the client’s anger & stress  offering help  asking relevant questions  conveying understanding  Guidelines: to provide understanding responses  focus on the feeling words of the client  note the general content of the message  restate the feeling & content of what the client has communicated 

Implementation Massage  These include effleurage (stroking), friction, pressure, petrissage (kneading or large, quick pinches of the skin, subcutaneous tissue and muscle), vibration and percussion.  Purposes -enhances or induces relaxation before sleep  -stimulates skin circulation 

Implementation Progressive Relaxation  Jacobson (1930), the originator of the Progressive relaxation technique

Implementation Guided Imagery  Imagery is "the formation of a mental representation of an object that is usually only perceived through the senses" (Sodergren 1985). Example: Visual -A valley scene with its many greens Auditory -Ocean waves breaking rhythmically Olfactory -Freshly baked bread Gustatory -A Juicy hamburger

Implementation 

Biofeedback is a technique that brings under conscious control bodily processes normally thought to be beyond voluntary command. muscle tension, heartbeat, blood flow, peristalsis, & skin temperature – can be voluntarily controlled feedback provided through:  a. temperature meters (that indicate temp. changes)  b. EMG (electromyogram) that shows

Implementation Therapeutic Touch  “a healing meditation, because the primary act of the nurse (healer) is to "center" the self and to maintain that center (mental concentration and focusing) throughout the process. The process consists of the following four steps:  Centering (sense of detachment, sensitivity & balance)  Assessing (head to toe scanning process)  Unruffling (to enhance the transfer of energy from nurse to client)

Implementation Therapeutic Touch The form of energy has different effects and is related to colors:  Blue energy is sedating  Yellow energy is stimulating and energizing  Green energy is harmonizing.

Evaluation 



The evaluation of the plan of care is based on the mutually established expected outcomes. It is important to observe BOTH verbal and non-verbal cues when evaluating the usefulness of the plan.

Evaluation The nurse must be able to determine the success of her action by:  Observing the client for absence or reduction of manifestations of fear and / or anxiety.  Measuring BP and Pulse Rate  Asking the client’s personal strengths or coping resources identified  Determining Effective and ineffective coping responses and consequences.  Identifying Situations that use specific adaptive coping method’s and the client’s perception of their effectiveness  Observing Support persons involved

Stress Management for Nurses  Plan daily relaxation program

Plan daily relaxation program  Establish a regular pattern of exercise  Study assertive techniques. Learn to say “no”  Learn to accept failures  Accept what cannot be changed  Develop collegial support  Participate in professional

Anxiety 



This is the most universal of all emotions that cannot be observed directly BUT must be inferred from behavior This is defined as a “Sense of impending doom” , an apprehension of dread that seemingly has no basis in reality

Characteristics of Anxiety 

 



Always perceived as a negative feeling Extremely communicable Cannot be distinguished from fear easily Occurs in degrees: mild, moderate, severe, panic

Origin of anxiety 



The PSYCHOSEXUAL theory believes that anxiety is a response to the emergence of the ID impulses that are NOT acceptable to SUPEREGO The EGO detects a real or potential conflict between the ID and the SUPEREGO resulting to the development of ANXIETY

Origin of anxiety 



BIRTH is the prototypical separation anxiety- the threat to life and the separation from the mother. In subsequent developmental changes, unconscious conflicts are perceived as life threatening associated with separation

Origin of anxiety 





SULLIVAN views anxiety as always occurring in an interpersonal context ANXIETY is generated when the individual anticipates or actually receives cues that signal disapproval from others Human being experiences anxiety during infancy when either his need for satisfaction or his need for security is NOT

Adaptation to anxiety 

Use of unconscious ego defense mechanisms 



Utilized when the person experiences conflict between the id and superego

Use of security operations

Identified by Sullivan  Apathy, Somnolent detachment, selective inattention and preoccupation 



Use of coping mechanisms 

This is adaptation to anxiety based on conscious acknowledgement of

GRIEF AND LOSS 

Loss is a universal experience that occurs throughout life span



Grief is a form of sorrow involving feelings, thoughts, and behaviors caused by bereavement

GRIEF AND LOSS 



Responses to loss are strongly influenced by one’s cultural background The grief process involves a sequence of affective, cognitive, and psychological states as a person responds to, and finally accepts a loss.

Loss and grieving  





LOSS= something valuable is gone GRIEF= total response to emotional experience related to loss BEREAVEMENT= Subjective response by loved-ones MOURNING= behavioral response

GRIEF AND LOSS Stages of Grieving (Kubler-Ross)  Denial- refuses to believe that the loss has occurred  Anger- the individual resists the loss and may “act out” feelings.  Bargaining- the individual attempts to make a deal in an attempt to postpone the reality of loss.  Depression- overwhelming feeling of loneliness and withdrawal from others  Acceptance- the individual comes to terms with loss, or impending loss, psychological reactions to loss to the loss cease, and the interaction to

Loss and grieving Stages of Grieving (Kubler-Ross) DABDA DENIAL= refusal to believe ANGER= hostility BARGAINING= feeling of guilt, fear of punishment DEPRESSION= withdrawn behavior ACCEPTANCE= comes to terms with loss 

Loss and grieving Stages

Behaviors

D

Refuses to believe that loss is happening Retaliation

A B D A

Feelings of guilt, punishment for sins Laments over what has happened Begins to plan like wills, prosthesis

Death and Dying (Kozier) AGE

Beliefs

Infancy to 5 years old

NO clear concept of Death It is Reversible, temporary Understands DEATH is sleep FINAL but can be AVOIDED Death is INEVITABLE, everyone will die someday Understands own mortality Fears a lingering Death

5 to 9 years 9-12 years

12-18 years 18-45 45-65 years 65 and above

Attitude is influenced by religion Experiences peak of death anxiety Death as multiple meanings

Nursing responsibilities In Death and dying  Nurses

need to take time to analyze their own feelings about death before they can effectively help others with terminal illness

Nursing responsibilities In Death and dying 

2. 3. 4.

The major goals for the dying clients are: To maintain PHYSIOLOGIC and PSYCHOLOGIC support To Achieve a dignified and peaceful death To maintain personal control

Loss and Death RESPONSIBILITIES Provide Relief from loneliness, fear and depression  Help clients maintain sense of security  Help clients accept losses  Provide physical comfort 

LOSS ,GRIEVING AND DEATH 

DEATH CONCEPTS 1-5 – IMMOBILITY AND INACTIVITY Wishes and unrelated action responsible for action  5-10 – final but can be avoided  9-12 – understands own mortality and fears death  12 – 18 – fears and fantasizes avoidance  18-45 – increased attitude awareness  45-65 – accepts mortality 

KUBLER ROSS – STAGES OF GRIEF 

D – SUPPORTIVE



A- PROVIDE STRUCTURE AND CONTINUITY



B – LISTEN AND ENCOURAGE



D- ALLOW EXPRESSION AND PROVIDE FOR SAFETY



A- ENCOURAGE PARTICIPATION

Neurosis 





any long term mental or behavioral disorder in which contact with reality is retained the condition is recognized by the patient as abnormal. Essentially features anxiety or behavior exaggerated designed to avoid anxiety ( anxiety disorder ; hysteria to conversion d/o, amnesia, fugue, multiple personality and depersonalization- Dissociative d/o ;oc d/o) Result of inappropriate early

Psychosis 





Mental or behavioral disorder wherein patient looses contact with reality Presence of delusions, hallucinations, severe thought disturbances, alteration of mood, poverty of thought and abnormal behavior (schizophrenia , major disorder of affect ( mania – depression), major paranoid states and organic mental

Mental disorders Neurosis  Does not require hospitalization  Considered moderate reaction to stress  Reality testing remains sound  Patient feels suffering and wants to get well  Ignores reality  Exploits symptoms for secondary gain  Desires are not externalized  Personality remains

Psychosis  Requires hospitalization  MAJOR reaction to stress  Reality testing is GREATLY impaired  Patient does not recognize he is ILL  Patient denies reality and substitute something else  NO secondary gain is derived from the symptoms  Desires and motives are often PROJECTED

Normal Anxiety Versus Abnormal Anxiety Normal Anxiety  A protective response and innate form of communication that the body uses to mobilize its coping resources to maintain homeostasis.  Arises from a realistic apprehension of a previously un-encountered situation that has symbolic meaning to the person

Normal Anxiety Versus Abnormal Anxiety PATHOLOGIC Anxiety  A response to thoughts, feelings, desires that if Conscious would be UNACCEPTABLE to the individual; that if known, would cause the loss of approval or love from others

Anxiety Disorders 

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The MOST common of all psychiatric disorders Cause an individual to feel frightened, distressed an uneasy mostly without a specific cause

Anxiety Disorders 

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Panic disorder (with or without agoraphobia) Specific phobia Social phobia Obsessive-compulsive disorder Post traumatic stress disorder Acute stress disorder Generalized anxiety disorder

Anxiety Disorders 

2. 3. 4. 5. 6. 7.

Major manifestations for all types: Autonomic nervous arousal Sense of doom Depersonalization Avoidant behaviors Paresthesias Recurrent attacks of intense fear or discomfort

Anxiety Disorders Global Manifestations of Anxiety disorders 2. Biological- tachypnea, tachycardia, diaphoresis 3. Behavioral- rituals, avoidance, increased dependence, clinging 4. Motor- tension, pacing, tremors, restlessness 5. Cognitive- Sense of doom, Confusion, Helplessness, Intense fear, powerlessness

Anxiety Disorders: Epidemiology  

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Affects 15% of the population Most common reason for seeking medical help Highest in adults Cultural factors may influence anxiety disorders

Anxiety Disorders: Etiology     

Psychodynamic theory Existential theory Behavioral theory Developmental theory Biological theoryneurotransmitter and genetic causes

Anxiety Disorders: Etiology Theory

Explanation

Psychodynamic theory

Anxiety occurs when the ego attempts to deal with psychic conflict or emotional tension If ego defense mechanisms will fail to protect the ego, immature

Anxiety Disorders: Etiology Theory

Explanation

Existential theory

Human existence and its relationship to God is the concept of this theory Sense of nothingness results in inadequate coping

Anxiety Disorders: Etiology Theory

Explanation

Behavioral theory

Anxiety occurs when there is danger perceived. Intense anxiety is a learned maladaptive response to stress and anxiety

Anxiety Disorders: Etiology Theory

Explanation

Developmental theory

Anxiety initially occurs with separation from early primary care givers

Anxiety Disorders: Etiology Theory

Explanation

Biological theory

Very high cortisol level Dysregulation of benzodiazepine receptors in the CNS Hereditary

Anxiety Disorders: related terms  Phobia= a specific pathological fear

Phobia= a specific pathological fear reaction out of proportion to the stimulus , irrational fear

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Simple phobia= persistent fear of a specific object/situation

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Agoraphobia= fear of open spaces

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Social phobia= fear of embarrassing situation in public places

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Anxiety Disorders: related terms

Phobias and related disorders The individuals recognize the fear as irrational but they feel inadequate or powerless to control the fear  There may be genetic component  Behavioral theory suggests that a phobia results form a conditioned response in which a person learns to associate a phobic object with uncomfortable feelings: the avoidance of the object will reduce 

Anxiety Disorders: related terms 

Obsession= an undesirable BUT persistent thought or intrusive idea that is forced into conscious awareness

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Compulsion= performance of an unwanted act or ritual that is contrary to the person’s wishes or standard. The behavior is done in a stereotypical and

Anxiety Disorders: related terms  Obsessive -Compulsive disorder

Obsessive -Compulsive disorder Recurrent obsession and compulsion that are severe enough to be time consuming causing marked distress or impairment of functions  Proposed etiology: Biologic vulnerability, striatum dysfunction theory and genetic vulnerability  The most common obsessions are repeated thoughts about contamination, repeated doubts  The most common compulsion 

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Anxiety Disorders: related terms

Obsessive -Compulsive disorder The client is WEL aware of his unrealistic and inappropriate nature of obsession and compulsion  He uses the defense mechanisms of : UNDOING and SYMBOLIZATION  Indulgence in obsessive thoughts and performance of the behaviors causes temporary anxiety relief ( a primary gain) 

Anxiety disorders 

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Post-traumatic stress disorders (PTSD) = characterized by the re-experiencing of the terror associated with a psychologically distressing event that was actually experienced at an earlier time. Former names: hysteria, war shock, battle fatigue The event is usually beyond the breath of normal human

Anxiety disorders Post-traumatic stress disorders  Major characteristics: 3. Persistent recurrent and intrusive thoughts, flashbacks, dreams and intense psychological distress 4. Avoidance behaviors (depersonalization) 5. Emotional numbing, hyper vigilance and ANS arousal

Anxiety disorders Generalized anxiety disorder= characterized by unrealistic or excessive anxiety, worry about life circumstances Chronic anxiety, apprehensive worrying, about 6 months  Prevalence is 5 % in the general population  Women affected more than men 

Anxiety disorders Panic Disorder= sudden, unanticipated intense anxiety persisting for at least 1 month Profound fear and urge to escape  Women more than men  With agoraphobia= anxiety attacks when in places or situation which can be embarrassing 

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Nursing Process for patients with Anxiety Disorders

Assessment Diagnosis Planning Implementation Evaluation

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Nursing Process for patients with Anxiety Disorders

Assessment

Process begins with a complete medical and physical examination to RULE out underlying physical and substance – related conditions  Utilize the mental status examination 

Assessment: Anxiety Disorders 

Assess activity process: Motor restlessness, ritualistic behavior, pacing, sleep pattern disturbances, staying at home, avoidant behaviors

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Assess cognitive processes: maintains reality testing, verbalization of persistent thoughts, nightmares

Assessment: Anxiety Disorders 

Assess Emotional process: fearful, feeling of anxiety, nervousness

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Assess Interpersonal process: strained relationships

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Assess perception process: hyperalertness, low self-esteem

Assessment: Anxiety Disorders 

Physiologic Assessment Tightness of stomach  Tachycardia  Anorexia  Palpitation  Shortness of breath  Feelings of exhaustion  Motor restlessness  Alertness 

Nursing Diagnoses: Anxiety Disorders         

Ineffective individual coping Altered role performance Impaired social interaction Defensive coping Sleep pattern disturbances Altered thought process Anxiety Fear Powerlessness

Planning: Anxiety Disorders 

The general nursing goals are to help patients lower their anxiety, develop functional pattern of adaptations and develop awareness of the effects of the disorders

Implementation: Anxiety Disorders Foster Activity process Allow the patient to carry out the anxiety-releasing rituals for them to develop security  Provide time-limit to individual rituals.  Rituals may e schedule earlier so as not to disrupt any hospital activity  Help patient develop interests outside himself by encouraging involvement in activities 

Implementation: Anxiety Disorders Establish therapeutic relationship with the client 

Teach the patient about the etiology, course and treatment of anxiety disorders

Implementation: Anxiety Disorders Encourage verbalization of concerns and feelings Utilize appropriate communication techniques  Convey warm, friendly and emphatic attitude  Introduce relaxation techniques and other positive anxiety management strategies 

Implementation: Anxiety Disorders Assist in Therapeutic modalities: Cognitive and behavioral Therapy: desensitization Pharmacotherapy: use of the anxiolytic drugs like benzodiazepines

Implementation: Anxiety Disorders Cognitive-Behavioral Therapy PsychoTeaching the client and education

family about anxiety disorders

Continuous symptoms monitoring

Utilizing a diary or recording of symptoms

Breathing retraining

Teaching client how to do abdominal breathing to control body physiologic responses

Implementation: Anxiety Disorders Cognitive-Behavioral Therapy CognitiveTeaching the client to restructuring

challenge the exaggerated worries and fears. Exposure to Involves gradual triggering exposure of the anxiety anxiety provoking or fearful (desensitizati event on)

Interventions for the client with OCD  

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Convey acceptance of the client Allow time to perform rituals because ANXIETY will increase if the client cannot perform the compulsive behaviors Encourage LIMIT setting on ritualistic behaviors The best time to interact with client is AFTER completing the ritualistic behavior

Interventions for the client with OCD 

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Assist the client in listing all of the objects and places that trigger anxiety Introduce coping techniques to deal with the anxiety situations

Interventions for the client with PHOBIA 

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DO NOT force the client to approach the specific object or situation Allow clients to verbalize feelings prior to exposure to object HELP client identify coping measures to utilize whenever the object/ situation is encountered Practice relaxation with the clients

Interventions for the client with PTSD 

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Validate with the client that the traumatic event can be experienced with a high anxiety response Allow VERBALIZATION of feelings in all aspects of the traumatic events Teach the patient coping strategies to manage symptoms of anxiety that accompanies the

Evaluation 

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Client identifies own anxiety responses Identifies stressors in past and current life situations Utilizes coping strategies rather than symptomatic behaviors Identifies and actively participates in continued treatment plan

Anxiety-related Disorders  

Dissociative disorders Somatoform disorders

Anxiety-related Disorders 

Dissociative disorders 

Alteration in conscious awareness which includes periods of forgetfulness, memory loss for past stressful events and feelings disconnected form daily events

Anxiety-related Disorders Dissociative disorders Dissociative amnesia Dissociative fugue

Characteristics Sudden inability to recall important personal information Sudden unexplained flight form home with an inability to recall events from the past

Anxiety-related Disorders Dissociative disorders Depersonalization disorder Dissociative identity disorder

Characteristics Feeling detached from one’s thoughts body Presence and of two or more distinct personalities, each with its own pattern of perceiving, relating to and thinking about the

Anxiety-related Disorders Dissociative disorders Dissociative disorders not specified

Characteristics Disorder that does not fit the criteria

Dissociative Disorders Etiology: 2. Trauma= these disorders are generally associated with traumatic events that the individual deals with them by “splitting” or dissociating self from the memory 3. Abuse- severe traumatic abusive event during childhood More common in women than men 

Dissociative Disorders NURSING MANAGEMENT  Establish a trusting relationship and provide support during times of depersonalization and amnesia  Encourage client to disclose and discuss feelings  Teach client to perform anxietyreducing techniques when the painful events are reexperienced

Dissociative Disorders NURSING MANAGEMENT 3. Pharmacotherapy: usually not employed 4. Psychotherapy: psychodynamic therapy with hypnosis to bring the conscious awareness of the traumatic events 5. Group therapy

Psychosomatic Disorders 

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Disorders characterized by somatic complaints for which no organic cause could be demonstrated Usually result from emotional factors

Psychosomatic Disorders Characteristics: 2. Involve the organ system innervate by the autonomic nervous system 3. Physiologic changes accompany emotional responses that are intense 4. Symptoms are physiological rather than symbolic, the emotions beings expressed through the viscera 5. Persistent psychosomatic reactions may produce structural organic changes over time

Psychosomatic Disorders Characteristics: 5. The somatic symptoms afford generous secondary gains for the for the patients in terms of attention

Somatoform disorders 

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Refer to a group of psychiatric disorders whose symptoms are severe enough to cause global impairment The clients often present with multiple, recurrent clinically significant somatic complaints, usually colorful and exaggerated hut lacking in factual basis

Somatoform disorders 

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The condition is characterized by PRIMARY GAIN (relief of anxiety) and SECONDARY gain (special attention) The individual becomes totally focused on the physical symptoms which can severely restrict activities The person visits MULTIPLE health care providers and may undergo unnecessary procedures

Somatoform disorders ETIOLOGIES 1. Psychodynamic theory= utilization of the mechanism to convert psychic energy to physical manifestations. Conversion represents the symbolic resolution of the anxiety 

Somatoform disorders ETIOLOGIES 2. Neurobiologic theoryneurotransmitter dysregulation. There is deficient communication between the brain hemisphere resulting to difficult expression of emotions, and distress is expressed as physical symptoms 

Somatoform disorders ETIOLOGIES 3. SOCIO-cultural factors- higher among low SES 

Types of Somatoform disorders Types

Characteristics

Somatization Disorder

History of multiple physical complaints without organic basis Unrealistic fear of having a serious disease Pre-occupation with an imagined defect in the normal appearing person

Hypochondriasis Body dysmorphic disorder

Types of Somatoform disorders Types

Characteristics

Pain disorder

Chronic pain in many anatomic sites Loss or change in physical functioning that cannot be associated with any organic cause and seems to be associated with

Conversion disorder

Somatoform disorders NURSING MANAGEMENT 2. Mainstay treatment is a long term relationship with a health care provider to prevent the patient from seeking multiple providers with multiple recommendations 3. Assist in psychotherapy as part of the treatment plan 4. Family Education