●​ Think about people in terms of their overall functioning and adaptation

rather than by the symptoms of their specific illness.

MENTAL HEALTH AND MENTAL ILLNESS

-​ Balance in a person’s internal life and adaptation to reality
-​ Possess the ability to love and work
-​ In contact with reality and the environment
-​ Resolve conflicts within a framework of reasonability

Elements of Mental Health

1.​ Self-acceptance
2.​ Personal growth
3.​ Sense purpose and meaning
4.​ Positive relations with others
5.​ Environmental mastery
6.​ Autonomy

Mental Illness
-​ Mental disorder or condition
-​ Manifested by disorganization and impairment of function
-​ Arises from various causes such as psychological, neurobiological and
genetic factors

Mental Health and Mental Illness Continuum

Adaptive
-​ Healthy
-​ Adaptive coping
-​ Interacts with real environment
-​ Socially acceptable behavior

Maladaptive
-​ Psychosis
-​ Maladaptive coping
-​ Hallucination/delusion
-​ Bizarre behavior
Qualities of a Psychiatric Nurse
1.​ Self Awareness
2.​ Self Acceptance
3.​ Accepting the Patient
4.​ Being Sincerely Interested in Patient Care
5.​ Being Available
6.​ Empathizing with the Patient
7.​ Reliability
8.​ Professionalism
9.​ Accountability
10.​ The Ability to Think Critically

Therapeutic Use of Self

Hildegard Peplau (1952), who described this therapeutic use of self in the
nurse-client relationship, believed that nurses must have a clear
understanding of themselves to promote their client’s growth and to avoid
limiting client’s choices to those valued by the nurse.
-​ It is the main tool used by the nurse in the practice of Psychiatric
Nursing
-​ It is the positive use of one’s self in the process of therapy
-​ Therapeutic use of self requires SELF-AWARENESS
-​ Self-awareness means the ability to monitor our inner world our
thoughts and feelings

Key Component of the Psychiatric Experience

-​ GOAL: To achieve authentic, open, and personal communication
-​ The nurse must be able to examine personal feelings, actions, and
reactions as a provider of care.
-​ A firm understanding and acceptance of self allows the nurse to
acknowledge a patient’s differences and uniqueness.

COMPONENTS OF SELF-AWARENESS BY CAMPBELL

1. PSYCHOLOGICAL COMPONENT
-​ Knowledge of emotions, motivations, self-concept, and personality.
-​ Being sensitive to feelings
2. PHYSICAL COMPONENT
-​ Knowledge of personal and general physiology, as well as bodily
sensations, body image, and physical potential
3. ENVIRONMENTAL COMPONENT
-​ Socio-cultural environment, relationships with others and knowledge of
the relationships between humans and nature.
4. PHILOSOPHICAL COMPONENT
-​ Sense of life having meaning

JOHARI WINDOW

ELECTROCONVULSIVE THERAPY
-​ A procedure, done under general anesthesia, in which small electric
currents are passed through the brain, intentionally triggering a brief
seizure
-​ Artificial induction of a grandmal seizure by passing a controlled
electrical current through electrodes applied to or both temples
-​ Client usually receive a series of 6 to 15 treatments scheduled thrice a
week.
 -​ Minimum of 6 treatments are needed to see sustained improvements
in depressive symptoms. Maximum benefit is achieved in 12 to 15
treatments.

Indicators of Effectiveness of ECT:

-​ The occurrence of generalized tonic clonic seizure

Voltage of electric current administered: 70-150 volts

Duration: 0.5-2 seconds

Indication
-​ Depression (clients who do not respond to antidepressants or those
who experience intolerable side effect at therapeutic doses)
-​ Bipolar disorder
-​ Catatonic Schizophrenia
-​ Actively Suicidal

Nursing Intervention during ECT of Pregnant Women

-​ Ask collaboration with obstetric and anesthesia services (prior to
initiating ECT, the patient should be screened by OB-GYN for any risk
factors for miscarriage and preterm labor)
-​ Fetal monitoring is recommended before and after ECT (sometime
during ECT) with the use of Doppler
-​ If uterine contraction occur, stop the procedure, document the
contraction and consult OB-GYN
-​ After ECT nausea and vomiting occur, usually treated with medication
(Ondansetron)
-​ Post-ECT headaches are managed usually with Acetaminophen

Contraindications
-​ Severe respiratory depression
-​ Glaucoma
-​ Increased Intracranial Pressure
-​ Recent Myocardial Infarction
-​ Cardiac dysrhythmias
-​ Recent stroke
-​ Recent fracture
 -​ Retinal Detachment
-​ Pregnant complication

Nursing Interventions
PRE-ECT
-​ Client must be given informed consent
-​ NPO after midnight
-​ Take vital signs
-​ Remove prosthesis and jewelry
-​ Bladder emptied
-​ The patient must complete a thorough physical, neurological and
laboratory examination.
-​ Informed consent is obtained
-​ Dress patient in loose, comfortable clothing
-​ Administer pre-treatment medications
-​ Make patient lie simply with the back resting on a pillow
-​ Let the patient bite mouth gag
-​ Apply electrode jelly on the temple to ensure complete contact.
-​ Treatment switch is pressed after adjusting the dosage and patient
goes into grand mal seizure
-​ When convulsion subsides and breathing is resumed, turn the patient
on his side to prevent swallowing of saliva.
-​ Ventilation and monitoring continues until the patient is recovered.
-​ Let the patient feel comfortable in bed and let him go to sleep.
-​ Monitor respiratory problem
-​ Reorient the patient when he wakes up
-​ Document all treatments
-​ After the patient is oriented and has rested, let him have a shower and
start his usual activities

Medications
-​ Atropine sulfate
-​ Anectine (Succinylcholine)
-​ Brevital (Methohexital sodium)

POST-ECT
-​ Vital Signs every 15 minutes
-​ Maintain patent airway
 -​ Side lying position - to prevent aspiration
-​ Provide ORIENTATION to time, place, and situation
-​ Advise the patient that memory will return

Common Complications
-​ Loss of Memory
-​ Headache
-​ Apnea
-​ Fracture
-​ Respiratory depression

NURSE-PATIENT RELATIONSHIP

Types of Relationships
-​ S - SOCIAL
-​ Purpose: Friendship, socialization, accomplishment of task
-​ I - INTIMATE
-​ Purpose: Sharing of two hearts
-​ T - THERAPEUTIC
-​ Purpose: Patient Only
-​ To be therapeutic, detach emotions

NON-VERBAL BEHAVIOR OF THE NURSE

-​ S - Sit in front of the Patient
-​ O - Open body position
-​ L - Lean forward towards the patient
-​ E - Eye contact
-​ R - Relatively relax

Components of a Therapeutic Relationship

-​ P - POSITIVE REGARD
-​ Unconditional, non-judgmental attitude, implies respect
irregardless of the patient’s behavior, background or lifestyle
(we start to be judgmental, when we use adjectives)
-​ A - ACCEPTANCE
-​ Nurse does not become upset or respond negatively to a client’s
outbursts, anger or acting out
-​ G - GENUINE INTEREST
 -​ Nurse is clearly focused and is comfortable with himself/herself
(Client can detect artificial behavior)
-​ E - EMPATHY
-​ Ability of the nurse to perceive the meanings and feelings of the
patient and communicates that understanding of the patient
-​ T - TRUST
-​ Patient is confident of the nurse and the nurse’s presence
conveys integrity and reliability
-​ Trusting behaviors: caring, consistency, approachability,
listening, keeping promises, honesty

PHASES (MAJOR TASKS)

-​ PRE-INTERACTION
-​ Self-awareness
-​ ORIENTATION
-​ Contract setting
-​ WORKING
-​ Identification of problems and exploring towards resolution.
-​ TERMINATION
-​ Major task is resolve feelings of loss and evaluate progress of
solutions

THERAPEUTIC COMMUNICATION TECHNIQUES

Accepting
-​ Indicating reception
-​ “Yes, “I follow with what you said”, “Nodding”

Broad Opening
-​ Allow the client to take the initiative in introducing the topic
-​ “Is there something you’d like to talk about?”; “Where would you like
to begin?”

Consensual Validation
-​ Searching for mutual understanding, for accord on the meaning of the
words
-​ “Tell me whether my understanding agrees with yours.”
Encouraging Comparison
-​ Asking that similarities and differences be noted
-​ “Was it something like…?”, “Have you had similar experiences?”

Encouraging Description of Perceptions

-​ Asking the client to verbalize what she or he perceives
-​ “What is happening?”, “What does the voice seem to be saying?”

Encouraging Expression
-​ Asking the client to appraise the quality of his or her experience
-​ “What are your feelings in regard to…?”, “Does this contribute to your
distress?”

Exploring
-​ Delving further into a subject or idea. (Can also be thru asking for an
example)
-​ “Tell me more about that.”, “Would you describe it more fully?”, “Give
me an example of you and your wife not getting along”

Focusing
-​ Concentrating on a single point
-​ “This point seems worth looking more closely.”, “Of all the concerns
you’ve mentioned, which is most troublesome?”

Formulating a Plan of Action

-​ Asking the client to consider kinds of behavior likely to be appropriate
in future situations
-​ “What could you do to let your anger out harmlessly?”, “Next time this
comes up, what might you do to handle it?”

General Leads
-​ Giving encouragement to continue
-​ “Go on.”, “And then?”, “Tell me about it.”

Giving Information
-​ Making available the facts that the client needs
-​ “My name is..”, “Visiting hours are…”, “My purpose being here is…”
Giving Recognition
-​ Acknowledging, indicating awareness
-​ “Good morning Mr. S”, “I've noticed that you’ve combed your hair
today.”

Making Observations
-​ Verbalizing what the nurse perceives
-​ “You appear tense…”, “I notice that your biting your lips”

Offering Self
-​ Making oneself available
-​ “I’ll sit with you awhile”, “I’ll stay here with you”, “I’m interested with
what you think.”

Placing Event in Time and Sequence

-​ Clarifying the relationship of events in time
-​ “What seemed to lead up to…?”, “Was this before or after?”

Presenting Reality
-​ Offering for consideration that which is real
-​ “I see no one else in the room.” “Your mother is not here; I am a
nurse.”

Reflecting
-​ Directing client actions, thoughts, and feelings back to client
-​ Client: “Do you think I should tell the doctor…?” Nurse: “Do you think
you should?”

Restating
-​ Repeating the main idea expressed
-​ Client: “I can’t sleep. I stay awake all night.”​
Nurse: “You have difficulty sleeping.”

Seeking Information
-​ Seeking to make clear that which is not meaningful or that which is
vague
-​ “I’m not sure that I follow.”; “Have I heard you correctly?”
Silence
-​ Absence of verbal communication, which provides time for the client to
put thoughts or feelings into words, regain composure, or continue
talking

Suggesting Collaboration
-​ Offering to share, to strive, to work with the client for his or her
benefit
-​ “Perhaps you and I can discuss and discover the triggers for your
anxiety”

Summarizing
-​ Organizing and summing up that which has gone before
-​ “Have I got this straight?”, “You’ve said that…”, “During the past hour,
you and I have discussed…”

Translating into Feelings

-​ Seeking to verbalize client’s feelings that he or she expresses only
indirectly
-​ Client: “I’m dead”​
Nurse: “Are you suggesting that you feel lifeless?”

Verbalizing the Implied

-​ Voicing what the client has hinted at or suggested
-​ Client: “I can’t talk to you or anyone. It’s a waste of time.”​
Nurse: “Do you feel that no one understands?”

Voicing Doubt
-​ Expressing uncertainty about the reality of the client’s perceptions
-​ “Isn’t that unusual?”, “Really?”, “That’s hard to believe.”

Non-Therapeutic Communication Techniques

-​ D - Discourages expression of feelings
-​ O - Overwhelming the patient/client
-​ R - Reassuring the client
-​ S - Sympathizing with the client
-​ A - Arguing with the client
-​ L - Limiting the ideas, opinions, of the client
 -​ T - Threatening the client
-​ J - Judgmental

ADVISING
-​ Telling what the client what to do

AGREEING
-​ Indicating accord with the client
-​ “That’s right.”, “I agree”

Belittling Feelings Expressed

-​ Misjudging the degree of the client’s comfort
-​ Client: “I have nothing to live for. I wish I was dead”​
Nurse: “Everybody gets down in the dumps.”

Challenging
-​ Demanding proof from the client
-​ “But how can you be President of the Philippines?”

Defending
-​ Attempting to protect someone or something from verbal attack
-​ “This hospital has a fine reputation.”

Disagreeing
-​ Opposing the client’s ideas
-​ “That’s wrong”, “I definitely disagree with…”

Disapproving
-​ Denouncing the client’s behavior or ideas
-​ “That’s bad”, “I’d rather you wouldn’t”

Giving Approval
-​ Sanctioning the client’s behavior or ideas
-​ “That’s good.” “I’m glad that…”

Giving Literal Responses

-​ Responding to a figurative comment as though it were a statement of
fact
 -​ Client: “They’re looking in my head with television camera.”​
Nurse: “Try not to watch television.”

Indicating the Existence of an External Source

-​ “What makes you say that?”, “What made you do that?”, “Who told you
that you are a prophet?”

Interpreting
-​ Asking to make conscious that which is unconscious
-​ “What you really mean is…”, “Unconscious you’re saying that…”

Introducing an Unrelated Topic

-​ Changing the subject
-​ Client: “I’d like to die.”​
Nurse: “Did you have visitors last night?”

Making Stereotyped Comments

-​ Offering meaningless cliches or trite comments
-​ “Keep your chin up.”, “Just have a positive outlook.”

Probing
-​ Persistent questioning of the client.
-​ “Now tell me about this problem. I need to know.”

Reassuring
-​ Indicating there is no reason for anxiety.
-​ “Everything will be alright.”

Rejecting
-​ Refusing to consider or showing contempt of the client’s behavior,
ideas
-​ “Let’s not discuss…”

Requesting an Explanation
-​ Asking the client to provide reasons for thoughts, feelings, behaviors,
events
-​ “Why do you think that?”, “Why do you feel that way?”
Testing
-​ Apparasing the client’s degree of insight
-​ “Do you know what kind of hospital this is?”

Using Denial
-​ “Refusing to admit that a problem exists
-​ Client: “I am nothing.”​
Nurse: “Of course, you’re something.”

TREATMENT MODALITIES IN THE PSYCHIATRIC MENTAL

HEALTH NURSING PRACTICE

Nurse’s Attitudes in Psychiatric Nursing Care

●​ Active friendliness
●​ Passive friendliness
●​ Indulgence and Permissiveness
●​ Watchfulness
●​ Matter of fact
●​ Kind firmness

Supportive Therapy - can be used for normal people

Individual Therapy
●​ A method of bringing about change in a person by exploring his/her
feelings, attitudes, thinking, and behavior.
●​ Purposes of Individual Psychotherapy
○​ To understand themselves and their behavior
○​ To make personal changes
○​ To improve interpersonal relationship
○​ To get relief from emotional pain or unhappiness

Family Therapy
●​ A group therapy in which the client and his family members participate
●​ Family education focuses on the client’s disorder
●​ Goals includes:
○​ Understand how family dynamic contribute to the client’s
psychopathology
○​ Mobilizing the family’s inherent
 ○​ Restructuring the maladaptive

Group Therapy
●​ Compose of number of persons who gather in a face to face setting to
accomplish tasks that requires cooperation, collaboration, or working
together.
●​ Members share a common purpose and are expected to contribute to
the group to benefit others.
●​ Therapeutic results of Group Therapy includeS:
○​ Feeling of acceptance and belonging
○​ Becoming aware that one is not alone and that others share the
same problems
○​ Gaining new information or learning
○​ Gaining inspiration or hope
○​ Gaining insight into one’s problems and behaviors and how they
affect others
○​ Giving of oneself for the benefit of others
○​ Interacting with others

Psychoeducation Groups
●​ Education group is to provide information to members such as specific
issues such as:
○​ Stress Management
○​ Medication Management
○​ Assertiveness training
○​ Conflict resolution
○​ Anger management
○​ Problem solving
Self-help Groups
●​ Concern about coping with a specific problem or life crisis
○​ Alcoholic anonymous - alcoholics
○​ Al-Anon - wives of alcoholics
○​ Ala-teen - children of alcoholics
○​ Overeaters Anonymous
○​ One Day a Time (A grieve group)
Support Group
●​ Organized to help members who share a common problem to cope
with it. It often provides a safe place for group members to express
 their feelings of frustration, boredom, or unhappiness and to discuss
common problems and potential solutions. Common support groups
includes:
○​ Those for cancer or stroke victims,
○​ Person with aids,
○​ Family members of someone who has committed suicide,
○​ Mothers Against Drunk Driving (MADD)

Psychotherapy

Cognitive Behavioral Therapy

●​ First developed and implemented by Albert Ellis in 1950’s. It used to
restructure how a person perceives self or events in his or her life to
facilitate behavioral and emotional change.
○​ Cognitive Restructuring - use to monitor automatic thoughts,
then to recognize the connection between thoughts, emotional
response, and behavior
○​ Thought stopping - used with patients who have obsessional
thoughts
■​ Obsession, Borderline, Panic, Aggression
■​ Cue cards - used to help patient destructive thought
patterns
○​ Thought Reframing - changing negative thoughts to a positive
one

Behavioral Therapy
●​ Behavioral therapy is a strategy that help patients change behavior:
○​ Positive feedback
○​ Behavioral modification
○​ Token economy

Milieu Therapy
-​ Purposeful use of the environment to enhance mental health of
psychiatric patients

Elements of Therapeutic Environment

-​ Unit structure
-​ Unit norms
 -​ Limit setting
-​ Unit modification

Therapeutic Activities as Adjunct Therapies to Patient Recovery

Remotivation Technique
●​ Used in an effort to reach the unwounded areas of patient’s personality
& get them moving back into the reality
●​ Develop the patient ability to communicate and share ideas and
experience with other
●​ Stimulate patient to think about something and talk about himself
●​ Stimulate patient to be fellow explorer of the real world
●​ Enhance feeling of recognition and acceptance to increase self-respect
and self-esteem
●​ Stimulate the patient’s interest in reality situation
●​ Take the patient out of the dullness of the ward and from the
“vegetative state”
●​ Develop group harmony
●​ Duration: 45-60 minutes for once or twice per week. The therapy
consists of 12 series of sessions.
●​ Subjects to be considered:
1.​ Nature
2.​ Sports
3.​ Literature
4.​ Industry
5.​ Science
6.​ Geography
7.​ History
8.​ Hobbies
●​ Subjects to be avoided
1.​ Family problem
2.​ Religion
3.​ Sex
4.​ Politics
5.​ Love
Remotivation Technique

Steps of Remotivation Techniques

 -​ Acceptance
-​ Bridge to Reality (15 mins)
-​ Sharing the world we live in (15 mins)
-​ Appreciation of the work of the world (15 mins)
-​ Appreciation

Music Therapy
●​ A technique of complementary medication that uses music to help
patient overcome physical, emotional, intellectual and social challenges
○​ To promote participation and social interaction
○​ To improve reality orientation
○​ To develop coping skills
○​ To reduce stress
○​ To help express feeling through music

Art Therapy
●​ The therapeutic use of art making such as drawing, painting, clay art,
and others
●​ Purposes:
1.​ To increase self-awareness
2.​ To cope with stress and traumatic experiences
3.​ To enhance cognitive abilities
4.​ To promote self-esteem
5.​ To promote self-discovery and personal fulfillment
6.​ To help express feeling through art

Music and Art Therapy

-​ Select appropriate music depending on your objective
-​ Prepare necessary materials needed such as crayons, bond paper,
music player, speaker and extension
-​ Gather clients in a U-shape, seated in a bench with a table
-​ Greet the group in general and express appreciation of the group’s
attendance
1.​ Introduce the activity. You may introduce the activity by asking client
about their favorite music, the importance of music to them, types of
music they know, etc.
2.​ Explain procedure of the activities.
 3.​ Play the music. During the session, play the same music until all
clients are done with their drawing.
4.​ Ask client to comment and explain their drawing while student nurses
listen and analyze the explanation of their assigned client.
5.​ Collect clients drawing.
6.​ End the activity by thanking participants and give a brief explanation
of what to expect in the next session.

Occupational Therapy
-​ Discipline that aims to promote health by enabling people to perform
meaningful and purposeful activities.
-​ Objectives
-​ To develop the patient’s ability to grasp reality through activities
of daily living
-​ To provide opportunity for creativeness and produce something
tangible out of patient’s own thinking and imagination
-​ To promote self-confidence and personal achievements.
-​ To prepare client before discharge from the institution to have
independent, productive, and satisfying lives.

Recreational Therapy
-​ A treatment service that provides treatment and recreation activities
to individuals with illnesses or disabling conditions. Treatment may
incorporate arts and crafts, animals, sports, games, dance and
movement, drama, music, and community outings.
-​ Purposes:
-​ Helps patients recover basic motor functioning, reasoning,
abilities, build confidence, and socialize more effectively.
-​ Improve or maintain physical, mental, and emotional well-being
-​ Help patients reduce depression, stress, and anxiety
-​ Process: The recreation therapy process begins with na individual
assessment of their:
1.​ Strengths, interests, and values
2.​ Previous leisure activities and expectations
3.​ Available resources in your home and community
4.​ Social needs and relationships
5.​ Economic and other potential problem areas
6.​ Lifestyle adjustments necessary for daily living functioning
 -​ Activity and treatment ideas for Recreational Therapy Includes:
-​ Arts/Crafts/Cooking
-​ Leisure/Education/Academics
-​ Dance/Drama/Music/Writing
-​ Social Activities
-​ Experiential
-​ Warm Up Activities
-​ Holiday and Special Events
-​ Wellness and Health
-​ Humor

Dance/Movement Therapy
-​ Type of therapy that uses movement to help individuals achieve
emotional, cognitive, physical, and social integration
-​ Beneficial for both physical and mental health, dance therapy, can be
used for stress reduction, disease prevention, and mood management
-​ Offers increased muscular strength, coordination, mobility and
decreased muscular tension.
-​ Can be used with all populations with individuals, couples, families, or
groups.
-​ Mental Health Issues:
-​ Anxiety
-​ Depression
-​ Disordered eating
-​ Poor self-esteem
-​ Post Traumatic stress
-​ Social Issues:
-​ Autism
-​ Aggression/violence
-​ Domestic violence trauma
-​ Social interaction
-​ Family conflict
-​ Physical issues:
-​ Chronic pain
-​ Childhood obesity
-​ Cancer
-​ Arthritis
-​ Hypertension
 -​ Cardiovascular disease
-​ Cognitive issues:
-​ Dementia
-​ Communicative Issue

PSYCHOSOCIAL ASSESSMENT

POINTS TO CONSIDER WHEN DOING A PSYCHOSOCIAL ASSESSMENT

●​ The nurse is trying to gain all the information needed to help the
client. Judgments are not part of the assessment.
●​ Being open, clear, and direct when asking about personal or
uncomfortable topics helps to alleviate the client’s anxiety or hesitancy
about discussing the topic.
●​ Examining one’s own beliefs and gaining self-awareness is a
growth-producing experience for the nurse
●​ If the nurse’s beliefs differ strongly from those of the client, the nurse
should express his or her feelings to colleagues or discuss the
differences with them.

ASSESSMENT
-​ The first step of the nursing process and involves collection,
organization, and analysis of information about the client’s health
-​ Referred to as psychosocial assessment
-​ Includes mental status examination (MS:PA, PSYCHE:MSE)

PURPOSES
-​ To construct a picture of the client’s current emotional state, mental
capacity, and behavioral function.
-​ Serves as the basis for developing a plan of care to meet the client’s
needs
-​ A clinical baseline used to evaluate the effectiveness of treatment and
interventions or a measure of client’s progress
FACTORS INFLUENCING ASSESSMENT
-​ Client participation/feedback
-​ Client’s Health Status
-​ Client’s Previous Experiences/Misconceptions About Health Care
-​ Nurse’s Attitude and Approach
-​ Client’s Ability to Understand
HOW TO CONDUCT INTERVIEW

Environment
-​ The nurse should conduct the psychosocial environment that is
comfortable, private, and safe for both the client and the nurse.

Input from Family and Friends

-​ If the family members, friends, or caregivers have accompanied the
client, the nurse should obtain their perceptions of the client’s behavior
and emotional state.

How to Phrase Questions

-​ Examples:
-​ What brings you here today?
-​ Tell me what has been happening to you.
-​ How can we help you?

Questions regarding several different behaviors or symptoms:

-​ “How are your eating and sleeping habits, and have you been taking
any over-the-counter medications that affect your eating and
sleeping?”
-​ Can be confusing to the client.

Examples of focused or closed-ended questions

-​ How many hours did you sleep last night?
-​ Have you been thinking about suicide?
-​ How much alcohol have you been drinking?
-​ How well have you been sleeping?
-​ How many meals a day do you eat?
-​ What over-the-counter medications are you taking?

For Example
-​ When asking a client about his or her parent role, the nurse should
ask, “What types of discipline do you use” rather than “How often do
you physically punish your child?”
 -​ The first question is more likely to elicit honest and accurate
information; the second question gives the impression that physical
discipline is wrong, it may cause the client to respond dishonestly.

PSYCHOSOCIAL ASSESSMENT COMPONENTS

Content of the Assessment

-​ History
-​ Age
-​ Developmental Stage (Erik Erikson)
-​ Cultural consideration
-​ Spiritual beliefs
-​ Previous history
-​ Example:
-​ Has the client experienced similar difficulties in the past?
-​ Has the client been admitted to the hospital, and if so,
what was the experience like?
-​ A family history that is positive for alcoholism, bipolar
disorder, or suicide is significant because it increases the
client’s risk for these problems
-​ General appearance and motor behavior
-​ Hygiene and grooming
-​ Appropriate dress
-​ Posture
-​ Eye contact
-​ Unusual movements or mannerism
-​ Speech
-​ Example:
-​ Is the client appropriately dressed for his or her age and
the weather?
-​ Is the client unkempt or disheveled
-​ Does the client appear to be his or her stated age?
-​ The nurse also observes the client’s posture, eye contact,
facial expression, and any unusual tics or tremors
-​ He or she documents observation and examples of
behaviors to avoid personal judgment or misinterpretations
-​ Mood and affect
-​ Thought process and content
 -​ Sensorium and intellectual processes
-​ Judgment and insight
-​ Self-concept
-​ Roles and relationships
-​ Physiologic and self-care concerns

Specific terms used in making assessments

-​ Automatisms
-​ Psychomotor Retardation
-​ Waxy Flexibility

-​
-​ Echopraxia: imitation of the movements and gestures of another
person whom the client is observing.
-​ Echolalia
 -​
-​ Other abnormal speech pattern
-​ Word Salad: combination of jumbled words and phrases that are
disconnected or incoherent and make no sense to the listener
-​ The nurses assess the client’s speech for quantity, quality, any
abnormalities.

-​
-​ Example:
 -​

Thought Process - refers to how the client thinks (the nurse can infer a
client’s thought process from speech and speech patterns

Thought Content - is what the client actually says

COMMON TERMS RELATED TO THOUGHT PROCESS AND THOUGHT

CONTENT

Delusions
-​ Fixed, false beliefs with no basis in reality.

Types of Delusions
-​ Persecutory/Paranoid Delusion
-​ Involve the client’s beliefs that “others” are planning to harm the
client or spying, following, ridiculing, or belittling the client in
some way.
-​ Example:​
“Everybody is working against me.”​
“There is a plot to kill me!”
-​ Grandiose Delusions
 -​ Characterized by the client’s claim to association with famous
people or celebrities, or the client’s belief
-​ Religious Delusions
-​ Often centered around the second coming of Christ or another
significant religious figure or prophet
-​ Somatic Delusions
-​ Generally vague and unrealistic beliefs about the client’s health
or bodily functions.
-​ Belief they have one physical defect, disorder, or disease.
-​ Sexual Delusions
-​ Involve the client’s beliefs that his or her sexual behavior is
known to others; that the client is a rapist, prostitute or is
pregnant, or that his or her excessive masturbation has led to
insanity.
-​ Nihilistic Delusions
-​ Client’s beliefs that his or her organs aren’t functioning or are
rotting away, or that some body part or feature is horribly
disfigured or misshapen.
-​ Example: The client denies reality or existence of self, part of
self, or some external object. “I have no head.”
-​ Delusion of Reference

Delusions Concerning the Possession of Thoughts

-​ Thought Broadcasting
-​ A delusional belief that others can hear or know what the client
is thinking
-​ Thought Insertion
-​ A delusion belief that others are putting ideas or thoughts into
the client’s head - that is, the ideas are not those of the client.
-​ Thought Withdrawal
-​ A delusional belief that others are taking the client’s thoughts
away and the client is powerless to stop it.
-​ Erotomatic Delusions
-​ The person who is believed to be in love with the individual is of
higher status, such as a famous celebrity or boss.
-​ Jealous Delusions
OTHER TERMS
-​ Circumstantial Thinking
-​ A client eventually answers a question but only after giving
excessive unnecessary detail.

-​
-​ Tangential Thinking
-​ Wondering off the topic and never providing the information
requested.

-​
-​ Flight of Ideas
-​ Shifting of one topic from one subject to another in a somewhat
related way
-​ Excessive amount of rate of speech composed of fragmented or
unrelated ideas
-​ Example: “The sun is shining. Where is my sun. I love Lucy. Let
us play ball.”
-​ Loose Associations
 -​ Disorganized thinking that jumps from one idea to another with
little or evident relation between the thoughts
-​ Incoherent, illogical flow of thoughts (unrealted way)
-​ Shifting of a topic from one subject to another in a completely
unrelated way.
-​ Thought Blocking​
-​ Stopping abruptly in the middle of a sentence or train of
thought; sometimes unable to continue the idea.

-​

ASSESSMENT OF SUICIDE OR HARM TOWADS OTHERS

-​ The nurse must determine whether the depressed or hopeless client
has suicidal ideation or a lethal plan.
-​ The nurse does so by asking the client directly, “Do you have thoughts
of suicide?” or “What thoughts of suicide have you had?”

Suicide Assessment Questions​

Assessment of Suicide or Harm Towards Others
-​ If the client is angry, hostile, or making threatening remarks about a
family member, spouse, or anyone else, the nurse must ask whether
the client has thoughts or plans about hurting that person.
-​ The nurse does so by questioning the client directly:
-​ What thoughts have you had about hurting (person’s name)
-​ What is your plan?
-​ What do you want to do (person’s name)
-​ When a client makes specific threats or has a plan to harm another
person, health care providers are legally obligated to warn the person
who is the target of the threats or plan.
-​ The legal term for this is duty to warn. This is one situation in
which the nurse must breach the client’s confidentiality to
protect the threatened person.

ORIENTATION, CONFUSION, MEMORY

Orientation
-​ Refers to the client’s recognition of person, place, and time - that is
knowing who and where he or she is and the correct day, date, and
year.

Memory

Questions to assess memory

-​ What is the name of the current president?
-​ Who was the president before that?
-​ In what country do you live?
-​ What is the capital of this state?

Ability to Concentrate
-​ Spell the word “world” backward
-​ “Serial Sevens”
-​ Repeat the days of the weeks backward
-​ CONSIDER LEVEL OF EDUCATION

Abstract Thinking and Intellectual Abilities

 -​ The nurse assesses the client’s ability to make associations or
interpretations about a situation or comment.
-​ The nurse usually can do so by asking the client to interpret a common
proverb such as “a stitch in time saves nine.” If the client can explain
the proverb correctly, his or her abstract thinking abilities are intact.
-​ If the client provides a literal explanation of the proverb and cannot
interpret its meaning, abstract thinking abilities are lacking.
-​ When the client continually gives literal translation, this is evidence of
CONCRETE THINKING
-​ Examples:
-​ Magsisi ka man at huli wala ng mangyayari
-​ Ang buhay ay parang gulong, minsan nasa ibabaw, minsan nasa
itaas

Abstract Thinking and Intellectual Abilities

-​ The nurse may also assess the client’s intellectual functioning by
asking him or her to identify the similarities between pairs of objects;
-​ For example:
-​ “What is similar about an apple and an orange?”
-​ What do the newspaper and the television have in common?”

SENSORY-PERCEPTUAL ALTERATIONS
HALLUCINATIONS
-​ False sensory perceptions or perceptual experiences that do not really
exist

Auditory Hallucinations
-​ The most common type involves hearing sounds, most often voices,
talking to or about the client.
-​ There may be one or multiple voices; a familiar or unfamiliar person’s
voice may be speaking
-​ COMMAND HALLUCINATIONS - are voices demanding that the
client take action, often to harm self or others, and are considered
dangerous.

Visual Hallucinations
-​ Involve seeing images that do not exist at all, such as lights or a dead
person, or distortions such as seeing a frightening monster instead of
the nurse.
-​ The second most common type of hallucination

Olfactory Hallucinations
-​ Involve smells or odors.
-​ They may be specific events such as urine or feces or a more general
scent such as rotten or rancid odor.
-​ Often occurs with dementia, seizures, or cerebrovascular accidents.

Tactile Hallucinations
-​ Refer to sensations such as electricity running through the body or
bugs crawling on the skin.
-​ Found most often in client undergoing alcohol withdrawal; they rarely
occur in clients with schizophrenia

Gustatory Hallucinations
-​ Involve a taste lingering in the mouth or the sense that food tastes like
something else.
-​ The taste may be metallic or bitter or may be represented as a specific
taste
Cenesthetic Hallucinations
 -​ Involve the client’s report that he or she feels bodily functions that are
usually undetectable.
-​ Examples: Sensation of urine forming, or impulses being transmitted
through the brain, burning in brian, pushing sensation in blood
vessels, cutting sensation in bone marrow.

Kinesthetic Hallucinations
-​ Occur when the client is motionless but reports the sensation of bodily
movement.
-​ The bodily movement is something unusual, such as floating above the
ground.
-​ Patient feels their limbs are being twisted pulled or moved
-​ Seen in schizophrenics
Judgement
-​ Refers to the ability to interpret one’s environment and situation
correctly and to adapt one’s behavior and decisions accordingly.

Insight
-​ The ability to understand the true nature of one’s situation and accept
some personal responsibility for that situation. (Illness)

SELF CONCEPT

Personal View of Self

-​ Description of physical self
-​ Personal qualities of attributes
 -​ The way one views oneself in terms of personal worth and dignity
-​ To assess a client’s self concept, the nurse can ask the client to
describe himself or herself and what characteristics he or she likes and
what he or she would change.
-​ The client’s description of self in terms of physical characteristics gives
the nurse information about the client’s body image, which is also part
of self-concept.

ROLES AND RELATIONSHIPS

-​ Current roles
-​ Satisfaction with roles
-​ Success at roles
-​ Significant relationships
-​ Support systems
-​ The nurse assesses the roles the client occupies, client satisfaction
with those roles, and whether the client believes he or she is fulfilling
the roles adequately.
-​ People function in their community through various roles such as
mother, wife, son, daughter, teacher, secretary, or volunteer.

Common Questions
-​ Do you feel close to your family?
-​ Do you have or want a relationship with a significant other?
-​ Are your relationships meeting your needs for companionship or
intimacy
-​ Can you meet your sexual needs satisfactorily?
-​ Have you been involved in any abusive relationship?
Physiologic and Self-Care Considerations
-​ Eating Habits
-​ Sleep Patterns
-​ Health Problems
-​ Compliance with Prescribed Medications
-​ Ability to perform activities of daily living
DATA ANALYSIS
-​ Involves thinking about the overall assessment rather than focus on
isolated bits of information.
-​ Looking for patterns or themes in the data lead to conclusions about
the client’s strengths and needs and to a particular nursing diagnosis.
-​ Consider the congruence of all information provided by the client,
family, or caregivers, as well as his or her observations

Assessment is an ongoing, dynamic process - not a one-time activity.

The nurse will assess (and reassess) throughout the care of the
client.

Reassessment is the basis for changing the plan of care, evaluation

of treatment effectiveness, discharge planning, as well as follow-up
care in the community.
 MOOD DISORDERS

Mood Disorders
-​ Also called affective disorders, are pervasive alterations in emotions
that are manifested by depression, mania, or both.
-​ Interferes with a person’s life
-​ With accompanying self-doubt, guilt, and anger which alter life
activities.

Categories
-​ Major Depression: 2 or more weeks of sad mood, lack of interest in
life activities, and other symptoms.
-​ Bipolar Disorder (formerly called “manic-depressive illness”): mood
cycles of mania and/or depression and normalcy and other symptoms.

1.​ Bipolar Mixed - Cycles alternate between periods of mania, normal

mood, depression normal mood, mania and so forth.
2.​ Bipolar Type I - manic episodes with at least one depressive episode
3.​ Bipolar Type II - Recurrent depressive episodes with at least one
hypomanic episode.
Related Disorders
 -​ Dysthymia: sadness, low energy, but not severe enough to be
diagnosed as major depression disorder
-​ Cyclothymia: mood swings not severe enough to be diagnosed as
bipolar disorder
-​ Substance-induced mood disorder
-​ Mood disorder due to a general medical condition
-​ Seasonal affective disorder (SAD) - mood affected seasons​
Symptoms can be: increased sleep or insomnia, increased appetite or
loss of appetite, weight gain, interpersonal conflict, irritability
-​ Postpartum or “maternity” blues - frequent normal experience
after delivery of a baby characterized by labile mood and affect, crying
spells, sadness, insomnia, and anxiety.
-​ Postpartum depression - meets all the criteria for a major
depressive episode with onset within 4 weeks of delivery
-​ Postpartum psychosis
-​ Non-psychotic

Major Depressive Disorder (MDD)

-​ 2x in women
-​ More on divorced
-​ 2 weeks
-​ Hallmark signs: Anhedonia and sad mood

Role of the Dexamethasone Suppression Test in Depression

HPA (Hypothalamic-pituitary-adrenal) axis

Dexamethasone-suppression test

Major Depressive Disorder (MDD)

-​ At least 5 of the following symptoms presenting in a two week period
-​ IN - Interest is lacking in most everything
-​ S - Sleep is hard to come by.
-​ A - Appetite is very often depressed.
-​ D - Depressed people can be very tearful.
-​ C - Concentration is often lacking.
-​ A - Activity is decreased
-​ G - Guilt may bring a negative view of self.
 -​ E - Energy level is decreased
-​ S - Suicide precautions are mandatory

Nursing diagnoses may indicate

-​ Risk for Suicide
-​ Imbalanced Nutrition: Less than Body Requirements
-​ Anxiety
-​ Ineffective Coping
-​ Hopelessness
-​ Ineffective Role Performance
-​ Self-Care Deficit
-​ Chronic Low Self-Esteem
-​ Disturbed Sleep Pattern
-​ Impaired Social Interaction

Intervention
-​ Safety - Providing for the client’s
-​ Medications - Managing medications
-​ ADLs - Promoting activities of daily living and physical care
-​ Relationship - Promoting a therapeutic relationship
-​ Teaching - Providing client and family education
-​ Communication - Using therapeutic communication

BIPOLAR DISORDER
-​ Occurs almost equally among among men and women
-​ It is more common in highly educated people
-​ The mean age for a first manic episode is in the early 20s.
-​ Involves mood swings of depression (same symptoms of major
depressive disorder and mania)

Major Symptoms of Mania include:

-​ I - Inflated self-esteem of grandiosity
-​ F - Flight of ideas
-​ S - Sleep decreased
-​ P - Pressured speech
-​ A - Agitation (Psychomotor)
-​ D - Distractibility
 -​ E - Excessive involvement in pleasure-seeking activities with a high
potential for painful consequences

Manic
-​ Mood elevated
-​ A grandiose delusion
-​ Need for sleep, eat decreased
-​ Inappropriate behaviors
-​ Clanging, loud vulgar

Depressive
-​ Depressed
-​ Out for suicide
-​ Won’t sleep, eat
-​ Negative

MANIA VS DEPRESSION

Mania Depression

Appearance Colorful, flamboyant Sad and grey

Behavior Psychomotor agitation Psychomotor

retardation

Communication Pressured speech Monotonous speech

Stuttering
Cluttering

Nx Risk for injury (others) Risk for injury (self)

suicidal precaution

Nursing priority Safety and nutrition Safety and nutrition

Nutrition Finger foods and high Increased nutrients

in calories

Treatment Lithium; ECT TCA; SSR; MAOIs ECT

Milieu Non-stimulating Stimulating

environment
Appropriate activity Quiet type Monotonous
non-competitive non-competitive

Attitude therapy Matter of fact Kind firmness; active

friendliness

UNDERSTANDING AND MANAGING SCHIZOPHRENIA IN

NURSING PRACTICE

World Health Organization

-​ According to the WHO, schizophrenia affects approximately 24 million
people worldwide, which is about 0.32% of the global population.
-​ In the Philippines, schizophrenia is a significant mental health concern.
Estimates suggest that approximately 1% of the population or about 1
million Filipinos, are affected by this disorder.

Schizophrenia
-​ A chronic mental disorder characterized by:
-​ Distorted thoughts, emotions, and perceptions.
-​ Hallucinations, delusions, and disorganized thinking.
-​ Importance for nurses:
-​ Early identification and effective communication are key.
-​ Nurses play a central role in managing care and building
therapeutic relationships.

Key Features of Schizophrenia

-​ Positive Symptoms
-​ Hallucinations
-​ Delusions
-​ Disorganized speech or behavior.
-​ Negative Symptoms
-​ Lack of emotion (flat affect)
-​ Reduced social interaction
-​ Apathy or lack of motivation
-​ Cognitive Symptoms
-​ Impaired memory and decision-making
-​ Difficulty concentrating
Communication Techniques
 -​ Therapeutic Communication
-​ Non-Therapeutic Communication
-​ Active Listening
-​ Clear and Simple Communication
-​ Non-Confrontational Approach
-​ Empathy and Patience

MANAGING HALLUCINATIONS AND DELUSIONS

Hallucinations
-​ Acknowledge the experience without validating it.
-​ Example: “I understand you’re hearing voices; I don’t hear them, but
I’m here to help.

Delusions
-​ Avoid challenging beliefs directly
-​ Focus on the emotions behind the delusion (e.g., fear, anxiety).

Disorganized Behavior
-​ Provide structured and predictable routines.

TECHNIQUES FOR DE-ESCALATING AGITATION

-​ Stay Calm and Maintain Safety:
-​ Keep a neutral tone and body language.
-​ Position yourself near an exit if needed.
-​ Set Clear and Respectful Boundaries:
-​ Use phrases like, “I’m here to help, but I need you to lower your
voice.”
-​ Reduce Environmental Stimuli:
-​ Move the client to a quieter area.
-​ Minimize noise and distraction.
-​ Engage in Grounding Techniques:
-​ Encourage deep breathing or sensory grounding (e.g., holding a
cool object).

ROLE OF THE NURSE

-​ Conduct thorough assessments:
-​ Monitor symptoms, medication adherence, and side effects.
 -​ Provide education:
-​ Teach clients and families about the disorder and coping
strategies.
-​ Collaborate with the care team:
-​ Work with psychiatrists, therapies, and social workers.
-​ Advocate for the client:
-​ Ensure access to resources and a supportive environment.

CASE STUDY

Scenario: A 25-year-old client with schizophrenia believes they are being

followed by spies.
-​ Nurse’s Response:
-​ Acknowledge the fear: “That sounds very frightening for you.”
-​ Avoid validating the delusion: “I don’t see any spies, but let’s
focus on how we can make you feel safer.”
-​ Offer grounding activities: Deep breathing or discussing their
favorite hobbies.
-​ Outcome: The client feels heard and begins to trust the nurse.

CONCLUSION
-​ Schizophrenia is a complex disorder requiring empathy, patience, and
skill.
-​ Key nursing techniques include active listening, clear communication,
and maintaining safety.
-​ Nurses play a vital role in promoting recovery and improving quality of
life for clients.
 UNDERSTANDING PERSONALITY DISORDER IN
PSYCHIATRIC NURSING

A screening survey across 13 countries by WHO using DSM-IV criteria

reported in 2009 a prevalence estimate of around 6% of personality
disorders.
Study conducted in a psychiatric unit of a tertiary care teaching hospital in
South India
-​ 21.55% inpatient population
-​ The most common types:
-​ Avoidant (7.7%)
-​ Antisocial (5.17%)
-​ Borderline (3.45%)

United States, data from the National Comorbidity Survey Replication

(2001-2003) indicated a population prevalence of approximately 9% for
personality disorders.
Definition of Personality Disorders:
-​ A group of mental health conditions characterized by enduring patterns
of behavior, cognition, and inner experience that deviate from cultural
expectations.

Importance in Nursing:
-​ Clients with personality disorders often have complex care needs.
-​ Nurses play a key role in establishing therapeutic relationships.

PERSONALITY
-​ Is the sum total of one’s behavior
-​ The early established behavior pattern related to how one thinks,
feels, and related to his environment and to others.

PERSONALITY DISORDER
-​ Spectrum of maladaptive traits that produce or influence considerable
psychological emotional disturbance and impaired relationship
(Kernberg)
-​ Psychological disorder that involves behaviors that make it difficult of a
person to succeed in interpersonal relationships.

Common Types of Personality Disorders

1.​ Cluster A (Odd or Eccentric):
-​ Paranoid, Schizoid, Schizotypal.
-​ Example: Suspiciousness or social detachment.
2.​ Cluster B (Dramatic or Erratic):
-​ Borderline, Antisocial, Histrionic, Narcissistic.
-​ Example: Intense emotions, impulsivity, or disregard of others
3.​ Cluster C (Anxious or Fearful)
-​ Avoidant, Dependent, Obsessive-Compulsive.
-​ Example: Excessive need for approval or rigid perfectionism.
Techniques for Handling Clients with Personality Disorders
1.​ Build a Therapeutic Relationship
2.​ Use Structured Communication
3.​ Encourage Positive Coping Mechanisms
4.​ Team Collaboration

CASE STUDY

Scenario: A client with Borderline Personality Disorder exhibits self-harming

behavior after a conflict.

Nurse’s Response
-​ Remain calm and assess for physical harm.
-​ Use empathetic yet firm communication: “I understand you’re upset;
let’s focus on how we can keep you safe.”
 -​ Collaborate with the care team to address triggers and coping
mechanisms.
Outcome:
-​ The client feels supported without reinforcing negative behavior

CONCLUSION
-​ Personality disorders require a nuanced approach to care.
-​ Nurses should focus on building trust, maintaining boundaries, and
fostering positive coping mechanisms.
-​ Collaboration and self-care are essential for effective and sustainable
nursing practice.