NCM 117: CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR

• Create
o Neurons are the building blocks of the central nervous
OUTLINE
system. Billions of these nerve cells can be found
I Mental Health
throughout the body and communicate with one
II Neuro - anatomy and Neurotransmission another to produce physical responses and actions.
III Psychosocial Theories and Therapy • Control
IV Psychosocial Assessment o Most systems and organs of the body control just one
V Therapeutic Relationship function, but the central nervous system does many
VI Therapeutic Communication jobs at the same time. It controls all voluntary
movement, such as speech and walking, and
involuntary movements, such as blinking and
breathing. It is also the core of our thoughts,
MENTAL HEALTH perceptions, and emotions.
• Coordinate
“All human has rights. Do not judge anybody” o This body system is responsible for integrating and
coordinating the activities of the entire body. Through
• Mental these physical structures, thought, emotion, and
o Psychosocial well-being sensation are experienced, and body movements are
• Health coordinated.
o Wellness of an individual
• Situation PARTS OF THE BRAIN
o Suicide
o Depression
CEREBRUM
o Anxiety
§ Top 3 • Cognitive functions
o initiates and coordinates movement and regulates
HOW TO BE A PSYCHIATRIC – MENTAL HEALTH temperature. Other areas of the cerebrum enable
learning, thinking, reasoning, remembering, problem
NURSE?
solving, decision making, and attention.
Deus (Faith) ◦ God
CEREBELLUM
Manus (Hands) ◦ Skills • Coordination functions
Caput (Head)
◦ Knowledge (dapat may alam) o Ensures that different departments and groups work in
sync. It is also responsible for a number of functions
◦ central, internal, and consistent part of an including motor skills such as balance, coordination,
Core individual's personality. It includes an and posture.
(Heart)
individual's self-concept, basic values,
attitudes, and motives; a person's true self. BRAIN STEM
(paniniwala kung bakit gusto moa ng isang bagat)
• Critical Functions
o They help to regulate breathing, heart rate, blood
pressure, and several other important functions.
HEALTHCARE DELIVERY IN THE PHILIPPINES

Assess → Diagnose → Judge – Stigma / Discrimination → NEUROTRANSMISSION

Treat / Rehabilitation → Follow up care • Neurotransmitters relay their messages by traveling
between cells and attaching to specific receptors on target
cells
NURSES SHOULD HAVE UNDERSTANDING HEART
AND CARING MIND PRESYNAPTIC NEURON
a neuron (nerve cell) that fires the neurotransmitter as a result
NEURO-ANATOMY AND NEUROTRANSMISSION
of an action potential entering its axon terminal
↓
IS MENTAL ILLNESS A BRAIN DISEASE OR NEUROTRANSMITTER RELEASE
BEHAVIORAL PROBLEM ?
Chemical transmission of a nerve impulse at the synapse.
• Disease ↓
o Everything starts from the brain and the brain SYNAPSE
translates it to behavior
• is a structure that permits a neuron (or nerve cell) to pass
FUNCTIONS OF THE CNS an electrical or chemical signal to another neuron or to the
• Control Center target effector cell.
• Spaces between neurons

BSN 1
 TRANS: NCM117

↓ NEOCORTEX
POST SYNAPTIC TERMINAL • may pag-iisip
• Is the place where the electrical signal (the action potential) o It is thought to be responsible for the neuronal
is converted into a chemical signal (neurotransmitter computations of attention, thought, perception and
release). episodic memory.
• Less than 50 nanometers away and contains specialized
receptors. REPTILIAN > MAMMALIAN
↓
POST SYNAPTIC NEURON REPTILIAN BRAIN
• neuron receiving the spike from the synapse • controls the body's vital functions such as heart rate,
↓ breathing, body temperature and balance
• dominated by the brainstem and cerebellum, which control
REACTION
instinctual thinking and behavior for survival
BRAIN MATTER MAMMALIAN BRAIN
• Gray
• Mental Disorder
o found on the brain's surface, or cortex
• Psychosis and Depression
• White
o buried deep in the brain ABNORMALITIES IN NEUROTRANSMISSION
CORPUS CALLOSUM
Lack/ excess of neurotransmitter
• Connects the left and right hemisphere of the brain +
Lack / Excess receptors
CIRCLE OF WILLIS =
• Is the joining area of several arteries at the bottom (inferior) MENTAL ILLNESS
side of the brain. • Schizophrenia
o imbalance in neurotransmitters
NEUROTRANSMITTERS
EXCITATORY
• Bipolar Disorder
• Increase the likelihood that the neuron will fire an action
o result of chemical imbalances in the brain
potential.
DOPAMINE PSYCHOSOCIAL THEORIES AND THERAPY
• pleasure HOW THINGS ARE MADE ?
• It helps us strive, focus, and find things interesting.
PSYCHOSOCIAL THEORIES
NOREPINEPHRINE • Psychoanalytic
• blood vessels • Developmental
• increases alertness and arousal, and speeds reaction time • Interpersonal
• acts to increase the force of skeletal muscle contraction and • Humanistic
the rate and force of contraction of the heart • Behavioral
EPINEPHRINE • Existential
• also known as adrenaline
• help neurons to communicate with one another PSYCHOANALYTIC THEORY
• relaxing the muscles in the airways and tightening the blood SIGMUND FREUD – FATHER OF PSYCHOANALYSIS
vessels • “All human behavior is caused and can be explained”
GLUTAMATE • Personality Components (ID, EGO, Super EGO)
• principal excitatory neurotransmitter in brain
send signals to other cells in the central nervous system COMPONENTS OF PERSONALITY
• Superego
INHIBITORY (PREVENT) o Conscience (holy)
• Decrease the likelihood that the neuron will fire an action • EGO
potential. o Maturity, Neocortex (right or wrong)
• ID
SEROTONIN o Pleasure, Desires
• mediated satisfaction, happiness and optimism
“ALL BEHAVIORS HAS REASONS”
GAMMA-AMINOBUTYRIC ACID (GABA)
• primary inhibitory
• reduce neuronal excitability by inhibiting nerve
transmission.

BSN 2
 TRANS: NCM117

PSYCHOSEXUAL DEVELOPMENT DENIAL

ORAL • No acceptance
• Age Range: Birth to 1 Year • ignoring the reality of a situation to avoid anxiety
• Erogenous Zone: Mouth (sexually sensitive)
o Freud believed the individual would have issues with DISPLACEMENT
dependency or aggression.
• Redirecting a negative emotion from its original source to
someone who’s less threatening
ANAL
• Age Range: 1 to 3 years
• Erogenous Zone: Bowel and Bladder Control DISSOCIATION
o Freud believed that the primary focus of the libido was • feeling disconnected from their thoughts, feelings, actions
on controlling bladder and bowel movements. or in a stressful or traumatic event – or feeling that the event
o According to Freud, inappropriate parental responses is not really happening
can result in negative outcomes. If parents take an
approach that is too lenient, Freud suggested that FIXATION
an anal-expulsive personality could develop in which • It is an obsessive drive that may or may not be acted on
the individual has a messy, wasteful, or destructive involving an object, concept, or person.
personality. • People act out behaviors from the stage of
psychosexual development in which they are fixated.
PHALLIC/OEDIPAL o Ex. an individual fixated at an earlier developmental
• Age Range: 3 to 6 Years stage might cry or sulk upon hearing unpleasant news.
• Erogenous Zone: Genitals
o Curiosity
o At this age, children also begin to discover the IDENTIFICATION
differences between males and females. • Associating self with other individuals
o Oedipal complex, also known as the Oedipus • Adopting the behavior of a person who is more powerful and
complex, is a term used by Sigmund Freud in his theory hostile towards them.
of psychosexual stages of development to describe a
child's feelings of desire for his or her opposite-sex INTELLECTUALIZATION
parent and jealousy and anger toward his or her same- • Using reason or logic to avoid thinking about the stressful,
sex parent. emotional aspect of the situation
o Electra complex has been used to describe a similar
• Provoking emotions
set of feelings experienced by young girls. Freud,
however, believed that girls instead experience penis
envy. INTROJECTION
• internalizes the ideas or voices of other people
LATENCY • commonly associated with the internalization of external
• Age Range: 6 to Puberty authority, particularly that of parents.
• Erogenous Zone: Sexual Feelings Are Inactive o Ex. Killer sya pero iba sinasabi nya
o During this stage, the superego continues to develop
while the id's energies are suppressed. PROJECTION
o Develop social skills, values and relationships with • taking your own unacceptable qualities or feelings and
peers and adults outside of the family. ascribing them to other people.
o Ex. if you have a strong dislike for someone, you might
GENITAL instead believe that they do not like you.
• Age Range: Puberty to Death
• Erogenous Zone: Maturing Sexual Interests
o Sexual Intercourse RATIONALIZATION
o The individual develops a strong sexual interest in the • logical reasons are given to justify unacceptable behavior
opposite sex o Ex. a person who is turned down for a date might
rationalize the situation by saying they were not
attracted to the other person anyway
EGO DEFENSE MECHANISM
COMPENSATION
• people overachieve in one area to compensate for failures REACTION FORMATION
in another (compensate to your weakness) • unconsciously replaces an unwanted or anxiety-provoking
impulse with its opposite, often expressed in an
exaggerated or showy way
CONVERSION • opposite way to which he or she thinks or feels.
• individuals reduce acute anxiety by converting
psychological suffering into physical symptoms
o Ex. a young boy who bullies a young girl because, on
a subconscious level, he's attracted to her.
o Psychosomatic

BSN 3
 TRANS: NCM117

REGRESSION
• returns to an earlier stage of development usually in
response to stressful situations.
o Ex. A patient had his stuffed toy for 20 yrs.

REPRESSION
• unpleasant thoughts or memories are excluded from the
conscious mind.
o Ex. someone who does not recall abuse in their early
childhood, but still has problems with connection,
aggression and anxiety resulting from the
unremembered trauma.

RESISTANCE
• mind unconsciously protects itself from danger from within
and without.
• oppositional behavior when an individual's unconscious COGNITIVE STAGES OF DEVELOPMENT
defenses of the ego are threatened by an external source. JEAN PIAGET – COGNITIVE DEVELOPMENT WITH
o Ex. a child fighting against her kidnapper. CHILDREN
• Biologic changes and maturation – cognitive development
• Useful when working with children
SUBLIMATION
• unacceptable impulses into behaviors that are positive and
socially acceptable COGNITIVE DEVELOPMENT
SENSORIMOTOR ( 0 – 2 YEARS OLD)
SUBSTITUTION • Object permanence
• replacement of one thing with another. • Mental images
• positive adaptation or solution (e.g., adoption when one • cognitive development, infants and toddlers acquire
cannot have a child of one's own) or as a negative, knowledge through sensory experiences and manipulating
maladaptive response (e.g., emotional eating after a objects. A child's entire experience at the earliest period of
frustrating day at the office) this stage occurs through basic reflexes, senses, and motor
responses.
SUPPRESSION
• Avoids thinking about it PREOPERATIONAL ( 2- 6 YEARS OLD)
• individuals cope with distressing mental contents by • Express self with language
voluntarily making efforts to put them out of conscious • Classify objects
awareness until there is an opportunity to cope adaptively • Children begin to think symbolically and learn to use words
with those stressors. and pictures to represent objects.
o Ex. A sexually abuse patient doesn’t want to share her
experience CONCRETE ( 6 – 12 YEARS OLD)
• Apply logic
UNDOING • Spatial and reversibility
• tries to cancel out or remove an unhealthy, destructive or • Social and apply rules
otherwise threatening thought or action by engaging in • During this stage, children begin to think logically about
contrary behavior. concrete events
o Ex. after thinking about being violent with someone,
one would then be overly nice or accommodating to
them.
FORMAL OPERATION
• 12 -15 years old
DEVELOPMENTAL THEORY
• Think and reason in abstract terms
ERIK ERIKSON’ PSYCHO SOCIAL DEVELOPMENT
• Achieves cognitive maturity
• Life task each stage
• At this stage, the adolescent or young adult begins to think
• Psychosocial is a sequential basis
abstractly and reason about hypothetical problems
• Teens begin to think more about moral, philosophical,
ethical, social, and political issues that require theoretical
and abstract reasoning

BSN 4
 TRANS: NCM117

INTERPERSONAL THEORIES Classical Conditioning Operant Conditioning

HARRY STACK SULLIVAN – INTERPERSONAL
Ivan Pavlov B.F. Skinner
RELATIONSHIP AND MILIEU THERAPY
• based on the belief that people's interactions with other Conditioned response People learn their behavior
people, especially significant others, determine their sense to those repeatedly
of security, sense of self, and the dynamisms that motivate reinforce
their behavior. Dog and bell Negative or Positive
• Personality is affected on how one interacts with others experiment reinforcement
• interpersonal relationship is important in mental health
• Prototaxic, Parataxic and Syntaxic modes
• Therapeutic community or Milieu
EXISTENTIAL THEORIES
o a structured environment that creates a safe, secure COGNITIVE THERAPY
place for people who are in therapy. • Immediate thought processing
• Aaron Beck

THERAPEUTIC NURSE- PATIENT RELATIONSHIP

HILDEGARD PEPLAU RATIONAL EMOTIVE
• Irrational belief that people use to make themselves
• Orientation
unhappy
o Anong nagyayari
• Albert Ellis
• Identification
o Introduce yourself
• Exploitation LOGOTHERAPY
o Delivering of interventions • Search for meaning (logos)
• Resolution • Viktor Frankl
o Closure
GESTALT THERAPY
ROLES OF NURSES IN THE THERAPEUTIC
• Increase self-awareness through journal – put past to rest
RELATIONSHIP and focus on present
• Stranger • Frederisk Perls
• Resource person
• Teacher
• Leader REALITY THERAPY
• Surrogate • Therapeutic focus in need for identity through responsible
• Counselor behavior
• William Glasser

ANXIETY – INITIAL RESPONSE TO PSYCHIC

THREAT HIERARCHY OF NEEDS
Mild → Moderate → Severe → Panic ABRAHAM MASLOW

HUMANISTIC THEORY
• people are intrinsically good, with an innate drive to make
themselves better
• Focuses on the person’s positive qualities, capacity to
change and promotion of self esteem
• Consider the person’s past experiences but they direct
more attention towards present and future

CLIENT-CENTERED THERAPY
CARL ROGERS
• Patient to CLIENT
o Client is the key of healing process
o Clients can cure themselves
• Therapist is a supportive role
• Unconditional positive regards, genuineness, emphatic
understanding

BEHAVIORAL THEORIES
• Behaviorism
o focuses on observation behaviors
o It does not attempt to explain how mind works
• View
o Behavior can be changes through a system of reward
and punishment

BSN 5
 TRANS: NCM117

PSYCHOSOCIAL ASSESSMENT • Concentration

ASSESSMENT • Abstract thinking abilities
• Collect
• Organize JUDGEMENT AND INSIGHT
• Analyze • Judgement
o Interpretation of environment
PSYCHOSOCIAL ASSESSMENT • Insight
• Emotional State o Understanding one’s own part
o Emotion and Feelings
• Mental Capacity SELF-CONCEPT
o Mental Status • Personal view of self
• Behavioral Function • Description of physical self
• Personal qualities or attributes
FACTORS INFLUENCING ASSESSMENT
• Client Participation/feedback ROLES AND RELATIONSHIPS
• Client’s Health Status • Current roles
• Client’s Previous Experiences/ Misconceptions about • Satisfaction with roles
healthcare • Success at roles
• Client’s ability to understand • Significant relationships
• Nurse’s attitude and approach • Support system

INTERVIEW PHYSIOLOGIC AND SELF-CARE CONSIDERATION

• Environment • Eating habits
• Input from family and friends • Sleep patterns
• Questions • Health problems
• Compliance with prescribed medications
HISTORY • Ability to perform activities of daily living.
• Age
• Developmental Stage THERAPEUTIC RELATIONSHIP
• Cultural consideration COMPONENTS OF THERAPEUTIC RELATIONSHIP
• Spiritual belief • Trust
• Previous history • Empathy
• Acceptance
GENERAL ASSESSMENT AND MOTOR BEHAVIOR • Genuine interest
• Hygiene and grooming • Positive regards
• Appropriate dress • Therapeutic use of self and self-awareness
• Posture
• Eye contact NURSE SHOULD EXHIBITS THE FOLLOWING TO
• Unusual movements or mannerism BUILD THE CLIENT’S TRUST
• Speech • Caring
• Openness
MOOD AND AFFECT • Objectivity
• Expressed emotions • Respect
• Facial expressions • Interest
• Understanding
THOUGHT PROCESS AND CONTENT • Consistency
• Content • Treating the client as a human being
o WHAT • Suggesting without telling
• Process • Approachability
o HOW
• Listening
• Clarity of Ideas
• Keeping promises
• Self-harm
• Honesty
SENSORIUM AND INTELLECTUAL PROCESS EMPHATHY
§ Sensorium is the level and stability of • involves putting yourself in the other person's shoes and
consciousness understanding WHY they may have these particular
• Orientation feelings.
• Confusion § “I’m so confused! My son just visited and wants
to know where the safety deposit box key is.”
MEMORY o Using reflection, the nurse responds,
• Abnormal § “You’re confused because your son asked for
• Sensory experiences the safety deposit key?”

BSN 6
 TRANS: NCM117

o The nurse, using clarification, responds, BELIEF

§ “Are you confused about the purpose of your • being sure that a person or thing exists or is true or
son’s visit?” trustworthy
• Hold true
SYMPATHY
• involves understanding from your own perspective. ATTITUDE
• feeling or way of thinking that affects a person's behavior
• Frame of reference

THERAPEUTIC USE OF SELF

• Nurses use themselves
as a therapeutic tool
to establish therapeutic
relationships with clients
and help clients grow,
change, and heal
• must clearly understand
themselves to promote
their clients’ growth and
to avoid limiting clients’
choices to those that
nurses value.
• Self-awareness –
process of
understanding one’s self

PATTERNS OF KNOWING
• Empirical knowing (obtained from the science of nursing)
ACCEPTANCE • Personal knowing (obtained from life experience)
• Avoiding judgments of the person, no matter what the • Ethical knowing (obtained from the moral knowledge of
behavior, is acceptance. nursing)
• This does not mean acceptance of inappropriate behavior • Aesthetic knowing (obtained from the art of nursing)
but acceptance of the person as worthy.
§ “John, do not place your hand on me. We are TYPES OF RELATIONSHIP
working on your relationship with your girlfriend
SOCIAL RELATIONSHIP
and that does not require you to touch me. Now,
• connections that exist between people who have recurring
let’s continue.”
interactions
o An inappropriate response would be,
• coworkers, distant relatives, and acquaintances.
§ “John, stop that! What’s gotten into you? I am
leaving, and maybe I’ll return tomorrow.”
o Leaving and threatening not to return punishes the INTIMATE RELATIONSHIP
client while failing to clearly address the inappropriate • an interpersonal relationship that involves physical or
behavior. emotional intimacy
• it may also be a non-sexual relationship involving family
GENUINE INTEREST
• not only you act as that you care, but you really do care and THERAPEUTIC RELATIONSHIP
listen to what people are saying. • the relationship between a healthcare professional and a
client or patient
POSITIVE REGARD
• Appreciates the client as a unique worthwhile human being THERAPEUTIC RELATIONSHIP
can respect the client regardless of his or her behavior, Orientation → Identification → Exploitation → Termination
background, or lifestyle.
• Unconditional nonjudgmental attitude BARRIERS
• Calling the client by name, spending time with the client, • Inappropriate boundaries
and listening and responding openly • Feelings of sympathy and encouraging client dependency
• Believes the client has the ability to make positive and • Nonacceptance and avoidance
meaningful contributions to his or her own plan of care.
ROLES
SELF-AWARENESS • Teacher
VALUES • Advocate
• individual beliefs that motivate people to act one way or • Caregiver
another. • Parent surrogate
• Abstract standard
BSN 7
 TRANS: NCM117

THERAPEUTIC COMMUNICATION • Focusing

HOW CAN YOU START A CONVERSATION? • Formulating a plan of action
COMMUNICATION • General leads
• Verbal • Giving information
• Non-verbal • Giving recognition
• Making observation
THERAPEUTIC COMMUNICATION • Offering self
• Establish a therapeutic nurse-client relationship • Placing event in time or sequence
• Presenting reality
• Identify the most important client concern at that moment
• Assess the client’s perception of the problem as it unfolds • Reflecting
• Restating
• Facilitate the client’s expression of emotions
• Seeking
• Teach the client and family necessary self-care skills
• Recognize client’s needs • Silence
• Suggesting collaboration
• Implement interventions
• Summarizing
• Guide the client towards identifying plan of action
• Translating into feelings
• Verbalizing the implied
PRIVACY AND RESPECTING BOUNDARIES
• Voicing doubt
• Proxemics
o amount of space that people feel it necessary to set
between themselves and others. NON-THERAPEUTIC COMMUNICATION
INTIMATE ZONE • Advising
• Agreeing
• very close relationships, such as that of parents and
• Belittling feelings expressed
children, lovers, spouses, and partners
• Challenging
• Defending
PERSONAL ZONE • Disagreeing
• distance zone adopted by those interacting with friends and • Disapproving
personal acquaintances • Giving approval
• Giving literal response
SOCIAL ZONE • Indicating the existence of an external source
• distance zone adopted between people engaged in • Interpreting
relationships of a relatively formal nature, such as attorney • Making stereotyped comments
and client. • Probing
• Reassuring
PUBLIC ZONE • Rejecting
• the distance zone adopted by people in highly formal, • Requesting an explanation
official, or ceremonial interactions. • Testing
• Using denial
TOUCH
• Functional - professional touch NONVERBAL COMMUNICATION
• Social - polite touch • Facial Expression
• Friendship - warmth touch • Body language
• Love - intimacy touch • Vocal Cues
• Sexual - arousal touch • Eye contact
• Silence
ACTIVE LISTENING
• Recognize the issue that is important to the client
• Know what further questions to ask
• Use additional therapeutic communication techniques to
guide the client
• Understand the client’s perceptions of the issue instead of
jumping to conclusion
• Interpret and respond to the message objectively.

THERAPEUTIC COMMUNICATION
• Accepting
• Broad openings
• Consensual validation
• Encouraging comparison
• Encouraging description of perceptions
• Encouraging expression
• Exploring

BSN 8