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• Mental illness is a disturbance in physical, emotional, mental and social well-being, potentially caused by genetic, physiological, or chemical imbalances

Neurosis vs. Psychosis

• Neurosis involves psychological imbalance but the patient remains in touch with reality and typically doesn't require hospitalization
• Psychosis is a disorder leading to personality disintegration where patients lose touch with reality and often require hospitalization

Models of Care in Psychiatric Nursing

• Multidisciplinary approach involves professionals from different fields working independently
• Interdisciplinary approach includes parents and professionals working together and interacting through formal channels
• Transdisciplinary approach includes parents and professionals working together in an integrated and interactive manner

Members of a Multidisciplinary Team

• Psychiatrists
• Psychologists
• Psychiatric nurses
• Social workers
• Dietitians
• Special education teachers
• Audiologists
• Geneticists
• Occupational therapists
• Physical therapists

Clinical Nurse Specialist (CNS) vs. Nurse Practitioner (NP)

• CNS provides direct and indirect care in all settings and areas
• NP practices care primarily in community-based settings

Functional Concept

• Nursing involves therapeutic interpersonal interactions
• Mental hygiene focuses on mental health
• Mental health is a state of overall well-being, not just the absence of illness
• Psychiatric nursing uses interpersonal processes to assist individuals, families, or groups in promoting mental health, preventing illness, and providing treatment/rehabilitation

Referral to a Professional

• Referral to a psychiatric facility is needed when symptoms interfere with daily living

Therapeutic Use of Self

• Therapeutic Use of Self involves positively using one's self during therapy

Methods to Increase Self-Awareness

• Methods include role-playing, introspection, discussion, and enlarging one's experience

Impaired Nurse

• An impaired nurse cannot meet ethical/practice standards due to psychiatric illness or substance abuse
• Signs of impairment include inappropriate clothing, mood swings, preoccupation with death/illness, absenteeism, increased phone time, rigidity, exaggerated self-importance, and difficulty remembering procedures
• Closed-door syndrome might be common among impaired nurses

Functional Concept

• A nurse uses themselves in a therapeutic way when they are secure and not threatened by the client's behavior.

Therapeutic vs. Holistic Communication

• Therapeutic communication is purposeful, planned, and focused on improving conditions
• Holistic communication is characterized by caring and healing via the therapeutic use of self

Human-to-Human Relationship

• It is how nursing fulfills its purpose, according to Joyce Travelbee

What is Communication?

• Communication is the reciprocal exchange of ideas, beliefs, attitudes, and feelings
• The 3 P's of communication are planned, patient-centered, and purposeful

Modes of Communication

• Verbal
• Non-verbal (including kinesthetics, paralanguage, and spatial orientation)
• Meta Communication
• Elements of Communication include sender, intent, message, receiver, channel, feedback and context

Psychiatric Symptoms Affecting Communication

• Dysarthria
• Aphasia
• Neologism
• Flight of ideas
• Looseness of association
• Clang association
• Perseveration
• Echolalia
• Verbigeration
• Tangentiality
• Word Salad

Focus in Therapeutic Response

• Therapeutic Communication Techniques includes using open-ended questions and focusing on common communication techniques learned in nursing education
• It involves using techniques prioritizing the patient's physical, mental, and emotional well-being
• Important techniques: Giving broad openings, active listening, focusing, reflecting, restating, suggesting collaboration, encouraging verbalization, clarifying, presenting reality, and summarizing

The Admission Interview

• Asking "Will your child allow me to talk to you alone?" addresses elderly abuse
• Asking "When was your last alcohol drink?" addresses alcoholism
• Asking "What happens when you do something wrong at home?" addresses child abuse
• Asking "Is the ritual interfering with your activities of daily living?" addresses obsessive-compulsive disorder
• Asking "Do you have any plans of killing yourself?" addresses suicide
• Asking "Do your folks get lost at home?" addresses dementia
• Asking "Do you wake up at night feeling frightened?" addresses PTSD
• Asking "Are you able to visit your mailbox without feeling anxious?" addresses agoraphobia

Therapeutic Relationship (NPR)

• NPR consists of ongoing interactions where nurses help patients achieve positive changes
• It is distinct form a brief therapeutic encounter
• NPR includes understanding the client, self-awareness, and empathy
• Issues include resistance, transference, and countertransference
• NPR characteristics include being professional, planned, and patient-centered

Social Relationships

• Social relationships are personal, spontaneous and participant centered

Requisites of Therapeutic Interaction

• Requisites include: eye contact, distance and touch

Phases of the NPR

• The phases are pre-orientation, orientation, working, and termination

Determinants of Personality

• The determinants include physical/biological, intellectual, psychological and social

Piaget's Cognitive Theory of Development

• Sensorimotor stage (0-2 years): Reflex activity progresses to voluntary activity; hallmark is object permanence
• Pre-operational stage (2-7 years): Learning progresses to pre-logical thought

Freud's Psychosexual Theory of Development

• Oral stage (0-18 months) involves fixation, potentially leading to substance abuse or eating disorders
• Anal stage (18 months-3 years) involves fixation and is linked to passive-aggressive or obsessive-compulsive behaviors
• Genital Stage (above 12 years) involves focuses on sexual response disorders

Erikson's Psychosocial Theory of Development

• Trust vs. Mistrust (0-1 year)
• Autonomy vs. Shame and Doubt (1-3 years)
• Initiative vs. Guilt (4-6 years)
• Industry vs. Inferiority (6-12 years)
• Identity vs. Role Confusion (13-17 years)
• Intimacy vs. Isolation (18-25 years)
• Generativity vs. Stagnation (26-64 years)
• Integrity vs. Despair (65 years and above)

Kohlberg's Theory of Moral Development

• Level 1: Pre-conventional, obedience and punishment
• Level 2: Conventional, interpersonal accord and conformity
• Level 3: Post-conventional, social contract, universal ethical principles

Significant Data Across the Lifespan

• Overly behaved is indicative of cretinism
• Restlessness (Hypoxia)
• Asymmetry of facial features indicates FAS
• A large tongue indicates Down syndrome
• Absence of eye contact indicates ASD
• Negativism (Risk for Depression)
• Arranging things in straight line indicates ASD
• A large head indicates Hydrocephalus
• Change in clothes alone indicates sexual abuse
• Head banging indicates ASD
• Acts out needs rather than verbalizing it indicates MR
• Language delay indicates ASD
• Lack of pain sensitivity indicates ASD
• Inability to sit still indicates ADHD
• Cannot differentiate good/bad indicates ODD
• Loss of personal belongings indicates ADHD
• Absence seizures (day-dreaming)
• Talks excessively indicates ADHD
• Excessive knowledge of Sex (Child Abuse)
• Non-compliance with rules indicates ODD
• Cruelty to animals indicates conduct disorder/anti-social
• Yearns for cross gender socialization (Gender Identity Disorder)
• Weight loss (Eating Disorders)
• Hypokalemia
• Overly concerned with body size or shape (Eating Disorders)
• Absence of menses (Eating Disorders)
• Mood Swings
• Irritability
• Rigid personality (dementia)
• Impaired cognitive function
• Difficulty in hearing
• Excessive silence (abuse alert!)

Identifying Clients at Risk

• Elderly clients living with family are at the highest risk of abuse

Personality Disorders (PD)

• They are lifelong inflexible patterns of functioning
• They cause impaired self-identity and interpersonal functioning (DSM 5)
• According to the APA, they are the the way of thinking about one's self or other
• They are marked by problems with one's emotional responses, relating to others and controlling behavior

Treating Personality Disorders

• Treatment only becomes effective if the patients acknowledge the problems are within themselves
• Psychotherapy is the gold standard for treating PD
• Treatment goals include providing a consistent environment, preventing splitting, decreasing maladaptive behavior, and modifying problem behavior
• One has to at least 2 of following (APA): 1. Way of thinking about one's self or others; 2. Way of responding emotionally; 3. Way of relating to other people; 4. Way of controlling ones behavior

Anxiety

• Anxiety is a vague sense of impending doom.
• Fear is a response to a perceived specific danger
• Treatment for anxiety includes creating a calm and minimizing environmental stimuli.

Levels of anxiety

• Mild
• Moderate
• Severe
• Panic

Anti-Anxiety Agents

• These are taken to decrease anxiety. Focus on:
  • How will you know its effective -Exactly what time do you give it -Client teaching tips -Keys to giving it safely

Common Types of Anxiety Disorders

• Panic disorder is characterized by unexpected panic attacks
• Generalized Anxiety Disorder is characterized by excessive anxiety for at least 6 months and treated with cognitive behavioral therapy and drugs.
• Obsessive-compulsive disorder is characterized by recurrent thoughts and actions
• Social anxiety is characterized by fear of public embarrassment
• Post-traumatic stress disorder (PTSD) is the long-term aftermath of a traumatic event with symptom onset occurring after a month.

Common Defense Mechanisms

• Identification: Consciously patterning one's self after another person
• Introjection: symbolic assimilation or taking in a loved/hated object
• Displacement: Redirecting feelings to a less threatening object
• Projection: Attributing one's unconscious wishes/fears onto others
• Dissociation: Detachment of certain activities from normal consciousness
• Isolation: Cutting off or blunting an unacceptable aspect of a total experience
• Repression: Unconscious forgetting
• Suppression: Conscious forgetting through deliberate blocking
• Compensation: An attempt to overcome an imagined shortcoming
• Conversion: Emotional problems are converted to physical symptoms
• Denial: Failure to acknowledge an intolerable thought, feeling, or experience
• Fantasy: Conscious distortion of unconscious feelings or wishes
• Fixation: Arrest of maturation at certain stages of development
• Intellectualization: Overuse of intellectual concepts to avoid expressing feelings
• Reaction formation: Expressing a feeling that is the direct opposite of one's real feeling.
• Rationalization: Justifying actions based on other motives
• Regression: Returning to an earlier level of development in the face of stress
• Substitution: Replacing a desired unattainable goal for one that can be attained
• Sublimation: Rechanneling unacceptable drives to acceptable ways
• Symbolization: Using a less threatening object to represent another
• Undoing: An attempt to erase an act, thought, feeling, or desire

Eating Disorders

Orthorexia is characterized by an obsessive focus on healthy eating New research suggests a genetic link to anorexia and bulimia. Perfectionist parents may contribute to the development of eating disorders.

Focus on Anorexia and Bullimia

• Anorexia and bulimia may be related to trauma, anxiety and depression. -In both disorders there is poor self-esteem, and depression occures.
• In anorexia, weight loss is due to suppression of appetite. In bulimia, weight loss is due to purging.
• Anorexia Nervosa develops when:
• Parents are PERFECTIONISTS
• Teenage child has:
  • Body dissatisfaction
  • Over and strict dieting
  • Low self esteem
• Difficulty expressing feelings History of: Physical or sexual abuse Eating disorder in the family

Positive Outcome Indicator

• Staying in a public place after meals is a positive outcome indicator for clients with eating disorders

Diagnostic of Anorexia

• No organic factor for the weight loss
• Induced vomiting
• Obviously thin but feels fat
• Refusal to maintain normal weight
• Epigastric discomfort
• X symptoms
• Abuse of laxatives or diuretics
• Arrythmia
• Induced vomiting
• Minimum of 1 binge eating per/week for at least 3 months
• Increased concern over body size/shape
• Intense fear of gaining weight
• Always thinking about food

Types of Anorexia

-Restricting Type: Weight loss is achieved through dieting, fasting or excessive exercise. -Binge Eating and Purging Type - May binge or eat very little, but after eating often purges by vomiting, taking laxatives, enemas, diuretics or excessive exercis

Types of Diagnostic of Bulimia Nervosa

Russell's Sign: A lesion on the knuckles caused by self-induced vomiting.

• Under strict dieting/exercise
• Lack of control for eating binges
• Minimum of 1 binge eating/week

Anorexia, the individual

• Lies about food eaten
• AIs socially withdrawn
• Has dry yellowish skin
• -Has a bluish tinge on fingers
• -Has intolerance to cold
• -May have arrythmia

Bulimics

• -May have weight fluctuation
• -Has cracked lips

• -With blood shot eyes
  

• -Have knuckle scars
• -Eriding tooth enamel
• -Have receding gums

Charicteristics of both (Anorexia & Bulimia)

Tooth decay

• Perfectionist parent/s
• Weight loss
• Low self esteem
• Preference to be alone in a room after meals
• Excessive exercise aimed at weight loss
• Pica involves substance like ice, chalk, laundry detergent, cornstarch or soil.
• It usually affects children and pregnant women

Drugs for Anorexia

Olanzapine

• To Increase appetite
• To treat depression Buspirone
• To decrease binge and purge

Drugs for Bulimia

• Bulimia(MAOI)
• Imipramine(TCA)
• Ondansetron
• (antiemetic):
• To decrease binge and purge
  • Cognitive behavioral therapy
• In binge eating disorder, episodes of large amount of food or consumed in a short amount of time but with out purging -Family therapy indicated for people with people with eating disorder -Rumination disorder involves regurgitation of previously chewed or swallowed food, re-chewing it re-swallowing or spitting in out(DUYGOT)

Avoidant/Restictive Eating

In avoidant-restrictive food intake disorders, there is under eating because of lack of interest in food, or an intense distaste for how certain foods look, smell or taste

Avoidant/Restrictive eating Disoders Decription

EatingDisorder -Anorexia nervosa 1 Fear of- -Fear of gaining weight even if underweight restricting type. -Involves fasting, exercise and abuse of laxatives enema Purging. diuretics 2.Bulmia Nervosa- -Involving induce vomiting abuse of enemia diuretic

Binge eating disorder is-

• involving consumptionof large amout of food W\O Purging -Pica -Eating disoder involving eating Non food substantial