Psychiatric Nursing Lecture Note for Third Year Extension Nursing Students Prepared by Tesfa D. (B.Sc.) July, 2003/2011.

Unit-One Introduction to psychiatric nursing

Basic concepts in psychiatry

 Psychiatry:- is a branch of medicine which deals with diagnosis, treatment and follow up of mentally ill people. Or doctrine of mental health.  Psychiatrist:- a physician who specialize in psychiatry or a health professional who is certified to diagnose, treat and follow mentally ill people.

Cont
 Psychology:- is a branch of social science which deals with normal human behavior.  Psychiatric nursing:- is the branch of nursing concerned with the prevention and cure of mental disorders and their sequel.

Cont

Branches of psychiatry
 Child  Geriatric  Forensic

Cont

Basic science related to psychiatry;

Psychology Neuroscience Biomedical science Psychopathology

Normality
What is normality?  It is sometimes employed for always or most usual.  In this sense normality may be:
y A sense of well-being y The use of sublimation as the

main defense mechanism

Cont
y The ability to postpone

present pleasures for future ones. y The presence of an intact sense of reality. y Good interpersonal relationship. y Optimal adjustment.

Cont
The activities of normal life in adults; Adaptation to the work situation. Leisure time activity. Management of social contacts. Adjustment to the opposite sex.

Mental health
It is a positive state in which a person is responsible, self-directive, and displays self awareness.  It is the ability to;  Solve problems.  Fulfill once capacity for love and work.  To cope with crisis with out assistance beyond family and relatives.  Maintain a state of wellbeing by enjoying life, setting goals and reality limits and becoming independent, interdependent, and dependent when situation arises with out permanent loss of independency. N.B. There is no universal definition of mental health.


Cont
Factors influencing mental health development ; 1) Inherited characteristics 2) Nurturing during child hood 3) life circumstances

Cont
1) Inherited

characteristics E.g. Includes genetic defects that predisposes a person to different mental disorder.

Cont
Nurturing during child hood E.g.  Positive nurturing (feeling of love, safety, acceptance).  Negative nurturing (maternal deprivation, paternal rejection, sibling rivalry, early communication failure)
2)

Cont
3) life circumstances E.g.  Positive (success in school, financial security, good physical health, enjoyable occupation, successful marriage).  Negative (it is the opposite of positive life circumstances).

Mental illness
Definition:- is illness with psychologic or behavioral manifestation and /or impairment in functioning due to a social, psychologic, genetic, physical /chemical, or biologic disturbance. Other definitions refers to mental illness:1) Displaying abnormal behavior more consistently than most people.

Cont
2) A psychopathology exhibiting frequent irresponsibility, the inability to cope, frequently being at odds with society, and an inaccurate perceptions of reality. 3) Absolute absence or constant presence of a specific behavior that has a socially acceptable range of occurrences.

Cont
Major criteria for the diagnosis of mental illness (Psychosis); 1. Bizarre behavior 2. Abnormal experience 3. Loss of reality contact 4. Lack of insight

Cont
Causes of mental illness Chronologically those causes are classified as; 1. Predisposing. 2. Precipitating. 3. Perpetuating.

Cont
Predisposing. E.g. Genetic endowment (Down syndrome, dementia, schizophrenia), uterine environment (maternal infection, drug, malnutrition), physical factors (birth injury, trauma, prematurity, drug, infection), social factors (poverty), psychological factors.
1.

Cont
2. Precipitating (shortly before the onset) E.g. Physical (body image disturbance, drug, infection, chat chewing and general medical condition), psychological factors (job loss, parent loss, material loss, spouse loss).

Cont
3. Perpetuating (prolong the course) E.g. Social withdrawal, demoralization, poor social support, family support, loss of job.

Misconceptions about mental illness

Abnormal behavior is odd and easily recognized. Abnormal behavior can be predicted or evaluated. Internal forces are responsible for abnormal behavior. People who exhibit abnormal behavior are dangerous. Maladaptive behavior is inherited. Mental illness is incurable.

Comparison b/n MH and MI

MENTAL HEALTH
Accepts self and others
Ability to cope or tolerate stress. Can return to normal functioning if temporarily disturbed Ability to form close and lasting relationships

MENTAL ILLNESS
- Feelings of inadequacy - Poor self-concept

- Inability to cope - Maladaptive behavior

Inability to establish a meaningful relationship

Cont
Uses sound judgment to make decisions Displays poor judgment Accepts responsibility for Irresponsibility or actions inability to accept responsibility for actions Optimistic Recognizes limitations (abilities and deficiencies) Pessimistic Does not recognize limitations (abilities and deficiencies)

Cont
Can function effectively and independently Able to perceive imagined circumstances from reality Able to develop potential and talents to fullest extent Exhibits dependency needs because of feelings of inadequacy Inability to perceive reality

Does not recognize potential and talents due to a poor self-concept

Cont
Able to solve problems Avoids problems rather than handling them or attempting to solve them Desires or demands immediate gratification inability to cope with stress, the inability to respond according to his expectations and the demands of society. Can delay immediate gratification Approach to life by communicating emotions, giving and receiving. Working alone as well as with other, accepting authority, displaying a sense of humor, and coping successfully with emotional conflict.

Maintaining mental health

Definition:- is keeping the mind free from psychological pain or disorders as much as possible until death. The person who achieves and maintains mental health has the following features;

a) b) c) d) e)

Emotionally matured Fully functioning Growing personally Fully human Self actualizing

Cont
Factors that affect maintaining mental health A. Interpersonal communication B. Dealing directly with ones emotions (facing emotions) C. Resorting to Human hiding places or ego defense one mechanism

A. Interpersonal Communication
Defn :- is the communication of two person. Defn of communication; It is a derivatives of the Latin word communes to mean sharing or understanding. It is a mutual interaction or reciprocal action that can occur between or among people. Or It is the giving and receiving of information.

Cont
 Therapeutic communication; It is a special form of communication that has a health related purpose and develops as continuous flow of interaction between nurse and patient. The main goal is to develop or maintain healthy personality by relieving stress and assisting a patient to develop a good coping mechanism .

Cont


Can be divided in to; A. Verbal:- this involves persons conversation either face to face or through other media like telephone. B. Non-verbal:-this involves communication with out oral conversation. C. Other:- Written communication.

N.B. Non-verbal communication is more accurately true feeling of the individual.

Cont
Types/ways of non-verbal communication; 1. Position/posture:- communication is done through different style of physical appearance. Can communicate many different attitudes, including shyness, fear or discomfort. 2. Gesture:- communication through body movement. 3. Touch:- communication through close physical contact.

Cont
4. Facial expression:- this is through using facial anatomical structures. Clients may register string feeling like anger, sadness, joy from facial expression. 5. Vocal cues:- those behaviors of voice that are observed during verbal conversation. 6. Eye contact:- Serves to indicate interest. 7. Active listening:- Listening involves not only receiving sounds, but also accurately understanding the meaning as much as possible.

Elements of communication
A. B.

be understood by one or more sense of the receiver, e.g. hearing, touching, smelling, tasting. C. Channel:- is the method that is used to communicate. E.g. written material, media (radio, TV, ). D. Receiver:- is the person who receive the sender message. E. Feedback:- is the response of receiver.

Sender:- is source of information. Message:- is any form of signal that can

Effective communication
 It

is a type of communication in which the elements of communication are included and mutual understanding (not always) is reached between or among people.

Cont.

Effective communication occurs when the receiver understands the message as the sender intended. Unfortunately ineffective communication often occurs due to some barriers.

Barriers of communication
 Reception

barriers. E.g. need, barrier. E.g.

attitude, environmental stimuli.

 Understanding  Acceptance

language, knowledge barrier.

barrier. E.g. emotional barrier. E.g. day

conflict, prejudices (bias).

 Psychological

dreaming, detouring, debating, private planning.

Skills of communication
        

Know yourself. Be honest with your feeling. Be sure in your ability to relate with people. Be sensitive to needs of others. Be consistent. Recognize the symptoms of anxiety. Watch your non-verbal reactions. Use words carefully. Recognize and evaluate your own action and responses.

B. Dealing directly with ones emotions (facing emotions)

People

handle their innermost thoughts and feelings in various way. A comparison of healthy and unhealthy ways to deal directly with ones emotions during an interaction follows:

Cont
Health reactions
Be aware of any emotional response or feeling during an interaction with your environment or with another person. Admit that you are capable of experiencing various emotions, including anger, hostility, frustration or disappointment.

Unhealthy reactions
Ignore any emotional response on your part. Bottle it up inside so that your mind is not aware of the response. Your body may feel abnormally.

Cont
Examine

the intensity of each emotion you feel. What caused such a reaction? How is it impacting on your relationship with others?

Deny

your true feeling by ignoring them or telling your Self they do not really exist. You are not type of person who become anger or bitter.

Cont
Share your emotional response. Let your mind tell you what is the correct approach to a specific interaction. Think Before you act.

Let

the emotion rule you as you become defensive during an interaction. It is not you; It is the other guy who is at fault.

Cont
E.t.c.

Allow yourself to lose control & become argumentative, incoherent, or disorganized. Blame your reaction on the other person or thing. Let your emotions rule your actions. Act without thinking & be impulsive.

Defense mechanism/Coping style

Are

automatic psychological process that protects the individual from anxiety and awareness of internal or external dangers or stressors. N.B. Maladaptive use of those defense mechanisms cause distortion and self-deception.

Cont
Uses;

y To resolve mental conflict. y To reduce anxiety or fear. y Protects ones sense of

security. y Protects ones self-esteem.

Cont
Defense mechanism organized into hierarchy of psychopathology

Mature Suppression Altruism  Humor Sublimation

Cont
Neurotic (intermediate) Intellectualization Isolation Repression Reaction formation/

overcompensation Displacement Undoing Rationalization

Cont
Immature defense Passive aggression Acting out Dissolution Projection Psychotic defense Denial Distortion

Types of defense mechanism

unpleasant reality by unconscious refusal to perceive or facing thoughts, wishes, feelings, needs, or reality factors those are intolerable. E.g. A person who has just been admitted to a mental hospital states I am really not sick, I am just in here to get a rest.

Denial:-protecting one self from

Cont
painful unpleasant thoughts or feeling to unconscious mind.

Repression:-involuntary putting of

E.g. The inability to remember the reason for an argument or the inability to recall feeling of fear after automobile accident. Or Forgetting sexual abuse in child hood.

Cont
Suppression: consciously/willfully/voluntarily putting unacceptable feeling or thought out of one's conscious mind. It is also called voluntary forgetting. E.g. I did rather not to talk about it right now. Lets talk about my accident later.

Cont
justification of ideas, actions, feelings with good acceptable reason.

Rationalization:-unconsciously

E.g. The exam is out of the course. Conversion:- the transferring of a

mental conflict in to a physical symptom to release tension or anxiety.

E.g. An elderly woman experiences sudden blindness after witnessing a robbery.

Cont
use it in an attempt to identify with the personality of another. Act as want while not/unconscious adoption/. Sublimation:- conscious rechanneling of intolerable or occasionally unacceptable impulse or behavior into practice/activity (socially more acceptable). E.g. A college student who has hostile feelings rechannels them by joining the debate team.

Identification/Imitation:- people

Cont
for a real or imagined inability or deficiency with a specific behavior to maintain self respect/esteem. The person overcomes an inability by becoming proficient in an other area.

Compensation:-the act of makeup

E.g. A short boy/girl may become a manager of basket ball team. Or unattractive boy/girl buy stylish expensive clothes.

Cont
Substitution:- the unconscious act of replacing a goal when it is blocked. E.g. A nurse student who feels unable to master pediatrics becomes sanitarian. Undoing/ Restitution :- the negation of a previous consciously intolerable action or experience to reduce or alleviate feeling of guilt. E.g. A person sends flowers to his fiance after he embarrassed her at cocktail party.

Cont
Displacement:-a mechanism that serves to transfer feelings such as frustration, hostility, or anxiety from one idea, person or object to another which is less threatening. E.g. A person slammed of a door when you were angry.  Reaction formation:- Transforming unacceptable impulse into its opposite. E.g. A woman who hates children may talk very lovingly to a friends young son.


Cont


characteristics of self and assigns then to others. E.g. The person may others for faults, feelings that are unacceptable to self.  Symbolization:- an object, idea or act represents another through some common aspect and carries to emotional feeling associated with the others. E.g. The engagement ring symbolize love and commitment.

Projection:- the person rejects unwanted

Cont


Regression:- retreating the past level

of behavior that reduce the anxiety. E.g. A 50 years old woman wear like 15 years old lady.

Introjection:- attributing to one self

the good qualities of another's. E.g. They have been observed and acting like the person age they profess to be.

Cont
Fantasy:- imagined events or mental images (e.g. day dreaming) to express unconscious conflicts, gratify, unconscious wishes, or pre pare for anticipated future events. E.g. A young woman fantasized she had a child, as she sat in a rocking chair, held a baby doll, and sang lullabies.

Cont
Isolation: the process of separating

unacceptable feeling, idea or impulse from one's thought (also referred to as emotional isolation. E.g. An oncologist is able to care for a terminally ill cancer patient by separating or isolating his feelings or emotional reaction to the patients inevitable death.

Cont
Dissociation: act of separating

and detaching a strong emotionally charged conflict from ones consideringness. E.g. a women who was raped was found wondering busy high way in torn, disheveled clothing.

Cont
Intellectualization: act of transferring emotional concern in to the intellectual sphere. E.g. A young man may use intellectualization as method of avoiding confrontation with his fianc if she changed her mind about wishing to marry him.

Cont
Others

(read about it);

Nomadism Altruism Passive aggression

Significant others or support persons

Mental health can be maintained by means of positive interpersonal communication, facing ones emotions, and using ego defense mechanisms, people may reach out to other individual or group for support during periods of increased stress or anxiety. Such persons are referred to as Significant others

or support persons.

History of psychiatric nursing and it trends

Early civilization  Mental illness began in the primitive age as human existence began.  At this time the cause of mental illness is organic dysfunction of brain.


Greeks, Romans and Arabs viewed mental deviations as natural phenomena and treated the mentally ill humanely.

Cont
The treatment approaches was sedation, good nutrition, good physical hygiene, music and recreational activities.  Greeks used temples as hospitals and provided an environment of fresh air, sunshine, pure water to promote healing of mental illness.


Cont


Contributors for the idea of mental illness at this time are; Hippocrates (MI is caused by disturbance of body fluid) Aristotle (mind has association with heart) Galen (mental disorder associated with brain)

Cont


 

Middle age It is an era of alienation, social exclusion and confinement and chaining. The cause was believed as demonic possession. Person who displays abnormal behavior were considered as lunatic witches or demonic possession with evil sprit.

Cont
18th and 19th centuries
The

first hospital, Bethelehm Royal hospital, was opened at this time. The animalistic treatment of patient were started. In 18th century, the era of reason and observation, philippe pinel, a French physician placed in charge in the insane hospital in Paris.

Cont
He

began more human treatment of the mentally ill people by removing the chain and advocating human treatment instead. Weyer, a German physician was is considered to be the first psychiatrist because of his description of several diagnostic categories.

Cont

Biniamin Rush y Often called the father of American psychiatry. y Wrote the American text book on psychiatry. y Encourage more human treatment of mentally ill. y In 1783, during the era of moral treatment, he joined the staff of Pennsylavia hospital and insisted that intelligent, kind attendant, be hired to read the patients, talk to them and share there activities.

Cont
During 1870 Dorthea Lynde dix, a Boston teacher spent much of time working for improved conditions for the mentally ill. In 1882, the first psychiatric training school for Nursing was established at Mclean hospital in Belmont, Massachuttes. Then after trained nurses were employed on Nursing staff of the state hospitals.

Cont
20th century


As a result of increased awareness of the public because of some published books on mental illness, large state hospital were built in the rural areas, where the patient could receive the benefit of fresh air, sunshine and rural environment. In 1915, Linda Rechards, the first graduate nurse in the US and referred as the first psychiatric nurse. Suggested that mentally ill people receives the same quality care as do physically ill.

Cont
In Ethiopia the first mental hospital (Emanuel Hospital) was established after the end of the Ethio-Italian war to protect the royal family from mentally ill patients. The patients were collected and taken to jails to the corner of the town that is now known as Emanuel Hospital.

Cont
Slowly

and gradually a more humanitarian type of care was introduced by one psychiatrist. Dr. Fikire Workineh. The first psychiatric nursing school was established in Emanuel Hospital in 1991 and twelve nurses graduated for the first time.

Cont
The service started to be decentralized to other corners of the country, such as Jimma, Nekemte, Harar, Dire Dawa, Yirgalem, Bahirdar, Mekele and Asmara. By now some of hospitals in Ethiopia have psychiatric units even though the quality is not yet of an appropriate level.

Cont
At this time text books focusing on psychiatric nursing were written. The national league for nursing conventions discussed undergraduate psychiatric nursing education to include some important aspects in the curriculum. The educational carrier s for psychiatric nursing were increased at that time.

Cont
School

of nursing offers a variety of programs in psychiatric nursing. Such as; y Associate degree. y Baccalaureate. y Masters degree.

Basic principles of psychiatric nursing

1. Accept and respect the person or individual regardless of their behavior. 2. Limit or reject inappropriate behavior without refusing the individual. 3. Recognize that all behavior have significations. The nurse should meet the needs of the performer despite how distorted or meaningless it appears to others. 4. Accept the dependent needs of the individual while supporting and encouraging them more toward independence.

Cont
5. Help the individual to set appropriate limits for themselves or set limits for them when they are unable to do so. Mechanical Chemical 6. Encourage individuals to express their feelings in an atmosphere or environment that is free from judgement. 7. Recognize that individuals need to use their defences until other defences can be substituted.

Cont
8. Recognize how feelings affect behavior and influence relationship. 9. Recognize that individuals frequently respond to the behavioural expectations of others, family, friends, etc. 10. Recognize that individuals have a potential for movement toward higher levels of emotional health.

Role of a Psychiatric Nurse

1.Technician care giving role (skills) 2.Mother Substitute or Mother Surrogate parent surrogate 3.Teacher influence 4.Counselor advocate
 Advocacy acting on the patients behalf by

ensuring privacy and modesty, preventing unnecessary.

5.Social Agent introduce patient to other patients 6.Ward Manager.

Characteristics of a psychiatric nurse

Empathy the ability to see beyond outward behavior and sense accurately another persons inner experiencing. Genuineness/Congruence ability to use therapeutic tools appropriately. Unconditional positive regard RESPECT.

Qualities of Psychiatric Nurse

Skills & knowledge Mental health nurses need to have: Excellent nursing skills, and knowledge of different nursing methods and theories. Knowledge of psychiatric disorders. Knowledge of different diseases and illnesses, and how the human body works. Knowledge of medicines and treatments, and the effect these have on patients.

Cont

knowledge of counseling and therapy techniques. An understanding of the Mental Health Act and other relevant legislation. Oral and written communication skills, including good listening skills. Organizational skills Decision-making ability. Need to keep up to date with the latest medical trends and nursing practices in mental health.

Cont
Personal Qualities Mental health nurses need to be:
 Patient  Concerned for and able to build

relationships with others.  Mature and responsible.  Able to work well under pressure.  Able to deal with people from a variety of backgrounds and cultures.

Cont
Physical Requirements Mental health nurses need to be reasonably fit and healthy to cope with the stress and pressure of the job. They may also have to spend long periods on their feet.

The End!!!