NCM-A Finals Mental Health - relative and dynamic Relative not the same to all people Dynamic changes

nges at different point in time Positive state in which one is responsible, displays ones self awareness, self directed, reasonable worry free and can cope with daily tensions Simultaneous success at working, loving, and creating with the capacity for mature and flexible resolution of conflicts between instinct conscience, important other people and reality. It is the state in the relationship of the individual and environment in which the personality structure is relatively stable and the environmental stresses are within its absorptive capacity (good mental health . !bility to solve problems. "ulfill one#s capacity for love and wor$. (could you satisfy one#s relationship !bility to cope with crises without assistance beyond the support of family and friends. It could maintain a state of well being such as enjoying life, setting goals, and realistic limits becoming independent, dependent, or interdependent as the need arises without permanently losing one#s independence.

!sychic "nergy %# $d present at birth& instinctual drive for pleasure and immediate gratification, unconscious& pleasure principle (wants . '. "go develop as sense of self that is distinct from world of reality. - (perates on reality principle which determines whether the perception has a basis in reality or is imagined. - )ses secondary process thin$ing by *udging reality and solving problems# - +ictates your needs. ,. %uperego develops as person unconsciously incorporates standards and restrictions from parents to guide behaviors, thoughts, and feelings. - -oncious awareness of acceptable.unacceptable thoughts, feelings, and actions /conscience0. !sychiatric &ursing - speciali1ed area of nursing, employing theories of human behavior as it science and the purposeful use of health as it art. %cience theories of human behavior 'rt purposeful use of self. - self awareness (oharis )indows *pen self that is $nown to you and $nown to others +lind self revealed by feedbac$ - )n$nown to you but $nown to others ,lose-.nknown / -not $nown to you and to others - -an be opened by situations.incidence

!rivate opened by self revelation - secrets

0*'1% *2 M"&3'1 Health 2oving towards assisting client to3 %. !ttain mental health '. 2aintain mental health. ,. Prevent mental Illness 4. 5o cope with mental illness 6. 5o find meaning in mental illness experienced and suffering.

,*&,"!3.'1 '!!R*',H"% 3* M"&3'1 H"'13H 1. Attitude towards the individual self. 5his involves aspects related to persons3 a. self awareness b. self acceptance c. confidence d. level of self esteem e. sense of personal identification in relation to roles self concept the term given to the type of self that lies between conscious awareness. - a collection of attitude and ideas about the self. - ! product of life experienced - It encompasses all that the person perceives $nows and holds to be true about his or her identity. - 7hat you believe you can do - Perceive (how you perceive yourself 4 '%!",3% *2 %"12 ,*&,"!3% %. +ody image physical dimension of self concept. - it is the entire gamut of human expression through the 6 senses as well as the physical representation of movement, express through dancing and gestures. - 8ow to present ourselves to others physically affects how other perceives us socially and emotionally. '. !ersonal $dentity refers to psychological aspect of self concept. - 2ore of the individual. - It prefers to the perception of internal and external reality. - inner world of the client in case by feelings, thought and tribute learning. - 2anifested by3 !ctions and 9anguage. 56 - :erbal (less effective 756 - ;on :erbal (more effective - It is unconscious stratum mental data by which individual is unaware. ,. %elf esteem - emotional component. - +escribe as the degree of value or worth ascribe to the self. - <epresents the perception of the worth attributed through him by significant others on the basis of his own presentation to the world. 4. Role performance expression of self concept. - 5he self representation to the outside world express through professional and social roles assumed in different situations such as family, school and wor$ place. - It is the totality of how one is $nown to others, one#s representation and public roles. %elf acceptance a regard to oneself with realistic concept of strength and wea$ness. %elf awareness noticing how self feels, things behave, and senses at any given time. - related to introspection involves evaluation or determining why self reacts at it does 2. Growth and Development and Self Actualization . =rowth increase in si1e of a structure - more on physical +evelopment maturation of structures. - more on psychological. Self !ctuali1ation when all individual goals have been achieved. 5op most level of !braham 2aslows hierarchy of needs. =rowth and development refers to what a person does to his abilities and potentialities. - <efers to person#s involvement with outside interest and relationship and concerns with an occupation or ideas as well as its goals. 3. Integrative apacit! - <efers to the balance of psychic forces (ex. Id, ego, superego - !bility to tolerate anxiety and frustration in stressful situation. Mild an8iety good thing cause it will cause you to push things. Moderate or severe an8iety will cause you panic and emotional paralysis ". Autonomous #ehavior - !bility to ma$e one#s own decision and react accordingly to his own convictions regardless of outside environment pressures and accept responsibilities for his actions.

$. %erception of &ealit! - 5he person#s perceptions of his environment and other people as well as his reactions towards them. - <eact depending on the culture, beliefs, and environment '. (aster! of )ne*s +nvironment - !bility to adapt, ad*ust and behave appropriately in situations according to approve standard so that satisfactions are achieve. - <efers to the problem solving ability of a person. 2',3*R% $&21."&,$&0 M"&3'1 H"'13H 9# $nherited ,haracteristics - 5heorists believe that no one is completely normal and that the ability to maintain a mentally healthy outloo$ on life is, in part, due to one#s genes. >x. -ognitive disability Schi1ophrenia or bipolar disorder &urturing During ,hildhood - <efers to familial child interactions - >x. *bsessive compulsive comply on the impose of their parents. a. !ositive &urturing starts with bonding at child birth and includes feelings of love, security, and acceptance. 5he child experiences positive interactions with parents and siblings. b. &egative &urturing circumstances such as maternal deprivation, parental re*ection, sibling rivalry and early communication failures. !oor nurturing develop poor self esteem, poor communication s$ills. 1ife ,ircumstances - -an influence one#s mental health from birth. !ositive circumstances - are generally emotionally secure and successful in school and establish healthy interpersonal relationship. &egative circumstances poverty, poor physical health, unemployment, abuse, neglect and unresolved childhood loss generally precipitate feelings of hopelessness, helplessness, and worthlessness# 5hese negative responses place a person at ris$ for3 %. depression, '. substance abuse ,. *ther mental health disorders# ,H'R',3"R$%3$,% *2 "M*3$*&'1 M'3.R$3; %. '. ,. 4. 6. ?. @. !bility to deal constructively with reality -apacity to adapt to change <elatively free from symptoms produce by tensions and anxiety. -apacity to find more satisfaction in giving and receiving (more of reciprocation !bility to relate to other people in a consistent manner with mutual satisfaction -apacity to redirect one#s instinctive hostile energy into creative constructive outlets. -apacity to love.

:#

2',3*R% 3H'3 $&21."&," 3H" '+$1$3; 3* ',H$"<" '&D M'$&3'$& "M*3$*&'1 M'3.R$3; 1. Interpersonal Communication - communication between two or more person - only as good as the interaction that occurs $ntrapersonal ,ommunication within self = 1evels of ,ommunication -!*)"11/ 1evel = ,lich> ,onversation no sharing of oneself occurs during this interaction. Auestions and comments ;o real answers are expected ;o personal growth can occur at this level >x.3 /8ow are you doingB0 /8ow#s your new *obB0

/5al$ to you later0 1evel 4 Reporting facts - reveals very little about oneself - minimal or no interactions is expected from others - ;o personal interaction occurs at this level 1evel Revealing $deas and (udgments - -ommunication occurs under strict censorship by the spea$er, who is watching the listener#s response for an indication of acceptance or approval. 1evel : %pontaneous, Here and &ow "motions -<evealing one#s emotions ta$e courage because one faces the possibility of re*ection by the listener. !owell -9?@?/ states that if one reveals the contents of the mind and heart, one may fear that such emotional honesty will not be tolerated by another. - result3 the spea$er may resort to dishonesty and superficial conversation to maintain contact with another person. 1evel 9 *pen, Honest ,ommunication - occurs in two people share emotions - they are in tuned with each other - capable of experiencing or duplicating each other#s reaction - interaction is termed: complete emotional and personal communication it helps one maintain emotional maturity. *pen communication may not occur until people relate each other over a period of time, getting to $now and trust each other. 2. Ego Defense Mechanisms - <eferred to as defense mechanism, described as mental processes - Identified as usually unconscious, protective barriers that are use to manage instinct and affect in the presence of stressful situations. - It can be therapeutic or pathologic, because all defense mechanisms include a distortion of reality, some degree of self-deception, and what appears to be irrational behavior. %. '. .ses of defense mechanisms 5o resolve mental conflict 5o reduce anxiety of fear 'n8iety unexplained feeling of apprehension, tension or uneasiness 2ear is an emotional response to recogni1able ob*ect or threat, it decreases when the danger or threat subsides. 5o protect one#s self- esteem 5o protect one#s sense of security.

,. 4.

%!",$2$, D"2"&%"% %. <egression the bac$ward turning to earlier patterns of behavior to solve personal conflict. >xample3 ! hospitali1ed patient ma$ing unnecessary reCuest and demands for care and attention. '. Suppression conscious and deliberate withholding of words or deeds that reflect an unfavorable light on the self. >xample3 ! rape victim consciously forgetting about experience. ,. <epression !n involuntary, automatic banishment of unacceptable ideas or impulses into the unconscious. 5he earliest type of defense available. -onsidered the principal defense in early years. >xample3 2rs. de la -ru1, a victim of incest, does not $now why she has always hated her uncle. 4. -ompensation ! conscious or unconscious attempt to balance a real or imagined deficiency in one area by developing other personal Cualities to hide wea$ness. >xample3 !n academically wea$ high school student become a star in a school play. 6. -onversion 5ransforming an emotional problem into a physical symptom or outlet. !n unconscious device. >xample3 2r. del 2ar suddenly develops impotence after his wife discovers he is having an affair with his secretary. 2alingering -onscious, deliberate attempt to escape from an unpleasant tas$.

?. +enial 5he );-(;S-I()S disapproval of thoughts, feelings, wishes, needs which are consciously unacceptable. -losely related to rationaliAation. ;ot the same as lying which is conscious. It protects the persons from finding out that he may be wrong. >xample3 2r. -arpio who is alcohol dependant states that he can control his drin$ing (when in fact he cannot . @. <ationali1ation !ttributing acceptable motive to thoughts, feelings or behavior which really have unrecogni1ed motives. Stating other motives instead of the genuine one. )sed to avoid the full honesty of the situation. >xample3! student states, /I got a @D on the test because the teacher as$ed poor Cuestions0. 2<. Eruno, a paranoid schi1ophrenia, states that he cannot go to wor$ because he is afraid of his co-wor$er instead of admitting that he is mentally ill. F. Intellectuali1ation 5he overuse of intellectual concepts of words to avoid effective experience or expression of feelings. >xample32r. Salvo tal$s about his son#s death bout with cancer as being mercifully short without showing signs of sadness. G. "ixation 5he arrest of maturation at an earlier level of psycho sexual development. Eehavior appropriate at an earlier age is maintained at a time such behavior should have been outgrown. >xample3 ! child#s attachment to a nursing bottle beyond the oral period. %D. Identification 5he unconsciousness, wishful adoption (internali1ation of the personality characteristics or identity of another individual generally one possessing attributes which the sub*ect envies or admires. I2I5!5I(; their behavior in contrast to identification is conscious. >xample3 Hulia state to the nurse, /when I get out of the hospital, I want to be a nurse *ust li$e you. %%. Intro*ections 5he symbolic assimilation or tal$ing into one#s self a loved or hated persons or external ob*ect. 5his is a form of identification, >xample3 7ithout reali1ing it, a patient tal$s and acts li$e his therapist. %'. Pro*ection )nconsciously ma$ing another persons or circumstances responsible for one#s unacceptable thought or actions It involves repression of undesirable Cualities. >xample3 ! parent#s fulfilled desire may be pro*ected on the child by demanding that the child prepare for a career which the parent would li$e to do, regardless of the child#s interest and wishes. %,. <eaction "ormation over compensation or reversal formation. >xample3 2others unconsciously do not love their children often over compensates be becoming overly protective of them. %4. Sublimation 5he substitution of unacceptable instinctual drives into socially acceptable expressions. >xample3 >xcelling in sports to sublimate hostile impulse. %6. Substitution <eplacement of unattainable therapy or unacceptable activity into one which is attainable and acceptable therapy assuring possibility of success. ,*M!'R'+1" 3* D$%!1',"M"&3. %?. +issociation 5he unconscious separation of painful feelings and emotions from an acceptable idea, situation or ob*ect. >xample3 Sleepwal$ing (somnambulism , amnesia, fugue. ! patient recalls that when she was sexually molested as a child, she felt as she was outside of her body watching what was happening without feeling anything. %@. )ndoing !n attempt to replace to a tone to ma$e amends for some undesirable act by process that attempt to ma$e it appear that the original act was never committed. >xample3 !fter span$ing his son, a mother ba$es his favorite coo$ies. %F. Symboli1ation !n idea of ob*ect is used to represent some other idea or ob*ect. >xample3 "etal position. ! re*ected boyfriend rushes into marriage in the rebound. %G. +isplacement ! transfer into another situation of an emotion in a previous situation where in expression would not have been socially acceptable. >xample3 ! husband comes home and yells at his wife after a bad day at wor$. 'D. "antasy )se of imagination or daydreaming. '% Isolation the separation of an unacceptable impulse act idea form its memory origin, there by removing the emotional charge. >xample3 P8(EI! . 5!E((S 2ost commonly seen in obsessive compulsive neurosis. !hobia an exaggerated and invariably pathological dread of some specific type of stimulus or situation. 'crophobia dread of high places 'goraphobia dread of open places

'lgophobia dread of pain 'stra-po/phobia dread of thunder and lightning ,laustrophobia dread of closed or confined places ,oprophobia dread of excreta Hematophobia dread of sight of blood Hydrophobia dread of water 1alophobia or glossophobia dread of spea$ing Mysophobia dread of dirt or contamination &ecrophobia dread of dead bodies &yctophobia dread of dar$ness, night !athophobia or &osophobia dread of disease, suffering !eccatophobia dread of sinning !honophobia dread of spea$ing aloud !hotophobia dread of strong light %itophobia dread of eating 3aphophobia dread of being buried alive 3hanatophobia dread of death 3o8ophobia dread of being poisoned Benophobia dread of strangers Coophobia dread of animals 3. Significant Others or Support People - 7ith anyone who the person fells comfortable trusts and respects. - !ct as the sounding board, shoc$ absorber of problem of a person - Simply listener while one vents various feelings or emotions. - 8e or she may interact as the need arises. 4. Personal Strategies. - <efers with dealing directly with one#s emotions - 8ow to manage your own problems and stresses - !lternate ways to reduce stress and enhance their well being while balancing responsibilities between wor$ and time spent at home. H$%3*R$,'1 !"R%!",3$<" *2 M"&3'1 $11&"%% '#/'&,$"&3 3$M"% I sic$ness indicated displeasure of the gods and in fact was a punishment for sins and wrong doings. I persons with mental disorder were viewed as being either demonic or divine depending on their behavior. +ivine worshipped and adored +emonic ostraci1ed, punished and sometimes burned. I !ristotle attempted to relate mental disorders to physical disorders and developed his theory that emotions were controlled by the amount of blood, water and yellow and blac$ bile of the body. 5hese four (4 substances or humors correspond to emotions of happiness, calmness, anger, sadness. Imbalance of the four humors causes mental illness. 5reatment is aimed at restoring imbalance through blood letting, starving or purging. "'R1; ,HR$%3$'& "R' (%-%DDD !+ D primitive beliefs and superstitious were strong D diseases are blamed and demon#s and mentally ill are possessed. D priest preformed exorcisms to rid the persons of evil spirits. D if failed, incarceration in dungeons, flogging, starving and other brutal treatment were used. R"&'$%%'&," (%,DD-%?DD D persons with mental illness were distinguished from criminals in >ngland D harmless were allowed wonders the countryside or live in rural communities. D /dangerous lunatics0 where still thrown in prison, chained and starved. 154 I 8ospital of St. 2ary of Eethlehem was official declared as the first hospital for the insane. 1 5 I visitors at the institution were charged for a fee for the privilege of viewing and ridiculing the inmates, who were seen as animals, less than humans. +#/!"R$*D *2 "&1$0HM"&3 '&D ,R"'3$*& *2 M"&3'1 $&%3$3.3$*&

1 !" I period of enlightenment concerning persons with mental illness. I establishment of asylum is credited to Phillippe Pinel in "rance and 7illiam 5u$es in >ngland. '%;1.M I a safe refuge or haven offering protection I this movement began the moral treatment of the mentally ill. 1#"2 $ 1## I +orothea +ix began a crusade to reform the treatment of mentally ill in the ).S. I +ix is instrumental in opening ,' state hospitals that offered asylum to the suffering. She believed that society has obligation to persons who are mentally ill and promoted adeCuate shelter, nutritious food and warm clothing. I the period of enlightenment was short lived. J within %DD yrs. after the%st !sylum was established state hospitals were in trouble. J attendants were accused of abusing clients J rural location of hospitals were viewed as isolating patients from family and their homes. J /insane asylum0 too$ on a negative connotation, rather than a protective haven. ,#/%$0M.&D 2R".D and 3R"'3M"&3 *2 M"&3'1 D$%*RD"R% I period of scientific study and treatment of mental disorders began with Sigmund "reud (%F6? %G,G I >mil Kraepolin (%F6? %G'? began classifying mental disorders according to their symptoms. I >ugene Eleuler (%F6@ %G,G coined the term /schi1ophrenia.0 I "reud challenged the society to loo$ at human dLbeings ob*ectively and studied the mind and its disorder and their treatment. D#/D"<"1*!M"&3 *2 !%;,H*!H'RM',*1*0; 1950 I development of psychotropic drugs (drugs used to treatment illness I chlorproma1ine (5hora1ine antipsychotic drug. I 9ithium antimanic drug !fter %D yrs3 I 2onoamine oxides inhibitor antidepressants I 8aloperidol (8aldol antipsychotic I 5ricyclic !ntidepressants +rugs reduced agitation, psychotic thin$ing and depression improved the condition of the patient.

"#/H$%3*R; *2 !%;,H$'3R$, &.R%$&0 $& 3H" !H$1$!!$&"% History of the Hospital 5he ;ational -enter for 2ental 8ealth (;-28 was established thru Public 7or$s !ct ,'6F. It was first $nown as I;S)9!< PSM-8(P!5I- 8(SPI5!9, situated on a hilly piece of land in Earrio 2auway, 2andaluyong, <i1al and was formally opened on +ecember %@, %G'F. 5his hospital was later $nown as the ;!5I(;!9 2>;5!9 8(SPI5!9 (n ;ovember %', %GF?, it was given its present name ;!5I(;!9 ->;5>< "(< 2>;5!9 8>!958 thru 2emorandum -ircular ;o.4F of the office of the President. (n Hanuary ,D, %GF@, ;-28 was categori1ed as a Special <esearch 5raining -enter and hospital under +epartment of 8ealth. 5oday, ;-28 has an authori1ed bed capacity of 4,'DD and a daily average of ,,4DD in-patients. It sprawls on a 4?.@ hectare compound with a total of ,6 Pavilions. -ottages and 6' 7ards. 5he -enter has an authori1ed personnel component of %,GG,, consisting of %%? +octors, ,@6 ;urses, ?66 ;ursing !ttendants, ?6% !dministrative Staff and %G? 2edical !ncillary Personnel. 5he ;-28 is a special training and research hospital mandated to render a comprehensive ( preventive, promotive, curative, and rehabilitative range of Cuality mental health services nationwide.

It also gives and creates venues for Cuality mental health education, training and research geared towards hospital and community mental health services nationwide. R*1" *2 3H" !%;,H$'3R$, &.R%" 1. Creator of the %herapeutic En&ironment It is an environment allows the client to3 <elax "eels secure physically and emotionally Is not afraid to share thoughts and feelings -an be achieved when the people around the client are3 8onest Sincere "riendly yet firm ;on*udgmental 5here is no cure to mental illness but we can provide support system, continuous medication, and therapeutic environment to restore to its optimum capacity. 2. %echnical 'ursing (ole <efers to our performance to nursing s$ills and procedure >xample3 -hec$ing of vital signs Perform treatment procedures !dminister medications 2a$es physical assessment ,ommunication skillE 2ost important s$ill that we need (pen self must be wide 3. %herapist !chieved by your performance of your treatment modalities to the clients. 5he nurse uses the principle of psychotheraphy to help the client of his behavior, feelings and thoughts. !ssist the client in finding solutions to his problems. 5he nurse must $now to assess thoroughly the level of readiness of the patient to coordinate in the activity. N +o not as$ Cuestions starting with why. 4. Sociali)ing *gent 7hen you allow the patient to participate in group activities. 5. Counselor !chieved when nurse shows active listening, and giving the client options, and possible solution to their problems. 7hen the nurse assists the patient in identifying stressors that can cause anxiety and helps client find acceptable outlets of anxiety. +. %eacher 7hen nurse gives instruction or educates the client about certain medications or therapeutic intervention. 7hen the nurse teaches the client to learn new s$ills such as game, song, dance, step or when the nurse becomes a role model of acceptable behavior. 3ransference patient client therapist - attribute our feelings to other person. ,ounter transference nurse patient therapist @. Parent Surrogate !cts as parent substitute of the patient 7hen the nurse performs functions for the client originally provided by the mother such as bathing, dressing, or bac$rubs. ME'%*, I,,'ESS - Is a complex problem and is uniCue response involving an individuals personality as it interacts with his environment at a time when he is particularly vulnerable to stress - 5he study of the individual#s life experiences with consideration of genetic physiological interpersonal and cultural factors is a reasonable approach. 3he following are contributing factors -predisposing and precipitating/ to mental illnessF ,'.%"% *2 M"&3'1 D$%*RD"R% $&,1.D"F

+#9# !R"D$%!*%$&0 2',3*R% - -onditions in which ma$e the individual susceptible to precipitating causes and thus more li$ely to develop psychosis. Inheritance !ge-adolescence, menopause, senile periods Sex female ( more mental disorder before 2ale (more mental disorder now >nvironmental and social factors3 - financial depression - war - family relationships - environmental factors - family organi1ation bro$en homes "amily 8ealth >nvironment "amily !ttitudes.practices.values Social class differences differences between the poor and the rich. develop $nferiority ,omple8 "amily control patterns - authoritarian - lax - ambivalent - overly permessive "amily Placement and roles - oldest - youngest - prettiest - ugliest Segregations sororities Social change (forced retirement -ultural conflicts. +#: !R",$!$3'3$&0 2',3*R% - exciting cause of psychiatry disorder - they are highly emotional and critical situations +#:a !hysical !recipitating causesF Infection "ever >xhaustion Intoxicants narcotics, alcohol, bromides, barbiturates Een1edrine (rganic conditions 5rauma +:b !sychic !recipitating ,auses - dynamic motivating and damaging causes of mental illness not easily identified or understood (emotions strong emotions conflicts between conscious and unconscious drives disappointment re*ection deprivation marital difficulties failure in one#s ambition inferiorities economic reverses '-(SI'. P(OCESS - ! systematic process or a six step problem solving approach to nursing that also serves as an organi1ational framewor$ for the practice of nursing. - It sets the practice of nursing in motion and serves as a monitor of Cuality nursing care. %3"!% *2 &.R%$&0 !R*,"%% 9# '%%"%%M"&3 the collection of data about a person, family, or group by the methods of observing, examining, and interviewing. 3)* 3;!"% *2 D'3' %ubjective data obtained from the client, family members, or significant others

provide information spontaneously during direct Cuestioning or during health history involves interpretations of information by the nurse

*bjective data information obtained verbally from the client, as well as the results of3 Inspection Palpation Percussion !uscultation G$&D% *2 '%%"%%M"&3 9# ,omprehensive assessment includes all the dimensions of a person E completed in collaboration with other health care professionals E includes data related to the clients biological, cultural, spiritual, and social needs !hysical e8amination performed to rule out any physiologic causes of disorders such as anxiety, depression, or dementia :# 2ocused assessment the collection of specific data regarding a particular problem as determined by the client, a family member, or a crisis situation "8ampleF suicide attempt # %creening assessment includes the use of a specific screening instrument to evaluate data regarding a particular problem. During any assessment, the psychiatric nurse uses the ff#F %. &ursing History and assessment tool uses to obtain factual information :# *bserve client appearance and behavior # "valuate the clients mental or cognitive status '%%"%%M"&3 D'3' ,*11",3$*& - discussion of the data collected by the nurse during a comprehensive assessment conducted in the psychiatric setting. 9# 'ppearance - physical characteristics, apparent age, peculiarity of dress, cleanliness, and use of cosmetics 2acial "8pression is a manner of non verbal communication in which emotions, feelings and moods are related. :# 'ffect, or "motional %tate 'ffect the outward manifestation of a person#s feelings, tone, or mood. - !ffect and emotion are commonly used interchangeably - !s a nurse you should assess congruently the language and the facial e8pression - <elationship between the thought and process is of particularly significance # +ehavior, 'ttitude, and ,oping !atterns 2actors for assessmentF a# >xhibit strange, threatening, suicidal, self in*uries, or violent behavior. b# >vidence of any unusual mannerism or motor activity such as grimacing, tremors, tics, impaired gait, psychomotor retardation or agitation. c# !ppear friendly, embarrasses, evasive, fearful. <esentful, angry, negativistic, or impulsive. d# Eehavior overactive or underactive. 4# ,ommunication and %ocial %kills - the manner in which the client tal$s enables us to appreciate difficulties with his thought processes - It is desirable to obtain a verbatim sample of the stream of speech to illustrate psychopathologic disturbances. 2actors to be consideredF 5hey spea$ coherently 5he rate of speech slow, retarded, or rapid -lients whisper or spea$ softly, or do they spea$ loudly or shout. 5here is delay in answers or responses, or so clients brea$ off their conversation in the middle of a sentence and refuse to tal$ further. 5hey repeat certain words and phrases over and over 2a$e up new words that have no meaning to others. 5heir language obscene 5heir conversation *ump from one topic to another 5hey stutter, lisp, or regress in their speech 5hey inhibit any unusually personality traits or characteristics that may interfere with their ability to sociali1e with others or adapt to hospitali1ation 7hat cultural group or groups do they identify.

$mpaired ,ommunication E "ollowing terminology is commonly used3 a# +locking sudden stoppage in the spontaneous flow or stream of thin$ing or spea$ing for no apparent external or environmental reason. b# ,ircumstantiality the person gives much unnecessary detail that delays meeting a goal or stating a point. - commonly found in clients with manic disorder and clients with some cognitive impairment disorders - Individuals who use substances may also exhibit this pattern of speech. c# 2light of $deas over productivity of tal$ and verbal s$ipping from one idea to another. 5he ideas are fragmentary, although tal$ is continuous. d# !erseveration is the persistent, repetitive expression of a single idea in response to various Cuestions. e# <erbigeration describes the meaningless repetition of incoherent words or sentences. f# &eologism a new word or combination of several words coined or self invented by a person and not readily understood by others g# Mutism refers to the refusal to spea$ even though the person may give indications of being aware of the environment. - occur from conscious or unconscious reasons. =# ,ontent of 3hought - alterations in thought processes freCuently sees in the psychiatric clinical setting. - -an be related to a functional emotional disorder or to an organic condition. a# Delusions E are fixed false beliefs not true to fact and not ordinarily accepted by other members of the person#s culture. - they cannot be corrected by an appeal to the reason of the person experiencing them 5he client believes that he or she is the ob*ect of environmental attention or is being singled out for harassment. 5he client believes his or her feelings, thoughts, impulses, or actions are controlled by an external source. 5he client denies reality or existence of self, part of self, or some external ob*ect. 5he client feels unworthy, ugly, or sinful ! client experiences exaggerated ideas of her or his importance or identity. 5he client entertains false beliefs pertaining to body image or body function. "alse feeling of remorse or guilt. E somebody inserted in his mind E somebody loo$ to withdraw his thought E reacts, interact Cuic$ly and believes that everybody can read his mind. E pathologic feeling of *ealousy that his partner is unfaithful EEhears present false voices(not feeling of over suspiciousness E seeing (not present E smells (not present E taste (not present E feels(movement

9# Delusions of reference or persecution :# Delusion of alien control # &ihilistic delusion 4# Delusion of selfE deprecation =# Delusion of grandeur @# %omatic delusions 7# Delusion of self E accusation H# 3hought control delusions a# thought insertion b# thought withdrawal c# thought broadcasting ?# Delusion of $nfidelity 'uditory hallucination 95# 9# !aranoid Delusion :# <isual hallucination #*lfactory hallucination 4#0ustatory hallucination =# 3actile hallucination

b# Hallucinations E sensory perceptions that occur in the absence of an actual external stimulus. %/PES O0 1*,,-CI'*%IO'S

c#

DepersonaliAation E feeling of unreality or strangeness concerning self, the environment or both. - these people may feel they are /going cra1y0 - causes includeF a. prolonged stress b. psychological fatigue c. substance abuse

d# *bsessions - insistent thoughts, recogni1ed as arising from the self, usually regarded by the client as absurd and relatively meaningless, yet persistent despite his or her endeavors to be rid of them. ,ompulsions E insistent, repetitive, intrusive, and unwanted urges to perform an act contrary to one#s ordinary wishes or standards. *rientation - ability to grasp the significance of their environment, an existing situation, or the clearness of conscious processes. e#

@#

1"<"1% *2 *R$"&3'3$*& '&D ,*&%,$*.%&"%% 9# ,onfusion E disorientation to person, place, or time, characteri1ed by bewilderment and complexity E +isturbance in perception of thought that is slight to moderate in degree, usually owing to physical or chemical factors producing functional impairment of the cerebrum. - a state in which the client does not react to or is unaware of the surroundings. - the client may be motionless and mute, but conscious. - -onfusion accompanied by altered or fluctuating consciousness. - disturbance in emotion, thought, and perception is moderate to severe. >x. Infections, toxic states, head trauma E 9oss of consciousness

:# ,louding of consciousness

# %tupor

4# Delirium

=# ,oma

7#

Memory

the ability to recall past experiences.

Recent Memory ability to recall events in the immediate past and up to ' wee$s previously. - loss of memory may be seen in clients with dementia, delirium, or depression. 1ongEterm Memory is the ability to recall remote past experiences such as place of birth, names, of school attended, occupational history, etc. - loss of memory is due to a physiologic disorder resulting in brain dysfunction. Memory defects may result fromF a# lac$ of attention b# difficulty with recall c# or any combination of these factors Disorders of MemoryF 9# Hyperamnesia abnormally pronounced memory :# 'mnesia E loss of memory # !aramnesia falsification of memory H# $ntellectual 'bility - ability to use facts comprehensively ?# $nsight Regarding $llness or ,ondition - $nsight self understanding, or the extent of one#s understanding about the origin, nature, and mechanisms of one#s attitudes and behavior - Insightful clients are able to identify strengths and wea$nesses that may affect their response to treatment. 95# %pirituality - by learning to ta$e a spiritual history and understand a client#s beliefs, values, and religious culture - nurses become better eCuipped to evaluate whether these beliefs and values are helping or hindering the client. 99# %e8uality - express any concerns regarding sexual identity, activity, and function. - !ge and sex of the clinician may affect the response given. 9:# &eurovegetative ,hanges - the client changes in psychophysiologic functions such as3 a# sleep patterns b# eating patterns c# energy levels d# se8ual functioning e# bowel functioning - usually complain of insomia or hypersomia, loss of appetite or increased appetite, loss of energy, decreased libido, and constipation, which are all signs of neurovegeattive changes. %leep !attern $nsomnia a symptom that have many different causes, and it occurs often in clients with psychiatric disorders. 'cute or primary insomnia often caused by emotional or physical discomfort such as chronic stress, hyperarousal, poor sleep hygiene, environmental noise, or *et lag. - it is not due to the physiological effects of a substance or a general medical condition. %econdary insomnia related to a psychiatric disorder such as depression, anxiety, or schi1ophrenia& general medical or neurologic disorders& pain& or substance abuse. D*,.M"&3'3$*& *2 '%%"%%M"&3 D'3' ,riteria for the documentationF %. *bjective the nurse documents what the client says and does by stating facts and Cuoting the client#s conversation. '. Descriptive the nurse describes the client#s appearance, behavior and conversation as seen as heard. ,. ,omplete +ocumentation of examinations, treatments, medications, therapies, nursing interventions, and the client#s reaction to each should be made on the client#s chart. - what should be done by the client. - Samples of the clients writing should be preserved. 4. 1egible with the use of acceptable abbreviations only and no erasures. - correct grammar and spelling are important, and complete sentences should be used. 6. Dated important to note the day and the time of each entry. ?. 9ogical presented in logical seCuence.

@.

%igned should be signed by the person ma$ing the entry.

&.R%$&0 D$'0&*%$% Is a statement of an e8isting problem or potential health problem that a nurse is both competent and licensed to treat. ,linical judgment about individual, family, or community responses to actual or potential health problems. life processes. Provides basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. Psychiatric nurse analy1es the assessment data before determining a nursing diagnosis. !%;,H$'3R$,E M"&3'1 H"'13H &.R%$&0 -!MH&/ D$'0&*%3$, %;%3"M -organi1ed F human response process3 %. activity '. cognition ,. ecological 4. emotional 6. interpersonal ?. perception @. physiologic F. evaluation ,ues are facts collected during the assessment process. $nferences are *udgments that the nurse ma$es about the cue#s 'ctual &ursing Diagnosis based on clinical *udgment of the nurse on review of validated data. Risk &ursing Diagnosis is based on clinical *udgment of the client#s degree of vulnerability to the development of a specific problem. )ellness nursing diagnosis is based on clinical *udgment about an individual, group, or community transitioning from a specific level to higher level of wellness. %yndrome &ursing Diagnosis cluster of actual or high ris$ diagnoses that are predicted to be present because of a certain event or situation. 2',3*R% *2 &.R%$&0 D$'0&*%$% <alidating data valid data can be assumed to be factual and true. :alidation of data may occur by3 o <echec$ing data collected o !s$ing someone to analy1e the data o -omparing sub*ective and ob*ective data o !s$ing the client to verify the data. 5o determine if a sufficient number of cues are present to confirm a nursing diagnosis, the nurse should consult a list of defining characteristics for the diagnosis suspected. ;ursing diagnosis should not be written in terms of cues, inference, goals, patient needs, or nursing needs. ;ursing diagnostic statements should not be stated or written to encourage negative responses by healthcare providers, the client, or the family.

*.3,*M" $D"&3$2$,'3$*& >xpected outcomes are measurable client oriented that are realistic in relation to the client#s present and potential capabilities. Involve the other member of the healthcare team formulate the outcomes. ;urse and multidisciplinary team members understand the problems identified by the client and the outcomes the client hopes to achieve. >xpected outcomes serve as a record of change in the client#s health status. *utcomes or measurable client oriented goals are both short term and long term& they should be clearly stated by the nurse and should describe the expected end result of care. *utcomes are conseCuences of a treatment or en intervention. (utcome statement should be directly related to the nursing diagnosis. !1'&&$&0 5o guide therapeutic intervention and achieve expected outcomes. Is individuali1ed, identifies priorities of care, identifies effective interventions, and includes client education to achieve the stated outcomes. 5he responsibilities of psychiatric nurse, client, and multidisciplinary team members are indicated.

+ocumentation of the plan of care should allow access to it by team member and modification of the plan as necessary. Priority setting considers the urgency of the problem or need and its impact on the client. 2aslow#s hierarchy of needs usually the guide for problem solving during formulation of plan care.

0eneral principles to remember when writing care plansF Individuali1e or personali1e the plan of care according to the nursing diagnosis or problem list )se simple, understandable language to communicate information about the client#s care Ee specific when stating nursing action. Prioriti1e nursing care State short and long term goals. Indicate the responsible party for each client intervention. $M!1"M"&3'3$*& )ses of various s$ills to implement the plan care Implement of care based on3 o nursing theory o establish trust with the client o promotes the client#s strengths o sets mutual goals with the client to promote wellness. Intervention used by the nurses in clinical setting: -ounseling interventions to help the client improve or regain coping abilities. 2aintenance of a therapeutic environment or milieu Structured interventions to foster self-care and mental and physical well-being. Psychobiologic interventions to restore the client#s health and prevent future disability. 8ealth education -ase management Interventions to promote mental health and prevent mental illness. Additional intervention used by clinical nurse specialist3 Individual, group, and child therapy Pharmacologic agent prescription -onsultation with other health care providers "<'1.'3$*& "ocuses on the client#s status, progress toward goal achievement, and ongoing reevaluation of the care plan. Four possible outcome may occur: %. 5he client may respond favorably or as expected to nursing interventions. '. Short term goals may be met but long term goals may remain unmet. ,. 5he client may be unable to meet or achieve any goals. 4. ;ew problems or needs maybe identified !ll members of the multidisciplinary treatment team, as well as the client, should be encouraged to provide feedbac$ regarding the effectiveness of the plan of care. !s a result of evaluation process, the care plan is maintained, modified or totally revised. %3'&D'RD *2 ,'R" 3he psychiatric mental health nurseF %tandard $# 'ssessment collects client health data. %tandard $$# Diagnosis analyses the assessment data in determining diagnosis. %tandard $$$# *utcome $dentification identifies expected outcomes individuali1ed to the client. %tandard $<# !lanning develops a plan of care that is negotiated among the client, nurse, family, and health care team and prescribes evidence-based interventions to attain expected outcomes. %tandard <# $mplementation implements the interventions identified in the plan of care. %tandard <a# ,ounselingF uses counseling interventions to assist clients in improving or regaining their previous coping abilities, fostering mental health, and preventing mental illness and disability. %tandard <b# Milieu therapyF

provides, structures, and maintains a therapeutic environment in collaboration with the client and other health care providers. %tandard <c# !romotion of %elf ,are 'ctivities F structures interventions around the client#s activities of daily living to foster self-care and mental and physical well-being. %tandard <d# !sychobiologic $nterventionsF uses $nowledge of psychobiologic interventions and applies clinical s$ills to restore the client#s health and prevent future disability. %tandard <e# Health 3eaching - through health teaching, assist clients in achieving satisfying, productive, and healthy patterns of living. %tandard <f# ,ase Management - provides case management to coordinate comprehensive health services and ensure continuity of care. %tandard<g# Health !romotion and Health Maintenance3 employs strategies and interventions to promote and maintain health and prevent mental illness. %tandard <$# "valuation

.nit $$ Development of the !erson Personality I refers to the aggregate of the physical and mental Cualities of the individual as these interact in characteristic fashion with his environment. I expressed through behavior. It is the sum total of one#s behavior I it is complex, dynamic and uniCue. "actors that influence Personality a. 8eredity b. >nvironment c. 5raining 3heories of !ersonality %. Psychoanalytic 5heory Sigmund "reud the father of psychoanalysis who stresses that early childhood experiences is important in the development of personality !ersonality ,omponent a. Id reflects basic or innate desires such as pleasure see$ing behavior, aggression and sexual impulses. I see$s instant gratification, causes impulsive, unthin$ing behavior and has no regard for rules or social convention. I /pleasure principle0 I developed during infancy. b. Superego I reflects on moral and ethical concepts, values and parental and socials expectations I the /conscience0 I the /censoring force of the self0 I developed during preschool age c. >go I the balancing or mediating force between the id and superego. I represent mature and adaptive behavior that allows person to function successfully I the integrator of personality I operates on reality principle

I developed during toddler hood Strict Superego leads to rigid, compulsive, unhappy person. 7ea$ or +efective Superego leads to antisocial behavior, hostility, anxiety or guilt.

'. Interpersonal 5heory (8arry S. Sullivan a. Infancy - Self-concept is developed - 2othering role is achieved by perception of the child as /=ood me0 it not /Ead me0. - If satisfaction and security of the child is achieved, he views himself as a worth while individual& but if an infant severely deprived, he develops /;ot me0 attitude. - 5ype of play3 Solitary Play b. 5oddlerhood - >mphasi1ed the sense of P(7>< the child feels as he attempts to control himself and others. - E>8!:I(<!9 5<!I5S3 %. 5oddlers are headstrong and negativistic (their favorite word is /;o0 . '. 5oddlers are naturally active, mobile and curious which ma$e them vulnerable to accident. ,. 5emper tantrums are common. 4. 5ype of play3 Parallel Play c. Pre-schooler - -haracteri1ed by3 -onsensual :alidation there is the use of language which can be consensually validated by others. - E!8!:I(<!9 5<!I5S %. 9ove to watch adults and imitate their behaviors. '. 5hey are very creative and curious (5heir favorite word is /78M0 . ,. 5hey love to tell /lies0, to brag and boast in order to impress others. 4. 5hey are very imaginative& imaginary playmates are common. 6. 5hey love offensive language. ?. Auestion about sex should be answered honestly at the level of their understanding. @. 5ype of play3 Associative Or Cooperative Play

d. Schooler %. Huvenile >ra3 (? %D years old %.a. 5he child turn away from his parents as being the most significant people in his life and loo$s to peers of the same sex to fill the functions of providing him sense of security and companionship. %.b. Period of gang loyalties %.c. -hild acCuire the very important interpersonal tools3 - !bility to complete - !bility to compromise '. Preadolescence (%% %' years old '.a. -hild develop the ability to experience intimacy. '.b. ,hum Relationship an intense love relationship with a particular person of the same sex whom the child perceives to be very similar to himself. e. !dolescence (%' %F years old %. Known as the >arly !dolescence. '. >stablish relationship with the opposite sex. ,. !dolescence experiences already sexual urges termed by Sullivan as 1.%3# 4. +evelopment of heterosexual relationship. f. Moung of >arly !dulthood ('D -4D years old %. Known as 9ate !dolescence. '. 5here is incorporation of I;5I2!-M (which developed during pre-adolescence with a chum and 1.%3 (which developed in early adolescence in heterosexual relationship. I humans are essential social being I human personality determined in the context of social interactions with other human beings. I early life experiences with parents, especially the mother, influence an individual development throughout life.

,. Eehavioristic 5heory I behavior can be changed by a system of reward and punishment. I derived form the wor$s of Ivan Pavlov, Hohn 7atson and E.". S$inner. I concerned only with observable behavior not with intra psychic or interpersonal processes or the personality itself. I all behavior are responses to a stimulus or stimuli from the environment. Ithere are conseCuences that results from behavior broadly spea$ing reward and punishments I behavior that are rewarded with reinforces tend to recur. I P(SI5I:> <>I;"(<-><S that follow a behavior increase the livelihood that the behavior will recur. I ;>=!5I:> <>I;"(<-><S that are removed after a behavior increases the livelihood that the behavior will recur. 4. -ognitive 5heory (Hean Piaget IPiaget believed that an individual has a genetically predetermined intellectual or cognitive potential that develops according to the Cuality of child#s interaction with the environment =>;>5I- >PIS5>2(9(=M the study of the nature of thought, especially the development of thin$ing. S-8>2! an innate $nowledge structure which initially enable the person to behave an interact with the environment. -(=;I5:> +>:>9(P2>;5 the development of the ability to thin$, remember and solve problems. ' P<(->SS>S (" -(=;I5I:> +>:>9(P2>;5 %. !ssimilation incorporation of a new $nowledge to the existing $nowledge. '. !ccommodation modification of the existing body of $nowledge in a person based on the newly acCuired $nowledge. 5he existing body of $nowledge maybe changed refined a reinforced. "()< P><I(+S (" -(=;I5:> +>:>9(P2>;5 %. Sensorimotor D ' years old /!ssimilation vs. !ccommodation0 a. -ognitive +evelopment a.%. !ssimilation the process by which an individual acCuires information or $nowledge or by which experiences are integrated into an existing scheme. a.' !ccommodation process of creating a new scheme by modifying an existing scheme after an individual#s interaction with the environment. ' Pre (perational 5hought (' ? years old Stage I 3 Pre-conceptual 5hought (' 4 years old Stage II3 Perceptual Intuitive ( 4 ? years old a. Stage I is characteri1ed by "gocentricity expressed in relating everything to himself. b. Stage II is characteri1ed by3 reason can be given for belief and reactions but still considered pre-logical and termed as pre-operational intuitive behavior. c. Hean Piaget described thin$ing of children as3 c.%. "gocentric thoughts are primarily centered to themselves c.'. Irreversible inability to go bac$ and rethin$ a process or concept or to conserve such process or concept ,. -oncrete (peration (@ -%% years old ;ot egocentric able to understand cause and effect in concrete situation but cannot yet reason hypothetically. Major "vents occurring during this stage according to !$'0"33 a. -onservation refers to the retention of the same properties even if they are arranged differently or reshaped. b. <eversibility refers to completion of certain operation in the reverse order and ending up the same. - Development proceeds from Pre-Logical to Logical Concrete thought - +eals with visible concrete ob*ects and relationship. - Increase intellectual and conceptual development. - !ccommodation is developed modifies ideas to fit reality. Eelieves that animate and remote inanimate ob*ectives (sun, moon have life. - Intellectual development proceeds and relations and can handle numbers. 4. "ormal (peration (%% %6 years old - >mploys logical reasoning - +evelopment proceed from Logical Concrete to Logical

%olution to all kinds of categories of problem# - !bstract thin$ing is fully utili1ed. - +evelops capacity to use hypothetic reasoning and considers all possible solutions problem. Eelieve that only plants, animal and people have life. - 9ogical, mathematical and scientific reasoning are completed %3'0"% *2 0R*)3H and D"<"1*!M"&3 a#/ !sychose8ual Development -%igmund 2reud/ I. (ral Phase (% % O yrs old 2outh J erogenous 1one& area of satisfaction and pleasure. Period of complete dependence. =reatest need security II. !nal Phase (% O J , yrs old !nus site of tension and sensual gratification Primary source of pleasure is elimination or retention. -ritical period of toilet training and urination. =reatest need Power "irst experience with discipline and authorities. <etention and expulsion (forcing out are experienced as pleasurable especially because these functions come under the child#s control. -hild uses this new s$ill to pleasure or annoy parenting adult. Eowel control 3 %F months +aytime Eladder -ontrol3 ' O yrs. old ;ighttime Eladder -ontrol3 , yrs. II. Phallic Stage (, ? yrs old =enital <egion erogenous 1one& the primary source of pleasure. Indicative Eehaviors a. 2asturbation b. "antasy c. Play activities, experimentation with peers and Cuestioning of adults about sexual topics. =irls develop penis envy =irls3 >le$tra -omplex Eoys3 (edipal -omplex Eecause of the desire to posses parent of the opposite sex, the child develops guilt feelings and fear of punishments by parent of the same sex (castration complex Imitation of parent of the same sex or internali1ation of the traits. I:. 9atency (? %' yrs old Stage of development mar$ed by expanding peer relationship. 9ibido is channeled into school, home, organi1ation activities, and hobbies relationship with peers. 5ime for increased intellectual activity. Significant other are the school and neighbors. :. =enital Phase Puberty -hild becomes sexually nature 9ibido is centered again to the genital area -haracteri1ed as establishment of relationship with the opposite sex b#/ !sychosocial 3heory -"rik "rikson/ %. Infancy 3 5rust vs. 2istrust 3 5as$3 +evelopment of trust in oneself, other people, the environment and meaningfulness of existence. 5rust3 7hen needs are meet consistently by mother or primary caregiver. 5he child will be able to relate well with others, share and has optimism and hope in life. 2istrust3 If needs are not met, child develops mistrust, hostility, suspiciousness, engages in excessive testing behaviors later in life, fears affection and becomes withdrawn. '. !utonomy vs. Shame and +oubt !utonomy3 Support and encourage the child to explore the environment 3 Supportive and consistent toilet training leads to development of self confidence that he can control himself and the environment.

,.

4.

6.

?.

@.

Shame and +oubt3 If the mother re*ects child#s attempt to explore the environment and the parents# lac$ of confidence to the abilities of the child. -hild becomes insecure and learns to become ashamed of himself. Initiative vs. =uilt 2a*or 5as$3 !ccomplishment proper sex rule identification resulting to resolution of (edipus complex. "ailure leads to improper sex rule identity. Initiative to explore and reach security outside the home could lead to guilt. 5he sense of /badness0 may develop which could restrict initiative. -hild is ready to learn Cuic$ly and to mature and to cooperate successfully with others. - 2reIuent 'sking $s $nitiative Social S$ill3 -ooperative Play Industry vs. Inferiority 2a*or 5as$s3 !cCuisition of competence -hild is halfway outside the family world. 5his is the active period of sociali1ation. -hild wor$s with others and produce thing which should be recogni1ed to prevent inferiority. !eer most important person. 5he child learns to win recognition by finishing tas$s to completion, producing things, solving problems. Identity vs. <ole +iffusion 2a*or 5as$s3 !cCuisition of fidelity. <apid physical development advent of sexual maturity precipitate. Diffusion the sense of one#s own identity or diffusion of identity because of attempt to be too many person. Search for self identity, period of rapid physiologic or psychologic revolution. >mancipation from family, heterosexual relationship, develops ideology and philosophy of life& highest incidence of Schi1ophrenia. Intimacy vs. Isolation >stablishment of friendship and eventually a satisfying marriage. ,haracteristicF 8uman closeness and sexual fulfillment. "orms mutually regulating wor$ procreation and recreation. !rrives at wor$ing philosophy of life. 5olerant. 8as a mastered environment. =enerativity vs. Self !bsorption and Stagnation 2a*or 5as$s3 !cCuisition of ability to care. 0enerativity J is reflected in the individual establishments and guiding the next generation. 5he person is productive and creative in both career and family. 5here is willingness to assume responsibility for others.

F. Integrity vs. +espair $ntegrity is achieved when the individual accepts responsibility for what his life has been and finds it has worth. ,haracteristicsF 7isdom is achieved. Period of <eminiscence characteri1ed by a unifying philosophy for life. )nit III - 5he Interacting ;urse Patient <elationship '# 3he ,ommunication !rocess %. "orms (f -ommunication a# &*& <"R+'1 ,*MM.&$,'3$*& actions or behaviors that communicate a message without spea$ing. >xample may include facial expressions, body language, posture, hand gestures of dress. 5he use of space and territory is a form of non verbal communication. 5he proximity a person maintains to another person or group in an expression of interpersonal communication. =eneral Principles3 ;on verbal communication is multichanneled ;on verbal communication is relatively spontaneous ;on verbal communication is relatively ambiguous ;on verbal communication may contradict verbal messages ;on verbal communication is very culture-bound 5erms to Know3 Kinesics the study of communication through body movements. Proxemics - the study of people#s use of interpersonal space.

Personal Space is a 1one of space surrounding a person that is felt to /belong0 to that person. 5erritoriality the mar$ing off and defending of certain areas as their own. Paralanguage refers to how something is said rather than what is said.

Interpersonal +istance Pone Public distance (%' feet and beyond for actors, total strangers, important officials Social +istance ( 4-%' feet for social gatherings, friends and wor$ situations Personal +istance (%F inches 4 feet close friends Intimate +istance ( D-%F inches parents and children, lovers, husband and wife b# <"R+'1 ,*MM.&$,'3$*& the transmission of a message using the spo$en and written language. +#9# 3herapeutic communication that pertains to treatment and healing. Important elements contributing to the establishment of therapeutic relationship are listening, empathy and genuineness. - intended to help the client to practice new ways of feeling and acting, gradually leading to the development of both courage and the ability to ta$e responsibility for their actions in socially acceptable ways. =oals of 5herapeutic -ommunication3 %. 5o obtain useful information '. 5o show caring ,. 5o help patient understand himself 4. 5o relieve stress 6. 5o provide information ?. 5o teach problem-solving s$ills @. 5o encourage acceptance of responsibility F. 5o encourage activities of daily living 5herapeutic -ommunication 5echniCues 5>-8;IA)> >QP9!;!5I(; %.silence Indicates acceptance and understanding of patient#s immediate needs '. accepting Indicates the nurse is listening and understands what patients is saying ,. =iving recognition Show positive regard to patient 4. offering self -ommunicates support to a patient unable to communicated conveys message that the nurse thin$s the patient is worthwhile and that she accept him as he is. )sed to encourage patient to tal$ >ncourages patient to tal$ 8elps patients arrange his ideas in a logical manner !n attempt to verify the nurse#s perception of the patient#s verbal and non-verbal message. :erifies the patient#s perception and ascertains his behaviors !ids in helping patient#s to focus on the communication topic 8as a prompting and encouraging effect and focuses on the communication topic >Q!2P9>

/Mea.0 /)h hmm..0 /I follow what you nodding0 /=ood morning, 2r. Q I noticed you#ve combed your hair.0 /I#ll sit with you awhile.0 /I#ll stay here with you.0 /I#m interested in your comfort.0 /Is there something you#d li$e to tal$ aboutB0 /7hat are you thin$ing aboutB0 /=o on...0 /!nd thenR..0 /7hat seemed to lead up toB0 /7as this before or afterB0 /7hen did this happenB0 /Mou appear tense.0 /!re you uncomfortable when you...B0 /I notice that you are biting your lips.0 /It is something li$e..0 /8ave you had similar experienceB0 P /I can#t sleep. I stayed awa$e all night.0 ; /Mou have difficulty at sleeping.0 /5his point seems more loo$ing at closely.0

6. broad opening ?. )sing general leads @. Placing the event in time or in seCuence F. )sing observations3 :alidations

G. >ncouraging description of perception %D. <eflecting

%%. "ocusing

%'. >xploring %,. =iving information %4. Presenting

!scertains the meaning of a patient behavior Provides to focus on reality and $eeps patient oriented Strives to focus on reality and encourages patient to give up his fantasies !n attempt to get patient to rethin$ his ideas. )sed to clear up possible misunderstanding or to see$ information necessary for understanding :erifies the nurse#s perception of the patient#s message on the affective domain >ncourages patients to tal$ -ommunicates support to the patients and that the nurse#s genuine interest in the patient have understand the patient#s message Indicates that the nurse have understand the patient#s message >ncourages patient to thin$ independently

%6. :oicing doubt %?. -larifying

%@.:erbali1ing

%F. >ncouraging %G. Suggesting

/9et#s tal$ more about it.0 /7ould you describe it more clearlyB0 /2y name is R0 /:isiting hours areR0 /I#m ta$ing you to theR0 /I see no one else in the room.0 /5hat sound was a car bac$firing.0 /Mour mother was not here. I#m a nurse.0 /Isn#t the unusualB0 /<eallyB0 /5ell me whether understanding of it agrees with yours.0 /!re you using this word to convey the ideaB0 /It#s not that I understand what you are saying.0 P /I can#t tal$ to or to anyone else. It#s waste of time.0 ; /Is it your feeling that no one understands.0 /7hat are you feeling with regard toRB0 /Perhaps you and I can discover that produces you anxiety.0

'D. Summari1ing

'%. >ncouraging formulation of a plan of action

/8ave I got this straightB0 /Mou#ve said that0 +uring the past hours, you and I have discussedR0 /;ext time this comes up, what might you do to handle itB0

*ther 3herapeutic 3echniIues %.

"8amples

Making *bservations----------------- Mou appear tense. !re you uncomfortable when youRB I notice that you#re biting your lips. It ma$es me uncomfortable when youR

:#

"ncouraging ,omparison EEEEEEEEEEEEEE7as this something li$e RB 8ave you had similar experiencesB

# %eeking ,larification EEEEEEEEEEEEEEEEEEI#m not sure that I follow. 4# !resenting Reality EEEEEEEEEEEEEEEEEEEEEEI see no one else in the room. 5hat sound was a car bac$ firing. Mour mother is not here, I#m a nurse. =# %eeking consensual validation EEEEEEE5ell me whether my understanding of it agrees yours. !re you using this word to convey the ideaB @# <erbaliAing the implied EEEEEEEEEEEEEEE9/ Patient3 I can#t tal$ to you or to anyone. It#s waste of time. ;urse3 Is it your feeling that no one understandsB

:/ Patient3 2y wife pushes me around *ust li$e my mother and sister did. ;urse3 It is your impression that women are domineeringB 7# "ncouraging evaluation EEEEEEEEEEEEEEE7hat are your feelings in regard toRB +oes this contribute to your discomfortB H# 'ttempting to translate EEEEEEEEEEEEEEEPatient3 I#m dead. ;urse3 !re you suggesting that you feel lifelessB or is it that life seems without meaningB Patient3 I#m way out in the ocean. ;urse3 It must be lonely or you seem to feel deserted. ?# %uggesting ,ollaboration EEEEEEEEEEEE Perhaps you and I can discuss and discover what produces your anxiety. E.'. ;on- 5herapeutic - communication that is a barrier to the expression of free expression of feelings. ;on-therapeutic communication may provide disruption to the treatment process

5>-8;IA)> %. Eelittling '. +isagreeing

,. +efending

4. Stereotyped response

>QP9!;!5I(; Statement tents to ma$e light of the patient#s fear and beliefs. <eal feelings not exploited. <esponse which indicates that the nurse believes the patient to be incorrect. It generally relates to the cognitive rather than the affective domain. )sed to repel a verbal attac$. It conveys anxiety in the nurse. It depends nurse#s ego but put patient on the defensive. -ommon statement made without sincerity. Patient recogni1es this and won#t respond anymore. +ifferent sub*ect are introduced to prevent tal$ing about topic that causes anxiety Some reassuring statements are not sincere and may ma$e patient loss confidence to the nurse

>Q!2P9> P /I won#t leave here alive.0 ; /5hat#s ridiculous. Mou shouldn#t thin$ that way.0 P /7hy am I hereB ;othing is being done to me and I#m not getting any better.0 ; /Mou are getting better.0 P /I#ll have my light on for fifteen minutes.0 ; /I# doing the best I can you are the only patient I have.0 P /I#m really worried about my children.0 ; /I $now exactly how you are going through.0 P /I will have >-5 tomorrow. I hope I will get better.0 ; /!re these your drawingsB Mou are good in arts.0 P /7hy are my parents not visiting meB0 ; /+on#t worry& they will soon visit you one of these days.0 P /7hat will I do is I#ll be discharged.0 ; /I#m sure you#ll do if you *ust stay home.0

6. -hanging the sub*ect

?. <eassuring

@. =iving advice

F. !greeing

&on E3herapeutic 3echniIues

5ells the patient what the nurse thin$s the patient should do. 5his suggests that some pressure is being placed on the patient to accept a prescribed course of action. If advice is accepted and situation is improved, the nurse is to be blamed by the patient. It closes communication and be P /I#m afraid the doctor won#t little patient#s concern. It shows discharge me tomorrow.0 no understanding of patient#s ; /I#m sure you are correct. I feeling and leaves no room for doubt he will let you go home further discussion. soon.0 "8amples

9# Rejecting EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE9et#s not discussR

I don#t want to hear aboutR :# Disapproving EEEEEEEEEEEEEEEEEEEEEEEEEEEEEE5hat#s bad. I#d rather you wouldn#tR # !robing EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE5ell me your life historyR ;ow tell me aboutR 4# ,hallenging EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEut how can you be President of the ).S.B If you#re dead, why is your heart beatingB =# 3esting EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE7hat day is thisB +o you $now what $ind of hospital this isB +o you still have the idea thatR @# ReIuesting an e8planation EEEEEEEEEE7hy do you thin$ thatB 7hy do you feel this wayB 7hy did you do thatB 7# $ndicating the e8istence of an e8ternal source EEEEEEEEEEEEEEEEEE7hat ma$es you say thatB 7ho told you that you were HesusB 7hat made you do thatB H# 0iving literal responses EEEEEEEEEEEEEEPatient3 I#m an easter egg. ;urse3 7hat shape, or you don#t loo$ li$e one. ?# .sing denial EEEEEEEEEEEEEEEEEEEEEEEEEEEEEPatient3 I#m nothing. ;urse3 (f course you are something, everybody is somebody. Patient3 I#m dead. ;urse3 +on#t be silly. 95# $nterpreting EEEEEEEEEEEEEEEEEEEEEEEEEEEEE7hat you really mean isR )nconsciously you are sayingR

3herapeutic ,ommunication 3echniIues

9# .sing broad openings open-ended comments or Cuestions and other broad openings can help the client begin, continue, or focus the expression of communication. 5o use broad openings3 a# 7ait for the client to finish his or her message. b# )se phrases such as3 /5ell me about what#s bothering you.0 /8ow are you feeling todayB0 & /7hat does this mean to youB0 /Is there something you would li$e to tal$ aboutB0 /7hat are you thin$ing aboutB0 /7here would you li$e to beginB0 c# =ive client sufficient time to respond. >xample3 Hovie, a ,%-year old married woman, is admitted to a psychiatric unit because of depression and alcohol abuse. -lient3 I shouldn#t be here& this is a mista$e. 7hat#s wrong with meB ;urse3 9et#s start, Hovie, with some basic information. 7hat can you tell me about coming to this hospitalB :# ,larifying 2eelings when clarifying the patient#s feelings3 a. <epeat the feeling tone of the message in your own words, or restate an emotional word or a phrase used by the client.

)se an open, Cuestioning tone of voice& that is, a nondirective and noninterrogating one. c. 7ait until the client responds. >xample3 -lient3 I don#t $now what happened I left the children at the neighbor and went to a bar *ust to see who was there. I wo$e up the next morning in a motel with a strange man (begins to cry, put her clenched fists to her eyes . ;urse3 Mou#re frightened and ashamed because you don#t $now what happened and you wo$e up in strange placeB -lient3 It was so scary. I#m afraid it will happen again. I wouldn#t leave even when my husband came for me. I feel so humiliated. # Reflecting 2eelings when reflecting the client#s feelings3 a. State your comprehension of the feeling message, using emotional and feeling descriptive words. b. )se a nonCuestioning tone of voice. c. 7ait until the client responds. >xample3 -lient3 I don#t $now who I am anymore (wipes eyes, lights a cigarette, tal$s in a whisper . I#m drawn to go to any bar eventhough I tell myself it won#t happen again. ;urse3 Mou feel frightened and ashamed that you#re not in control of yourself. -lient3 I can#t seem to control my actions when those feelings come over me. 4# ,larifying ,ontent when clarifying the content of the client#s communication3 a. <epeat your comprehension of the thought or idea in your own words. b. <epeat a specific word or idea used by the client. c. )sed an open, Cuestioning tone of voice. d. 7ait until the client responds. >xample3 -lient3 5he man who brought me bac$ to the motel was a gentleman. ;urse3 5he man in the barB -lient3 Mes, the one I went with the motel. I didn#t even $now him. =# Reflecting ,ontent when reflecting the content of the client#s communication3 a. State your comprehension of the content message using descriptive or cognitive words. b. )se a nonCuestioning tone of voice. c. 7ait until the client responds. >xample3 -lient3 2y brother is a diabetic and my sister has hypoglycemia problems. I read in a maga1ine that people who drin$ a lot may have trouble burning up sugar in their blood. ;urse3 Mou thin$ because of the history of diabetes and your sister#s glucose tolerance, you may have a glucose problem, too. -lient3 Mes, I#m wondering if the doctor would chec$ my blood. @# ,onfronting 2eelings when confronting the client feelings3 a. +escribe the emotional message or feelings you are perceiving. b. +escribe the client#s ongoing behavior that is influencing your perceptions. c. Identify the contradictions using a Cuestioning tone of voice. d. 7ait for the client#s response. >xample3 Hovie has been less depressed since intensive therapy began one wee$ ago. She is ta$ing an antidepressant medication and is participating actively in the unit program. 5he team has noticed incongruence in Hovie#s expression of feelings toward her husband. Hovie discusses her feelings of love and need for closeness with her husband, but refuses his phone calls and does not open his letters. 5he team has decided to confront Hovie with her behavior. -lient3 I love my husband so much, and I $now he understands why I go to bars when I#m upset. ;urse3 Mou feel your husband $nows you love him so much that he accepts your behavior when you became anxious. !re refusing his calls and not opening his letters contrary to those strong feelings of love you say you feel for himB

b.

-lient3 Sometimes I feel so confused. I hate him at times and then, at other times, feel overwhelming love for him. 7# ,onfronting ,ontent when confronting the content of the client#s communication3 a. +escribe the message you are perceiving, using cognitive terms. b. +escribed the mixed-content messages you are perceiving, using the specific cognitive terms of the client. c. Identify the contradictions using a non-Cuestioning tone of voice. d. 7ait for the client#s response. >xample3 -lient3 2y husband isn#t interested in visiting me. I $now 6D miles is a long way to come, but he won#t ma$e the effort. ;urse3 Mou thin$ your husband doesn#t care about you because he hasn#t visited you, but you told me you sent him a letter as$ing his not to come. I#m confused, Hovie. -lient3 7ell, don#t you thin$ he should $now I really didn#t mean for him not to comeB ;urse3 I#m sure he#s trying to do what you want and not to visit you if that#s your reCuest. 8e has called everyday. H# <erifying !erceptions when verifying or chec$ing out your perceptions of the client#s behavior3 a. +escribe your perceptions of the client#s behavior, using terms similar to the client#s descriptions of content or feelings. b. )se an open, Cuestioning tone of voice to enable the client to verify your perceptions. c. 7ait for the client#s response. >xample3 -lient3 I don#t thin$ I have a drin$ing problem. I thin$ all my trouble stems from my parent#s divorce when I lost my friends and home. ;urse3 Mou#re having difficulty accepting the fact that you are an alcoholic, and it is easier to blame your parents for your problems. -lient3 I feel so uncomfortable when I loo$ at the other people at our meetings who are so open about being alcoholics I guess I can#t or don#t want to accept the fact that I#m li$e them. ?# %elfEDisclosure the nurse reinforces a genuine regard for, and respect of, the client by means of the therapeutic use of self. Self-disclosure may be used after the client describes a feeling or an emotional message. 7hen self-disclosing3 a. -larify the client#s message or feeling tone. b. +escribe similar experiences or feeling of your own. c. 7ait for the client#s response. >xample3 -lient3 I#m very frightened to go to the employment agency and apply for a *ob. ;urse3 I thin$ I $now what you mean. I#ve always felt scared when I had to apply for a new *ob. 95# 0iving $nformation communicating facts to the client is a common component of intervention. 5he cognitive, goal-directed function meets an identified ob*ective for the client. 7hen giving information to the client3 a. State the purpose of the activity, procedure, or situation. b. +escribe the activity, procedure, or situation. c. Identify the components of the activity, procedure, or situation. >xample3 -lient3 I signed some $ind of a contract yesterday about drugs and passes, but can#t remember all the facts. ;urse3 >ach client signs a contract with our unit within '4 hours of admission. 5his contract identifies the rules and regulations about drugs and 'D-minute, free- time passes. 5he contract you signed stated two things3 a. I do not have any drugs with me nor will I ta$e any drugs that are not a part of my treatment.

I will sign out when I leave the unit, identifying where I#m going in the hospital, and will return in 'D minutes. 99# %ilence when using silence3 a# +escribe the behavior that needs the client#s response. b# )se an open, Cuestioning, or declarative tone of voice. c# 7ait for the client#s response. >xample3 Hovie had signed a behavioral contract to attend !lcoholics !nonymous meetings held at another area in the hospital. ;urse3 Mou didn#t attend the !! meeting last night. -lient3 I *ust R(Hovie puts her head in her hands& silence follows for about '-, minutes. She then begins to cry. It#s so hard for me to see myself as an alcoholic. (Silence for about % minute. I feel so ashamed and even unclean when I go to those meetings. ;urse3 Mou feel humiliated and dirty. -lient3 I $now it#s not the people there. It#s accepting myself as I am and not the ma$e-believe that I#ve been living. 9:# Directing when directing the client#s interaction3 a# )se nonverbal or succinct, open-ended Cuestioning, or declarative statements. b# 7ait for client#s response. >xample3 ;urse3 Mou were saying -lient3 I $now that when my husband called last night, I wanted to be $ind and considerate about the out-of-town trip he needs to ta$e, but ;urse3 Please go on, Hovie. 9 # Kuestioning freCuently, the nurse uses direct Cuestions or indirect Cuestion-li$e responses during therapeutic communication. (pen-ended Cuestions are helpful ways to elicit the /how0, /what0, /where0, S /when0 of the client#s behavior. >xamples3 /7ill you elaborateB0 & /7ill you give me an exampleB0 /!m I correctB0 5he nurse avoids as$ing Cuestions that reCuire on answer of /yes0 or /no0 and those that are probing and interrogative during the therapeutic communication. ! client may become defensive or may intellectuali1e when as$ed the /why0 of a behavior. 94# %ummariAing when summari1ing the interaction with the client3 a. <eview the interaction in specific terms. b. 7ait for and listen to the client#s response. c. -larify any misunderstandings. >xample3 &urse3 Hovie, during the last ' wee$s, you#ve said that you accept the fact that you abuse alcohol, you have complied with the behavioral contract, and you have attended two !! meetings a wee$ for the past two wee$s. ,lient3 I#ve gotten something out of them, too. I#ll continue until my stay here ends, rightB ;urse 3 !s I recall, that is correct, but let#s loo$ at the behavioral contract. 9=# $nterviewing is a specific type of guided and limited intercommunication with an identified purpose. !n interview is usually conducted to collect a database for analysis and decisionma$ing purposes. 5he nurse commonly uses structured assessment tools and Cuestionnaires to gather and categori1e data. =uidelines for interviewing include the following3 a. b. c. d. e. f. -onduct sessions seated in a private, comfortable area with adeCuate lighting and hearing distance. !t the beginning of each session, plan and discuss with the client the length and purpose of the session. (bserve, listen, and use facilitative communication techniCues. -onvey a professional demeanor through dress and manner. Summari1e the interaction at the end of the session and ma$e arrangements with the client for the next session. Positively reinforce the client#s attention, effort, and so on. "8amples

b.

*ther 3herapeutic 3echniIues

'. ,. 4. =#

'ccepting EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE I follow what you said ;odding 0iving RecognitionEEEEEEEEEEEEEEEEEEEEE =ood morning, 2r. S. I notice that you#ve combed your hair. *ffering %elfEEEEEEEEEEEEEEEEEEEEEEEEEEEEE I#ll stay here with you. I#m interested in your comfort. !lacing the event in time or $n seIuenceEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE 7hat seemed to lead up toRB 7as this before or afterRB

?.

Making *bservations----------------- Mou appear tense. !re you uncomfortable when youRB I notice that you#re biting your lips. It ma$es me uncomfortable when youR

7#

"ncouraging description *f perceptionsEEEEEEEEEEEEEEEEEEEEEEEEEE 5ell me when you feel anxious. 7hat is happeningB 7hat does the voice seem to be sayingB

7# H# ?#

"ncouraging ,omparison EEEEEEEEEEEEEE7as this something li$e RB 8ave you had similar experiencesB 2ocusing EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE5his point seems worth loo$ing at more closely. "8ploring EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE5ell me more about that. 7ould you describe it more fullyB 7hat $ind of wor$B

95# %eeking ,larification EEEEEEEEEEEEEEEEEEI#m not sure that I follow. 99# !resenting Reality EEEEEEEEEEEEEEEEEEEEEEI see no one else in the room. 5hat sound was a car bac$ firing. Mour mother is not here, I#m a nurse. 9:# <oicing doubt EEEEEEEEEEEEEEEEEEEEEEEEEEEIsn#t that unusualB <eallyB 5hat#s hard to believe. 9 # %eeking consensual validation EEEEEEE5ell me whether my understanding of it agrees yours. !re you using this word to convey the ideaB

94# <erbaliAing the implied EEEEEEEEEEEEEEE9/ Patient3 I can#t tal$ to you or to anyone. It#s waste of time. ;urse3 Is it your feeling that no one understandsB :/ Patient3 2y wife pushes me around *ust li$e my mother and sister did. ;urse3 It is your impression that women are domineeringB 9=# "ncouraging evaluation EEEEEEEEEEEEEEE7hat are your feelings in regard toRB +oes this contribute to your discomfortB 9@# 'ttempting to translate EEEEEEEEEEEEEEEPatient3 I#m dead.

;urse3 !re you suggesting that you feel lifelessB or is it that life seems without meaningB Patient3 I#m way out in the ocean. ;urse3 It must be lonely or you seem to feel deserted. 97# %uggesting ,ollaboration EEEEEEEEEEEE Perhaps you and I can discuss and discover what produces your anxiety. 9H# "ncouraging formulation of plan of action EEEEEEEEEEEEEEE 7hat could you do to let your anger out harmlesslyB E.'. ;on- 5herapeutic - communication that is a barrier to the expression of free expression of feelings. ;on-therapeutic communication may provide disruption to the treatment process.

&on E3herapeutic 3echniIues 9#

"8amples

Reassuring EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE I wouldn#t worry aboutR >verything will be all right. Mou#re coming along fine.

:# 0iving approval EEEEEEEEEEEEEEEEEEEEEEEEEE5hat#s good. I#m glad that youR # Rejecting EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE9et#s not discussR I don#t want to hear aboutR 4# Disapproving EEEEEEEEEEEEEEEEEEEEEEEEEEEEEE5hat#s bad. I#d rather you wouldn#tR =# 'greeing EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE5hat#s right. I agree. @# Disagreeing EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE5hat#s wrongR I don#t believe that. I definitely disagree with. 7# 'dvising EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEI thin$ you shouldR 7hy don#t youR H# !robing EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE5ell me your life historyR ;ow tell me aboutR ?# ,hallenging EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEut how can you be President of the ).S.B If you#re dead, why is your heart beatingB 95# 3esting EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE7hat day is thisB +o you $now what $ind of hospital this isB +o you still have the idea thatR 99# Defending EEEEEEEEEEEEEEEEEEEEEEEEEEEEEEEE5his hospital has a fine reputation. ;o one here would lie to you. Eut +r. E is a very able psychiatrist. I#m sure that he has your welfare in mind when he R 9:# ReIuesting an e8planation EEEEEEEEEE7hy do you thin$ thatB 7hy do you feel this wayB 7hy did you do thatB

9 # $ndicating the e8istence of an e8ternal source EEEEEEEEEEEEEEEEEE7hat ma$es you say thatB 7ho told you that you were HesusB 7hat made you do thatB 94# +elittling feelings EEEEEEEEEEEEEEEEEEEEEEEPatient3 I have nothing to live for. I wish I was dead. ;urse3 >verybody gets down in dumps or I#ve felt that way sometimes 9=# Making stereotyped comments EEEEEE;ice whether we#re having. I#m fine and how are youB It#s for your own good. Hust listen to your doctor and ta$e part in activities, you#ll behome in no time. 9@# 0iving literal responses EEEEEEEEEEEEEEPatient3 I#m an easter egg. ;urse3 7hat shape, or you don#t loo$ li$e one. 97# .sing denial EEEEEEEEEEEEEEEEEEEEEEEEEEEEEPatient3 I#m nothing. ;urse3 (f course you are something, everybody is somebody. Patient3 I#m dead. ;urse3 +on#t be silly. 9H# $nterpreting EEEEEEEEEEEEEEEEEEEEEEEEEEEEE7hat you really mean isR )nconsciously you are sayingR 9?# $ntroducing an unrelated topic EEEEEEPatient3 I#d li$e to die. ;urse3 +id you have visitors this wee$endB

E. 58> -9I;I-!9 I;5><:I>7 2ental Status >xamination

,# 3H"R'!".3$, &.R%"E!'3$"&3 R"1'3$*&%H$! DefinitionsF &urseE!atient Relationship results from a series of interaction between a nurse and a patient. client over a period of time, with the nurse focusing on the needs and problem of the person.family.group while using the scientific $nowledge and specific s$ills of the nursing profession. 3herapeutic &urseE!atient Relationship a mutual learning experience and a corrective emotional experience for the patient& the nurse uses herself and specified clinical techniCue in wor$ing with the patient to bring about behavioral change.

3ypes of Relationship Differentiation ,haracteristics 0oal 3ermination $dentification of &eed Resources .sed %ocial Relationship Personal and Intimate +oing favor for mutual benefit ;ot defined 2ay not occur :ariety during interaction 3herapeutic Relationship Personal but not intimate Promoting functional use of one#s latent inner resources +efined in the beginning Ey the client with help of the nurse Speciali1ed professional s$ills for intervention

0oals of the 3herapeutic &urseE!atient RelationshipF %. '. ,. 4. Self-reali1ation, self-acceptance and increased genuine self-respect. -lean sense of personal identity and an improved level of personal integration. !n ability to form intimate, interdependent, interpersonal relationship with a capacity to give and receive love. Improve functioning and increased ability to satisfy needs and achieve realistic personal goals.

,haracteristics of 3herapeutic &urseE!atient RelationshipF %. '. ,. 4. 6. ?. @. F. 9istening perceiving the patient#s message in the cognitive and affective domains. 7armth feeling of cordiality and affection. =enuineness being oneself and not acting out a role& being open S truthful. !ttentiveness demonstrating a concentration of time and.or attention on the patient. >mpathy understanding the patient#s feelings& viewing the world as the patient does. Positive <egard accepting the patient as he is& non-*udgmental. 8umor ability to see the /funniness0 of a situation to be amused by one#s own imperfection, to see the funny side of the otherwise serious situation. -onsistency maintaining the same basic attitude toward the client, so that he derives security from being able to predict her behavior.

Response of !atients and &urse in the &!RF %. <esistance patient#s attempt to remain unaware of anxiety-producing aspects within herself. '. 5ransference the experiencing of feelings, drives, attitudes, fantasies, and defenses toward a person in the present that do not befit that person but rather are a repetition of reactions originating with significant others during early childhood, unconsciously displaced onto figures in the present. ,. -ounter-transference involves feelings of the nurse (positive or negative toward the patient, such as special concern, sexual attraction, anger, impatience or resentment. ,onsiderations in %etting 1imits for !atientsF %. '. ,. 4. 6. ?. @. 5he most general consideration is that the nurse cannot be completely permissive or completely restrictive. 5he nurse should ta$e into account the patient#s degree of comfort and feeling of being respected which may result from limits set on his behavior. 5he nurse should also ta$e into account the conseCuences of the limits set on his behavior. 5he nurse should also consider her own feelings and attitudes in restricting a patient. 5he effect of limit setting on a relationship of the nurse and patient. 5he extent to which the nurse will be able to maintain the limits set for the patient. 5he time at which a limit is set and the nurse#s attitude in setting it.

$ndications or %igns of a &onE3herapeuticLDistorted $nvolvement Distorted $nvolvement - the nurse uses the patient primarily for her own emotional needs and purposes. %. '. ,. 4. 6. ?. @. F. >xcessive worry over the patient. "eeling of intense hatred for him. Preoccupations with him to the exclusion of other patients or being constantly /overcome with pity0 for him. Eeing possessively attached to a patient that she resents to anyone#s relationship with or interest in him. "eeling that no one else can nurse him as well as she can. Eeing freCuently upset when the patient is upset or when /things don#t go right0 for him. )nable to accept anyone#s point of view concerning activities with the patient. Ho$e or tease in harsh belittling manner.

3he nurse !atient $nteraction ! single encounter engaged in by a particular setting for the purpose of facilitating the patient#s recovery through the utili1ation of the nurse#s special $nowledge and s$ills, professional not social and is directed toward moving patients from maladaptive behavior. !hases 5f &urseE!atient $nteraction

Orientation phase. 5he purpose of the orientation phase is to become acCuainted& gain rapport& demonstrate genuine caring and understanding& and established trust. 5he orientation phase usually last from ' to %D sessions, but with some patients can ta$e many months. %. Euild trust and security (first level of ant interpersonal experience 3 a. >stablished contract. b. Ee confident- follow contract, $eep appointments. c. !llow patient to be responsible for contract. d. -onvey honesty. e. Show and caring and interest. f. 7hen patient is unable to control behavior, nurse set limits and.or provide appropriate alternatives outlets. +iscuss the contract3 dates, times, and place of meetings& duration of each meetings& purpose of meetings& role of both patient and nurse& use information obtained& arrangements for notifying patient. nurse if unable to $eep appointment. "acilitate the patient#s ability to verbali1e his or her problem. Ee aware of themes3 a. -ontent (what the patient is saying . b. Process (how the patient interacts . c. 2ood (hopeless, anxious . d. Interaction (did the patient ignore you, was he or she submissive, did he or she dominate conversationB . (bservation and assess the patient#s strengths and positive aspects of his or her personality. Include the patient in identification of his or her own attributes. Identify patients# problems, nursing diagnosis, outcome criteria, and nursing interventions& formulate nursing care plan. !atient Responses to *rientation !hase %. '. 2ay willing engage in the therapeutic relationship. 2ay test you and the limits of the relationship3 a. 2ay be late for meetings b. 2ay end meeting early. c. 2ay play nurse (you against the staff. 2ay not remember your name or appointment time3 a. Put information on a card and give this to patient. b. <einforce contract in early meetings and restate limits if necessary. 2ay attempt to shoc$3 a. 2ay use profane words. b. 2ay share an experience that patient feels will shoc$ or frighten you. c. 2ay use bi1arre behavior. 2ay focus on nurse in an attempt to see if nurse is competent. "ocus on patient.

'. ,. 4.

6. ?.

,. 4.

6.

Working phase 5his phase begins when the patient assumes responsibility to uphold the limits of the relationship. "ocus is on the /here and now0. 5he purpose of the wor$ing phase is not to bring about positive changes in the patient#s behavior. %. Set priorities when determining patient needs3 a. Preserve life and safety3 is patient suicidal, not eating, smo$ing in bed while medicated, acting out behavior harmful to othersB b. 2odify behavior that is unacceptable to others3 such as e.g., acting out of hostile verbali1ation, bi1arre behavior, withdrawal, poor hygiene, and inadeCuate social s$ills. c. Identify with patients those behaviors he or she is willing to change& set realistic goals. 2a$e goal testable and attainable for successful experiences. 5his will increase sense of self worth and help patient accept need for growth.

!atient Response to )orking !hase %. '. ,. 4. 6. 2ay use less testing, less focusing in nurse, fewer attempts to shoc$ nurse. 2ay remember anticipate appointment with nurse. 2ay use more description and clarification to facilitate understanding& wants you to $now how he.she feels. 2ay be more responsive in interaction. 2ay improve appearance.

?. @.

2ay bring up topic he.she wished to discuss. 2ay confide more confidential materials. 5he wor$ing phase is painful for patient, and is reached when change occurs as problems are analy1ed and discussed by patient and nurse.

Termination phase 5he purpose of this phase is to dissolve the relationship and assure the patient that he or she can be independent in some or all of his or her functioning. Ideally the termination phase should begin during orientation phase. 5he more independent and involved relationship reCuired longer time for termination. 5ermination usually occurs if the patient has improved sufficiently for the relationship to end, but it may occur if as patient is transferred or you as a nurse leave the agency. Methods of decreasing the involvement3 '. ,. 4. 6. Space your contracts farther apart (not usually necessary in the student clinical experience . <educe the usual length of time you spend with patient. -hange the emotional tone of the interactions by3 a. ;ot responding to or following up clues that led to new areas to investigate. b. "ocusing on the future oriented material. Some patient may want to wor$ up to the last meeting& use your *udgment. )hat to discuss with patient about termination %. '. ,. 4. 6. ?. 8elp patient to discuss his.her feelings about it. 8ave patient tal$ about gains he.she has made. (Include negative aspects of sessions also Share with the patient the growth you in him.her. >xpress benefits you have gained fore the experience. >xpress your feelings regarding leaving patient. ;ever give patient your address or telephone number. !atient Responses to 3ermination %. '. ,. 2ay deny separation. 2ay deny significance of relationship and.or termination. 2ay express anger or hostility (overtly or covertly . !nger openly express to nurse, may be a natural and healthy response to events. Patient feels secure enough to show anger. ;urse responses to above in accepting, neutral manner. 4. 2ay display mar$er change in attitude toward nurse.therapist& may ma$e critical remar$s about nurse or be hostile because of pending brea$ of emotional ties. If the nurse doesn#t understand the reason for the patient#s reaction, he.she may react with anger or defensiveness and bloc$ the termination process. 6. 2ay display a type of grief reactions. It ta$es time to get over the loss, which is why it is important to start the termination process early. ?. 2ay feel the re*ected and experience increased negative self-concept. @. 2ay terminate relationship prematurely. F. 2ay regress to exhibition of old symptoms. G. 2ay reCuest premature discharge. %D. 2ay ma$e suicide attempt. %%. 2ay be accepting but may still express regret or fell momentary resentment. 5his is healthy response. 2a$e a clean brea$ or you may hinder the patient reali1ation that relationship often must and do, terminate.

'&B$"3; DefinitionF T ! diffused unpleasant uneasiness, apprehension, or fearfulness stemming from anticipated danger. 5he source of which is unidentifiable. ,haracteristics T It is the basic element of behavior. T Serves as a signal which alerts an individual to defensive action to handle exhibition. T ;ecessary for one#s survival. T It is an emotion and a sub*ective experience of the individual. T It is an energy and as such cannot be observed directly. It can only be inferred from the person#s behavior. T >motion without a specific ob*ect. T It is provo$ed by the un$nown. It therefore precedes all new experiences li$e entering school, moving to new places, starting a new *ob, etc. T It is communicated personally. !recipitating 2actors to 'n8iety 3wo ,ategoriesF a# Threat to biological integrity refers to the disturbance in homeostasis i. e., temperature control, vasomotor stability, etc. b# Threat to self esteem refers to the threat to the tendency of an individual toward maintaining established views of self and the values and patterns of behavior he uses to resist changes in self view. a. Sense of helplessness b. Sense of isolation (alienation c. Sense of insecurity (5hreat to identity +ehavior Response to 'n8iety !nger +efensive behavior Irritation -omplaining -rying +enial 7ithdrawal "orgetfulness Auarreling

1"<"1 *2 '&B$"3; 1evel 9# Mild "ffects .pon the 'bility to *bserve Person is alerted, sees, hear, and grasps more the previously - 9evel this can motivate learning and can produce growth and creativity in the individual. - !ssociated with the tension of everyday living Person#s perceptual field is narrowed sees, hears, grasps less but can attend to more if directed to do so. "ffects .pon the 'bility on )hat is Happening - Increased awareness and alertness - !ttention is possible. - S$ills in seeing relations can be used.

:# Moderate

Selected in attention i. e., individuals fails to notice what goes on in situations peripheral to the immediate focus but can

# %evere

Perceptual field is greatly reduce. 8>!<I;= IS ;(5 P(SSIE9> - 8e tends to focus on a specific detail and all his behavior aimed at getting relief. Involves disorgani1ation of the personality. - Individual experience loss of control - )nable to do things even with direction - +istorted perception - 9ost of rational thought

4# !anic

notice if attention is pointed there by another observer. +issociating tendencies operate to panic i. e., the person does not notice what goes on in a situation (specifically communication with reference to the self . !nd there is inability to do so even when attention is pointed to this direction by another observer. Person becomes immobili1ed (emotional paralysis Increase motor activity +ecrease ability to relate to others

1evel of 'n8iety depends on the following factorsF %. 2aturity of individual '. 5he understanding of the illness ,. 9evel of the self esteem 4. )se of coping mechanisms 0"&"R'1 $&3"R<"&3$*& 2*R '&B$"3; %. "or the patient with severe or panic level of anxiety. a. =oal3 5o lessen the degree of anxiety through supportive and protective measures. b. 9imits environmental stimuli. c. >stablish a supportive and trusting relationship. d. Keep demands at a level the patient can handle. 2inimi1e problem solving activities. e. +o not confront the patient about coping mechanisms. f. Provide physical activities to release energy. g. !dminister prescribed tranCuili1ers in a time manner. It gives immediate relief in acute distress or to stabili1e the patient so that he will be able to participate in the process of therapy. "or the patient with moderate anxiety. a. =oal3 5o help patient develop the capacity to tolerate anxiety and use it consciously and constructively. b. 5each about precipitating stressors, coping strategies, adaptive and maladaptive responses. c. )se the problem solving process to help the patient recogni1e onset of anxiety, situational stressors and coping abilities. d. Promote relaxation responses. e. Provide explanations.information briefly and repeat if necessary.

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K>M ;)<SI;= I;5><:>;5I(;S 5( <>+)-> !;QI>5M %. Provide a calm and Cuiet environment <ationale3 to identify and reduce stimulation! "hich includes e#posure to situations and interactions "ith other patient that could provo$e an#iety '. !s$ patients to identify what and how they feel <ationale: to help patient increase their recognition of "hat is happening on them ,. >ncourage patients to describe and discuss their feelings <ationale3 5o help patients to increase their awareness of the connection between feelings and behavior. 4. 8elp patients to identify possible causes of their feelings. <ationale3 5o assist patients in connecting their feelings with earlier experiences. 6. 9isten carefully to patients expression of helplessness and hopelessness. <ationale3 5o assess for help-harm, patients could be suicidal because they want to escape their pain and do not thin$ they ever feel better. ?. !s$ patients if they feel suicidal or have a plan to hurt themselves 5o assess for help-harm and to initiate suicides precautions as necessary. @. Plan and involve patients in activities such as going for wal$s or playing recreational games.

5o help patients release nervous energy and to discourage preoccupation with self.

K>M ;)<SI;= I;5><:>;5I(;S I; P<(E9>2 S(9:I;= %. +iscuss with the patients their present and previous coping mechanism <ationale3 5o reinforce effective adaptive coping. '. +iscuss with the patients the meaning of problems and conflicts <ationale3 5o help patients appraise stressors, explore their personal values and define the scope and seriousness of their problems ,. )se supportive confrontation and teaching. <ationale3 5o increase patients# insight into the negative effects of their maladaptive and dysfunctional coping behaviors. 4. !ssist patients in exploring alternative solutions and behaviors <ationale3 5o increase adaptive coping mechanisms. 6. >ncourage patients to test new adaptive coping behaviors through role-playing or implementation <ationale3 5o provide an opportunity for patients to practice new behaviors. ?. 5each patients relaxation exercises. <ationale3 5o reduce the level of anxiety. 5hese techniCues help patients to manage or control anxiety on their own. @. Promote the use of hobbies and recreational activities <ationale3 5o help patient deal with routine feelings of stress and anxiety. +>5<I2>;5!9 I;5><:>;5I(;S I; !;QI>5M %. Pressuring the patient to change prematurely. '. +isapproving verbally a patient#s behavior ,. !s$ing patient a direct Cuestion that place him on the defense -onfrontation. 4. "ocusing in a critical way on the anxious feelings of the patient with other patients. 6. 9ac$ing awareness of her (nurase own behavior. ?. 7ithdrawing from the client. ,R$%$% 3H"*R; '&D $&3"R<"&3$*& -risis theory is based on a body of concept that has, when applied, great potential for improving mental health. -<ISIS refers to the state of the reacting individual who finds himself in a ha1ardous situation oin which the habitual problem solving activities are not adeCuate and do not lead rapidly to the previously achieved balance state. -<ISIS I;5><:>;5I(; means the entering into the life situation of man individual, family or group to alleviate the impact of a crisis including stress in order to help mobili1e the resources of those directly affected, as well as those who are in the significant /social orbit.0 -(;->P5S3 %. -<ISIS I;5><:>;5I(; -!; ("">< 58> I22>+I!5> 8>9P 58!5 ! P><S(; I; -<ISIS ;>>+S I;(<+>< 5( <>- >S5!E9IS8 >A)I9IE<I)2. '. -<ISIS IS !; )PS>5 I; ! S5>!+M S5!5> a. ! person in crisis is at a turning point. b. 8e finds himself in a ha1ardous situation c. 8e face a problem he cannot readily solve by using the coping mechanisms that have wor$ for him before. d. !s a result, his tensions and anxiety increases. e. 8e becomes less able to find a solution. f. 8e feels helpless and caught in a state of great emotional upset and feels unable to ta$e action on his own to solve his problem.

,. 58><> !<> 58<>> 5MP>S (" -<ISIS a. ;ormal developmental or 2aturation life crisis - e.g. birth, school age, marriage, pregnancy, etc. b. !bnormal and accidental or Situational life crisis e.g. accident, death, illness, etc. c. -ombination of developmental and accidental crisis e.g. pregnancy in women who are victims of rape.

4. -<ISIS IS S>9" 9I2I5I;= I; ! 5>2P(<!9 S>;S>. a. Some solutions are sought which will lead to the previous state of eCuilibrium, or a higher or lower level of functioning. 6. 58><> !<> -><5!I; 5MPI-!9 -8!<!-5><IS5I-S (" 58> P><I(+ (" -<ISIS. Phases of crisis a. Initial there is rise in tension in response to initial impact of stress. b. Intermediate emergency problem solving mechanisms are called forth which may lead to actual solution of the problem. c. 5hird Phase ma*or disorgani1ation if no solution occurs. 58> P><S(; I; -<ISIS >2P9(MS :!<I()S -8!<!-5><IS5I- -(PI;= P!55><;S a. 2aladaptive uses avoidance, fantasy, regression, panic b. !daptive able to verbali1e, see$ and use help from the environment.

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@. 58> P><S(; I; -<ISIS E>-(2> 2(<> S)S->P5IE9> 5( 58> I;"9)>;-> (" SI=;I"I-!;5 (58><S I; 58> >;:I<(;2>;5. a. 5he degree of activity of the helping person does not have to be high. b. 5ime of intervention should be of strategic importance. F. -<ISIS I;5><:>;5I(; IS +>SI=;>+ 5( "!-I9I5!5> !+!P5I:> -(PI;= P!55><;S (; 58> P!<5 (" I;+I:I+)!9, "!2I9M (< -(22);I5M. a. 8elp is given during the period of time when this individual in crisis is wor$ing at establishing coping patterns. G. -<ISIS 8!S =<(758 P<(2(5I;= P(5>;5I!9S , ;(5 !; I99;>SS. a. 7ith help given at the proper time, people in crisis can come through trouble in a healthy way. b. -risis may enable the individual to establish new coping mechanism which serve to strengthen his capacity to deal with life problems, thereby raising his level of mental health.