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• Learners should be able to describe at least two personality traits that could affect their ability to interact with clients in the clinical setting
• Learners should be able to state the goals of the therapeutic Nurse-patient relationship
• Learners should be able to describe the nurse's tasks and possible problems in the four phases of the relationship process
• Learners should be able to discuss the level of, two models of the communication process, and therapeutic communication techniques communication
• Learners should be able to analyze how the nurse uses each of the responsive dimensions in a therapeutic relationship
• Learners should be able to analyze how the nurse uses each of the action
• Learners should be able to evaluate therapeutic impasses, and identity nursing intervention to deal with them

Self Awareness

• Requires reflection on personal fears, anxieties, and prejudices before interacting with clients in a psychiatric setting

Addressing Client Interactions

• Clients are to be informed that you are a student nurse
• Unit staff, clinicians, or supervisors inform clients about the clinical rotation's purpose
• The student nurse will be present
• Introduce yourself using your first name only, via name tags
• Refrain from sharing personal information about yourself or colleagues with clients
• In regards to the potential of saying the wrong thing, sincerity, honesty, respect, and a caring attitude are key
• Do not be afraid of saying the wrong things
• CIs, unit staff, or clinicians determine the appropriateness of client assignments and whether you can be left alone with a client
• Mental institution staff are experienced in assessing a client's potential for violence
• In the event a client becomes violent, notify your CI and nursing staff, following instructions

Recommendations

• Avoid assumptions about a client's medical and psychiatric history
• Approach clinical supervisors or staff with questions about a client's needs or care plan
• Discuss feelings about your clinical rotation or assigned client with your instructor
• Take time to adjust at a slower pace
• Do not become frustrated with non-verbal clients
• Be patient with clients needing repeated prompting
• Listening, observing, and self-awareness are important tools when providing care

Self Awareness Defined

• Ability to recognize one's behavior, attitude, and emotions
• Effective for interacting with clients exhibiting anxiety, depression, confusion, or psychosis

Personality Traits: Extrovert

• Outgoing, relates easily to people and environments
• Likes to take charge
• Experiences little difficulty in socializing

Personality Traits: Introvert

• Quiet, relates better to inner ideas, thoughts, and feelings
• Prefers following, letting others initiate and direct

Attitudes: Open-minded

• Defer decision-making until aware of all facts

Attitudes: Judgmental

• Often inflexible, risking neglect of others' perceptions
• Potentially forms opinions based on personal values without enough facts or regard for others

Psychiatric Nursing

• In any clinical setting, you'll encounter patients with mental and emotional problems
• Care for patients with depression, anxiety, thought disorders, or dementia is inevitable
• Effective patient care involves considering the psychological and physiological aspects of health.
• Many medical conditions are linked to or lead to emotional and mental distress
• Recognizing such problems and how they affect patients' health is crucial.

Scope

• No longer revolves around psychiatric-mental health units, having grown in number and diversity
• Mental health programs can be found in family advocacy, substance abuse rehabilitation, stress management, domestic violence shelters, and school counseling

Links Between Stress and Disease

• Hans Selye, a stress research pioneer, found a link between environment and biological response
• Noted emotional and physical stress as a response pattern, if untreated, can lead to infection, illness, disease, and death

General Adaptation Syndrome

• Identifies three stages: alarm reaction, resistance, and exhaustion

Alarm Stage

• Any physical or mental trauma triggers immediate biological responses to counteract stress
• Immune system is depressed, lowering resistance and making the person susceptible unless the stress is resolved quickly

Resistance Stage

• Body adapts to prolonged stress; immune system increases to meet demands
• Perception of threat remains, preventing complete equilibrium and stressing body organs

Exhaustion Stage

• Chronic stress depletes adaptive mechanisms, compromising the body's ability to meet stress demands
• Immunity declines, increasing the likelihood of illness

Interrupting Stress Responses

• Selye's work led to relaxation techniques to interrupt stress, reducing susceptibility to illness and disease

Social Factors

• Increased mental/emotional disorders are attributed to social changes altering family structure and extended family loss
• Loss of support strains coping ability
• Mental disorders occur at all ages and socioeconomic levels
• Teenage depression and suicide rates have tripled in the past 20 years, especially with alcohol and substance abuse

Elderly

• Isolation, fear of crime, and loneliness increase depression among the elderly

Mental Disorder Defined

• Defined by the American Psychiatric Association. Diagnostics and Statistical Manual, with clinically significant behavioral or psychological syndrome or pattern associated with at least one of these criteria:
• Current distress (a painful symptom)
• Disability (an impairment in one or more important areas of functioning)
• A significantly greater risk of suffering, death pain, and disability
• An important loss of freedom

Diagnostic Approach

• Greater diagnostic details require the multiracial approach.
• The DSM – IV – TR uses this approach, specifying that every patient be evaluated on each of five axes.

Axis I

• Clinical Disorders such as mental disorders comparable to general medical illness

Axis II

• Personality Disorders and Mental Retardation includes personality disorders and traits, and mental retardation

Axis III

• General Medical Condition, such as general medical illness or injury

Axis IV

• Psychosocial and Environmental Problems, consisting of life events or problems that may affect diagnosis of mental disorder

Axis V

• Global Assessment of Functioning (GAF), reports level of functioning via a number from 0-100 based the patient's overall psychological, social, and occupational function

Psychiatric Nurse's Role

• Includes legal and ethical parameters, social accountability, clinical competence, nurse-patient relationship, interdisciplinary collaboration, patient (family) advocacy, and fiscal responsibility
• Psychiatric nurses can no longer focus solely on bedside care and immediate patient needs
• Practice demands sensitivity to social environment and families
• Requires considering complex legal ethical dilemmas arising from delivery systems
• All elements influence education, research, and clinical aspects of contemporary psychiatric nursing practice

Therapeutic Roles

• Nurses serve in various roles, functioning in both direct and indirect care:
  • Teaching
  • Communication
  • Coordination
  • Delegation
  • Collaboration
  • Management
  • Staff Nurse
  • Primary Care provider
  • Administrator
  • Consultant
  • In-service educator
  • Clinical fractioned
  • Researcher
  • Program evaluator
  • Liaison between the patient and other health care team members

Nursing Process

• Consists of assessment, nursing diagnosis, risk problem, related factors, risk factors, signs and symptoms, projected S/S if problem were, outcome identification, planning, implementation, and evaluations

Cyclic and Dynamic Nature

• Encompasses database mental status, cognitive, perceptual, affective, and behavioral elements, and assessment
• The components that create therapeutic intent are:
  • Nursing
  • Diagnoses
  • Outcome identification

Assessment

• Collect patient health data via assessment interview, requires culturally effective skills, interviewing, behavioral observation, record review, and a comprehensive system assessment

Diagnosis

• Analyse assessment data to determine applicable diagnosis, recognizing and identifying response patterns

Outcome Identification

• The nurse identifies expected outcomes individualized for the patient.

Planning

• The nurse develops a negotiated care plan with the patient, family, others, and the healthcare team that prescribes strategies using an evidenced based method
• Guide for therapeutic interventions and documenting progress for desired outcomes

Implementation

• Implementing interventions in the care plan

Range of Interventions

• Nurses use a wide range of interventions designed to prevent mental and physical illness
• Goal is the promotion, maintenance, and restoration of mental and physical health

Counseling

• Counseling interventions assist patients in improving or regaining coping abilities to foster mental health, and preventing mental illness and disability

Milieu Therapy

• The nurse provides, structures, and maintains a therapeutic environment in collaboration with the patient and other health care provider

Self-Care

• Nurses promote self-care abilities by structuring interventions around activities of daily living to faster self-care and mental and physical well-being

Psychobiological Intervention

• Applies skills to restore the patient's health and prevent injuries

Health Teaching

• Through health teaching, the nurse assists patients in achieving satisfying, productive and healthy patterns of living

Case Management

• The nurse coordinates case management to coordinate comprehensive health services and ensure constant care

Health and Maintenance

• Use strategies and interventions to promote and maintain mental health

Evaluation

• Requires evaluation of patient progress in obtaining expected outcomes

Advance Practice Intervention

• Performed by the Advanced Practice Registered Nurse in psychiatric and Mental Health specialists

Psychotherapy

• Use individual, group, and family psychotherapy assisting in the prevention or in treating mental illness and disability, overall health, and functional skill

Prescriptive Authority and Treatment

• The APRN-PMH uses prescriptive authority procedure and treatment in accordance with state and federal laws and regulations to treat symptoms of psychiatric illness and improve functional health status

Consultation

• The APRN-PMH provides consultation to enhance others, or affect chances in a system

Psychoanalytical Theory

• Freud's addresses the relationship among inner experiences, behavior, social roles, and functioning
• Conflicts among unconscious motivating forces affect behavior
• People develop certain structures in their mind or ways to maintain balance via defense mechanisms is called repression
• Freud viewed humankind as stimulus driven regarding drives as urges/impulses from biological/psychological needs which produces mental activity seeking gratification results in decreased tension

Primary Drives: Eros & Thanatos

• Eros: Instinct concerned with the survival of the species
• Thanatos: Expressed as aggression/hate directed inwardly (suicide) or outwardly (murder)

Structure of Personality: The id

• Represents psychological energy or “libido” that's primarily fueled by sexual, aggressive
• Developed as the first structure in personality the source of the pleasure principle in reducing tension, it is characterized by primary imaginary thinking, is irrational, not based on reality, and under unconscious control

Structure of Personality: The Ego

• Chief executive officer of the mind that mediates between the id, maintains reality via controlling inhibitive forces
• Operates on reality and providing the ability to delay needs
• Functions under conscious control

Structure of Personality: Super ego

• Functions for moral rewards/punishment, it is the conscience
• Residue of values internalized in childhood, and are unconscious

Result of An Unbalanced Structure

• When ego can't manage/mediate against unconscious drives, anxiety results as a warning
• Repression is an unconscious process keeping unacceptable impulses out of awareness

Development Theory

• Personality is almost completely developed by 5 years of age
• Adult traits and behaviors result from crucial events in development years

Oral Stage Birth-18 months

• Involves mouth stimulus is primary satisfaction via basic trust and identification
• Negative characteristics could present as autoeroticism or narcissism

Anal Stage: 18months-3 years

• Involves anal sex and gratification shifts to the anus. Basic self-control
• Developing sphincter control, auto control, and feelings of autonomy that produce a sense of reality but causes fear
• Retentive or expulsive characteristics

Phallic Stage: 3-5 years:

• Establishing sexual identity that results in basic social skills and identification
• Oedipal and castration anxieties develop from societal norms

Latency stage 6-12 years

• Focuses on peer experiences and intellect via leadership qualities and basic intellectual abilities
• Developing group identifying based on a internalized superego

Puberty and Adolescence – 12-15 years

• Established heterosexual relationship that results in social control in instincts and identity

Genital 15 years adult

• Sexual maturity includes resolving dependency and interdependence that results in normal relations

Application of Psychoanalytic Theory to Nursing

• Allows the understanding that unconscious conflict is the motivation behind behavior so it is important to remind ourselves that people cannot identify the motivation because it is unconscious, and highlights the role of anxiety in maladaptive patterns

Social Theories

• Reflect a significant social interaction that influence adaption on each stage across the individuals lifespan

Erik Erikson: Eight Stages of Ego Development

• His theories believes that a person's social view of themselves is more important than their libido.
• Believes that personality continues to develop and particular strengths must be upheld throughout all stages
• Failure to develop the characteristics can cause failure to adapt through all stages

Stage 1: Infancy

• Orally sensory period birth-1 year focused identifying trust vs mistrust during periods of mistrust results is a need for withdrawing

Stage 2: Early Childhood

• Muscle and Anus skills develop from 1-3 years during this period a shame and doubt vs autonomy is assessed, if they cannot control their own will power they become aware of the constraints from others resulting in doubt

Stage 3: Late Childhood

• locomotor and genital phases can be achieved from 3-5 years that results in guilt if not achieved through education and economic restrictions result in the need for denial

Stage IV: School Years

• Involves method and competence, as well as technology, so people will never be "great "at everything and pull themselves from school or peers as a result

Stage V: Adolescence

• With Ideology an Identity vs role confusion is characterized during devotion when the individual develops a lack of personal goals

Stage VI: Young Adulthood

• Intimacy vs Isolation is achieved when the individual develops relationship and devotion that lacks personality

Stage VII Adulthood

• A stage of Genrerativity when a lack of success results self-concern and impoverishing of self

Stage VIII Maturity

• Ego integrity vs despair occurs when someone has contempt for others because they cannot adjust to ageing

Carl Jung

• Discovered the human psyche by understanding art, myths, and folklore
• Archetype: A universal idea expressed in a mythical figure
• Persona: a public personality that the individual shows to other
• Shadow: a characteristic that contrasts the opposite of what the self, reflecting the wild side of the self
• Anima: is the feminine archetype in men
• Animus is the masculine archetype in women
• He believed that the healthy personality maintains a balance in all spheres-male and female, introversion and extroversion, conscious and unconscious

Interpersonal Relationship: Application to nursing

• Emphasized the importance of symbolism, rituals, and spirituality.
• We must understand the human mind as we enter our patient's environment

Alfred Adler

• Emphasized the importance of social forces or what one does in relation to internal biological factors
• Inferiority can be a motivation
• Proposes that people actively guide their own growth stimulating a need for growth throughout their life with behavioral traits

Basic Styles

• Avoiding
• Getting things from others
• Dominating others
• Cooperating with other people
• Healthy people must be self-reliant and cooperatively working with others with a mutual goal

Sullivan

• Cultural influence that greatly shape the direction of the infant
• Develops into the person their talking is when the person refers to me and I as the person's existence

Levels of Interacting during Infancy

• Babies will experience maternal anxieties and intuit a sense of security and the need to avoid a relationship with an authority

Juveniles

• Learn to accept authority figure relationship outside of the home

Early Adolescence

• Heterosexual relationship that attempts to integrate sex with the other relationships

Late Adolescence

• The relationship when individual learns how to master sexual relationships but form successful and satisfying communication

Karen horney

• Believes that people are dependent on each other with conflicted relationships which is why people tend to be so aggressive when they don't feel like their treated well

Cognitive Theories by Aaron Beck

• Emphasized the mental precess in the human knowing and perceiving that direct human attention
• cognitive distortion: Produces symptoms of psychological disturbances

Sensorimotor

• Child thinking from birth, the objects are the one's they see giving attention to the senses

Cognitive functions

• Ability for the child to develop a sense of knowledge and language from reality but casual reasoning's is also a limitation

Concrete operational

• A child's ability of objects and objects but limits the full development of abstract meaning

Formal operational

• Formal reasoning that reflects on inconsistency that develops into a series of functional problem-solving.

Piaget's Theory for Nursing

• help's to recognize a sense of impaired judgment that develops through interactions
• helps in gaining a overall understanding and knowing the correct steps that are important in nursing

All Behaviors

• A reflection of brain function that allows for a range for the nervous system

Dopamine

• Responsible for movement memory and emotional behaviors that is metabolized by a MAO.
• D1-5 Receptor allows for different degrees of stimulation and function where an overactivity is linked to schizophrenia

Norepinephrine

• Precursor for adrenaline
• Impacts anxiety and substance behavior

Serotonin

• Impacts many emotions
• Modulates wakenss
• Controls temp, sleep, and influences some senses.

Gamma-Aminobutyric Acid

• An inhibitory for modulator
• Is a prevention tool for stimuli

Glutamate

• Functions in specific ways, resulting in schizophrenia

Behavior function

• Functions on a motive where people are likely to follow if basic needs

Defense mechanism

• Provides protective force for instincts but if used they can be used the wrong way

Three defense mechanisms are

1. Use of behaviors

2. Expression of conflict as physical

3. Avoiding thoughts or events

• This Includes*

4. Intolerable thoughts and statements
5. shifting thoughts
6. Separation from conscious emotion
7. Identity
8. Application of thought
9. blame
10. Justification

Communication

Communication

Receiving giving of information containing there dimensions

1 Sender 2 Message 3 Reciever

• the receiver then gives feedback to the sender

Main factors of communication are:

• Attitude- Developed in various ways but can be described as, Prejudice, judgmental or open
• Sociocultural- Display of different patterns, and traditions
• Past experiences- Positive or negative experiences help better communication.
• Knowledge of the subject- Allows for a better connection and conversation

Factors that influence patterns of communication are:

Cultural and religious aspects

• Past experience
• Feelings
• Sociocultural beliefs

Types of communication that influence patterns are:

Verbal is direct and expressive

• Nonverbal- eye expression, posture, grooming, affect and even silence

Main components of types of communication are:

Intimate zone contact

1. social Zone
2. spatial territory
3. Personal space

Therapeutic phases are as following:

1. Open the conversation
2. be an active listener
3. Help the listener take note of your feelings

Main therapeutic tools

• Using silence- allow client to organize thoughts
• Listening- examining emotions with a message
• Open ended- encouragement from being accepting
• Restating Main thoughts the patient express
• Value that there is mutual understanding
• Clarifying- attempting to understand vague or unclear thoughts

Humor

• helps to connect emotionally

Sharing opinion

• understanding by knowing that the patient understands that his sharing is acceptable.

Therapeutic communications

• acceptance
• asking direct questions
• personal connection
• self-awareness
• understanding

All of these components can help better the ability to improve the success of treatment.

Phases of relationship:

• A goal of initial exploration
• identity and address misconseptions
• A goal of self exploration

Orientation phases for therapists

• Find patients thoughts and feelings
• Goal to find treatment plans
• Be flexible
• Identify patients behaviors

Termination phase

• The main goal is to set achievable goals and set a method for improvement and trust

Some tips you as a provider should take is:

• Help to remind them of the benefits
• Set reasonable plans
• Assure great follow up plans
• A good communication is key

therapeutic communications, you are crucial to:

• Establishing trust
• Honest conversations
• with*
• Genuineness
• Being honest at all points
• Being positive in everyway
• With having great understanding and sympathy will have a great connection

With constant use of a understanding is a great trait to possess a helpful therapeutic relationship

Main therapeutic impasses points

1 The most important part is the need for a helpful response that will allow for reduction in stress

• a key term to consider is resistance The ability to recognize the needs for the change
• Transference
• understanding the actions of patients behaviors
• counter-transference:
• Is transference applied to the nurse
• Boundary violation
• Occurs when the nurse goes outside the boundaries of the therapeutic relationship and
• A main point to keep in mind is restraint
• • is the direct application of physical force to a person

and key is be with clients

• It gives client a right to speak. without the nurse's
• Be available Confidential
• Duty for the nurse must be with a.
• The client is dangerous to other with a need for a the family and self worth
• A main ethical responsibility is to have a clear conscience
• The steps one must take. . .
• 1. Understand the main laws
• 2 Use set standards
• 3 . Respect those around you
• A normal way that you show you love them is with autonomy

Anger is part in many cultures:

• Asian/ Native show a high respect
• The main point for any cultures
• To manage a safe spot for everyone

a major step should be to know that the clients is not in distress or distress . . .

• Give comfort when possible. . .
• A key to deescalate is to
• Recognize and give space
• Give empathy

that clients are in distress and needs some assistance

A key step for you as a provider is to be reassuring while giving advice. The goal is to teach angry feelings verbally without threats or harm to others.

The goal: is with good management.