Introduction to Psychiatric Nursing Lecture Notes PDF

**Introduction to Psychiatric Nursing** At the end of eight hour-hour lecture the learners will be able to: Knowledge 1. Describe at least two personality traits in theirselves that could affect their ability to interact with clients in the clinical setting. 2. State the goals of the t...

**Introduction to Psychiatric Nursing** At the end of eight hour-hour lecture the learners will be able to: Knowledge 1. Describe at least two personality traits in theirselves that could affect their ability to interact with clients in the clinical setting. 2. State the goals of the therapeutic Nurse-patient relationship. 3. Describe the nurse's tasks and possible problems in the four phases of the relationship process. 4. Discuss the level of, two models of the communication process, and therapeutic communication techniques communication. 5. Analyze how the nurse uses each of the responsive dimensions in a therapeutic relationship. 6. Analyze how the nurse uses each of the action. 7. Evaluate therapeutic impasses, and identity nursing intervention to deal with them. I. Hx of Psychiatric Nursing II\. Self Awareness Things to ponder before anything else: a. Do you have any fears? b. Do you feel nervous knowing that you will be interacting with clients in a psychiatric-mental health setting? c. Do you feel adequately prepared to provide proper interventions for clients and clinical symptoms of mental illness? d. Do you have any prejudice or feelings of intolerance about persons who are hospitalized in psychiatric-mental health facilities? Frequently ask questions: a. Will the client know that I am a student nurse? Yes! The unit staff, clinician or supervisor is responsible for informing clients about the purpose of the clinical rotation and explaining that the student nurse will be present for a specific time period. b. How do I introduce myself? The use of name tags. (First name only) Never give your client any personal information about yourself and colleagues. c. What do I wear? CHN uniform. d. What if I say the wrong things? Do not be afraid that you might say the wrong things. Just be sincere, honest, show respect for the clients and display a caring attitude trust from clients and staff. e. Will I be left alone with a client? Yes. Your C.I. and unit staff or clinician will determine which clients are appropriate for an assignment and whether you will be left alone or not. f. What if the client becomes Violent? Staffs in Mental institution are well experienced in assessing the client's potential for violence. Notify your C.I. and a number of the nursing staff and be ready to follow instructions. Recommendations: - Avoid making assumptions about any client's medical or psychiatric history. - Don't hesitate to approach your clinical supervisor or a staff member with questions about your assigned client's needs or plan of care. - Feel free to discuss with your instructor any feeling that you have about your clinical rotation or your assigned client. - Take time to adjust at a slower pace. - Don't become frustrated with a client who refuses to speak to you. - Be patient with a client who requires repeated prompting to complete a task. - Recognize that listening, observing, and self awareness are important tools that you posses when providing care. Self Awareness: - Refers to the ability to recognize the nature of one's own behaviour, attitude, and emotions. - It can be an effective tool when interacting with clients who are exhibiting anxiety, depression, confusion, or psychosis. Questions: Have you ever reflected on your personality traits or distinguishing characteristics of your personality? The extrovert - Is an outgoing person who relates more easily to people and things in the environments. - Likes to take charge of situations. - Has little difficulty in socializing. The introvert - Is a quiet individual who relates better to the inner world of ideas, thoughts, and feelings. - Prefer to be a follower, and usually lets others initiate and direct interaction. Open-minded Attitude - Do not make decisions until they are aware of all facts pertaining to a certain situation. Judgemental Attitude - Are often inflexible. - Run the risk of neglecting the perception of others. - Possibly arriving at an opinion based on their own values without enough facts or enough regards for what other people may feel or think. III\. Psychiatric Nursing "A glimpse" - In any clinical setting, you'll encounter patients with mental and emotional problems. - You'll inevitably care for patients with depression, anxiety or thoughts disorders, or dementia. - To provide effective care for any patient, you must consider both the psychological and physiological aspects of health. Many medical conditions are linked to or lead to emotional and mental distress. Example: chest pain - anxiety and depression. Anxiety - chest pain. Recognizing such problems and how they affect the patients over all health is crucial. Psychiatric Nursing does not revolve around the corners of the psychiatric-mental health unit; it has grown in number and diversity. Mental Health program can be found almost anywhere. Example: family advocacy, substance abuse rehabilitation, stress management, domestic violence shelter, school guidance and counselling. You can found them in books, not only in medical library but also in self help books, media, and magazines. Links between Stress and Disease (the mental health illness continuum) - Hans Selye - a pioneer in stress research. - Found a link between the environment and biological response. - Noted that emotional and physical stress because a pattern of response that unless treated, leads to infection, illness, disease and eventually death. - He called this set of response the general adaptation syndrome and the identified three stages: 1. Alarm reaction 2. Resistance 3. Exhaustion 1\. Alarm stage - During this stage, any type of physical or mental trauma triggers immediate biological responses designed to counteract stress. These responses depress the immune system, which lower resistance and make the person suitable to infection and disease. Unless the stress is severe or prolonged, though, the person recovers rapidly. 2\. Resistance - Begins when the body starts to adapt to prolonged stress. The immune system shifts into high gear to meet increased demands. At this point, the person becomes more resistant to illness. - However, the perception of the threat still lingers so the body never reaches complete equilibrium. Instead it stays aroused, which places stress on body organs and system. - Because adaptation appears to work initially, a person in the resistance stage may become co placement and assumes he is immune to the affects of stress and thus fail to take steps to relieve it. 3\. Exhaustion - With chromic stress, adoptive mechanisms eventually wear down, and the body can no longer meet the demands of stress. Immunity and resistance decline dramatically and illness is likely to set in the point at which exhaustion occurs differs among individual. Interrupting the stress responses Selye's work laid the groundwork for the use of relaxation techniques in interrupting the stress response, thereby reducing susceptibility to illness and disease. Social Factor - Some researchers attribute today's seemingly increased incidence of mental and emotional disorders to social changes that have altered the traditional family structure and contributed to loss of the extended family. - Loss of effective support systems strains a person's ability to cope with problems. " No man is an island" - Mental disorders occur at all ages and socioeconomics levels. - Rates of teenage depression and suicide have more than tripled in the past 20 years especially alcohol and substance abuse. - Among elderly -- isolation, fear of violent crime and loneliness = rise in depression. American Psychiatric Associations Diagnostic and Statistical Manual of Mental Disorders, Fourth Education, Text Revision - Defines a mental disorder as a clinically significant behavioural or psychological syndrome or pattern associated with at least one of the following 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. Five axes for greater diagnostic details; the DSM -- IV -- TR uses a multiracial approach, which specifies that every patient be evaluated on each of five axes. Axis I -- Clinical Disorders - Mental disorders comparable to general medical illness Axis II -- Personality Disorders and Mental Retardation - Personality disorders and traits as well as mental retardation. Axis III -- General Medical Condition - General medical illness or injury. Axis IV -- Psychosocial and Environmental Problems - Life events or problems that may affect diagnosis of mental disorder. Axis V -- Global Assessment of Functioning (GAF) - Level of functioning reported as a number from 0-100 base on the patient's over all psychological, social, and occupational function. Example: Axis I -- adjustment disorder with anxious mood Axis II -- Obsessive Compulsive Personality Axis III -- Crohn's disease, acute bleeding episodes Axis IV -- recent remarriage, death of father. Axis V -- GAF -- 83 **Role of Psychiatric Nurse** Elements of the Psychiatric Nursing role - No longer can psychiatric nurses focus exclusively on bedside care and the immediacy of patient needs. - The current practice of psychiatric nursing requires greater sensitivity to the social environment family/families. - It also requires thoughtful consideration of complex legal ethical dilemmas that arises from a delivery system. - Each of these elements must influence the education, research and clinical aspect of contemporary psychiatric nursing practice. Continuum of Care The Domains of Contemporary Psychiatric Nursing Practice Teaching Direct Care Communication Coordination Delegation Collaboration Management The Versatile Nurse Roles - - Staff Nurse - Primary Care provider - Administrator - Consultant - In-service educator - Clinical fractioned - Researcher - Program evaluator - Liaison between the patient and other health care team member **The Nursing Process of Actual and Risk Problems** **Cyclic and Dynamic Nature of the Nursing Process** iii **Standard I: Assessment** The nurse collects patient health data. Rationale: The assessment interview which requires linguistically and culturally effective communication skills, interviewing, behavioural observation, record review, and comprehensive assessment of the patient and the relevant system. **Standard II: Diagnosis** The nurse analyzes assessment data to determine applicable diagnosis. Rationale: The basis for providing psychiatric and mental health nursing care is recognizing and identifying patterns of response to actual or potential psychiatric illness, mental health problems, and potential co morbid physical illness. **Standard III: Outcome Identification** The nurse identifies expected outcomes individualized for the patient. Rationale: Within the content of providing nursing care, the ultimate goal is to influence health outcomes and improve the patient's health status. **Standard IV: Planning** The nurse develops a care plan that's negotiated among the patient, nurse, family and significant others, and health care team -- the plan prescribes evidence -- based interventions to attain expected outcomes. Rationale: A care plan is used to guide therapeutic intervention, systematically document progress and achieve expected patient outcomes. **Standard V: Implementation** The nurse implements the interventions identified in the care plan. Rationale: Nurses use a wide range of interventions designed to prevent mental and physical illness to promote, maintain, and restore mental and physical health. Standard V a: Counselling - Uses counselling interventions to assist patients in improving or regaining their previous coping abilities, fostering mental health, and preventing mental illness and disability. Standard V b: Milien therapy - The nurse provides, structures, and maintains a therapeutic environment in collaboration with the patient and other health care provider. Standard V c: Promotion of self--care abilities - The nurse structures interventions around the patient's activities of daily living to faster self-care and mental and physical well-being. Standard V d: Psychobiological Intervention - Applies skills to restore the patient's health and prevent further injury. Standard V e: Health Teaching - Through health teaching, the nurse assists patients in achieving satisfying, productive and healthy patterns of living. Standard V f: Case Management - The nurse provides case management to coordinate comprehensive health services and ensure continuity of care. Standard V g: Health promotion and health maintenance - The nurse uses strategies and interventions to promote and maintain mental health and prevent mental illness. Standard VI: Evaluation The nurse evaluates the patient's progress in obtaining expected outcomes. Rationale: Nursing care is a dynamic process involving change in the patient's health status overtime, giving rise to the need of new data, different diagnoses, and modifications in the care plan. This is a continuous process. Advance Practice Intervention - Performed by the Advanced Practice Registered Nurse in psychiatric and Mental Health (APRN-PMH) specialist. Standard V h: Psychotherapy - The ARRN-PMH uses individual, group, and family psychotherapy and other treatment to assist patients in preventing mental illness and disability, treating mental health status and functional abilities. Standard V i: 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. Standard V j: Consultation - The APRN-PMH provides consultation to enhance the abilities of other clinicians, provides service for patients, and affect change in the system. **Theories and Determinants of Psychopathology: Implications for Mental Health-psychiatric Nursing Practice** - **Why do patients or a person behave in such?** ***Psychoanalytical Theory*** - Freud's addresses the relationship among inner experiences, behaviour, social roles, and functioning. - Proposes that conflicts among unconscious motivating forces affect behaviour. - People usually don't like conflicts and therefore develop certain structures in their mind or ways to maintain balance. This defense mechanism is called repression. Drives- Freud, viewed humankind as stimulus driven. - Human's perceived stimulus as a state of excitation know as drive or instinct. - Drives are urges and impulses arising from biological and psychological needs. - They produce mental activity that seeks gratification, or discharge; that results in a decrease in tension. The two Primary Drives **Eros** - Instinct that concerned with self-preservation and survival of the species. **Thanatos** - Is expressed as aggression or hate which can be directed inwardly (suicide) or outwardly (murder) Structure of Personality **The id** - Represents psychological energy or "libido" - Is primarily a sexual and aggressive drive. - Is the first structure to develop in the personality - It operates on the pleasure principle to reduce tension. - Characterized by primary process thinking-imaginary - It is irrational and not based on reality - Under the unconscious control. **The ego** - The chief executive officer of the mind. - Mediates between the id and the super ego. - Maintains reality orientation - Keeps the strong forces of the super ego from being extremely inhibitive. - Keeps the strong forces of the id from causing the person overly exhibitionistic. - Operates on reality principle. - Characterized by secondary process thinking. - Provides a means of delaying gratification of needs. - Under the conscious control. **The super ego** - Functions as reward or punishment - Rewards moral behaviour - Punishes actions that are not acceptable by creating guilt. - Is also known as conscience - A residue of internalized values and moral training of early childhood. - An overly strict super ego may lead to extremes of guilt and anxiety - Unconscious control - When ego can't manage or mediate against the unconscious drives, anxiety results. - Anxiety is a warning to the ego of an emerging danger - Repression is the first line of defense, it is the unconscious process that keeps unacceptable impulses out of awareness and prevents these impulses from becoming conscious. ***Psychosexual Theory of Development*** - Adult character traits, behaviours, and thinking process are a result of crucial events in the development years. - Personality is almost completely develop or formed by 5 years of age. **Oral Stage: (birth 18-months)** - Stimulation of the mouth is the primary source of satisfaction. Critical Experiences wearing Developmental Task Establishing Trust Major Characteristic Autoeroticism, narcissism, omnipotence, pleasure principle, frustration and dependence. Other Possible Personality traits Fixation at the oral stage is associated with positivity, gullibility, and dependence, the use of sarcasm, and the development of orally focused habits smoking, nail biting) the instinctual behaviour that motivates the person to receive gratification by symbolically swallowing the important other. **Anal Stage: (18months-3 years of age)** - Sexual gratification shifts to the anus Critical Experience Toilet training Development Task Developing sphincter control, self control, and feeling of antonomy. Major Characteristic Reality principle, fear of loss of beginning super ego development. Other possible Personality Traits Fixation associated with anal retentiveness (stinginess, rigid thought pattern, obsessive -- compulsive disorder) or anal expulsive character (Messiness, destructiveness, cruelty) **Phallic (3-5 years)** Critical Experience Oedipal conflict, castration anxiety Development Task Establishing sexual identity, beginning socialization Major Characteristic Differentiation between the sexes, super ego more internalized Other possible Personality Traits Unresolved outcomes may result in difficulties with sexual identity and with authority figures. **Latency (6-12 years)** Critical Experience Peer group experience, intellectual growth Developmental Task Group Identification Major Characteristics Super ego influence in erotic interest, immense intellectual development. Other possible Personality Traits Fixation can result in difficulty in identifying with others and in developing social skills, resulting in a sense of inadequacy and inferiority. **Puberty and Adolescence (12-15 years)** Critical Experience Established Heterosexual Relationship Developmental Task Developing social control Over instincts Major Characteristics Identity, turmoil, consideration of needs of others. **Genital (15 years -- adult)** Critical Experiences Sexual Maturity Developmental Task Resolving dependence -- independence conflict Major Characteristics Heterosexual relations Other Possible Personality Traits Inability to negotiate this stage could result in difficulties in becoming emotionally and financially independent, lack of personal identity and future goals, and inability to form satisfying intimate relationships. **Applications of Psychoanalytic Theory to Nursing** - The understanding that the role of unconscious conflict is the motivation of behaviour. - When we are tempted to ask "why did you... "we are reminded that the person cannot identify the motivation because it is unconscious. - This theory has demonstrated the central role of anxiety in maladaptive behaviour. - We have to be aware of the client's defense mechanism against instinctual demands and anxiety. - Once we recognize the defense mechanism, we know that the anxiety may need to be reduced before the defences can be disengaged. **SOCIAL THEORIES Erik Erikson, Carl Jung** - Social theories reflect a significant social interaction that governs developmental milestones that influence adaptation across the lifespan. - Focus on challenges and achievements of each development stage and their impact resolving the next stage. ***Erik Erikson: Eight Stages of Ego Development*** - Student of Anna Freud - Believed that a person's social view of self is more important than libidinal urges. - Believed the personality development continues over the lifespan. - Particular strengths to develop at each stage and must be upheld throughout the lifespan to be useful. - The task of identity is seen as the major predicted on comfortable resolution of identity. - Failure to resolve each development task leads to mal adoption or mental illness (particularly trust). - Realistically each task is not mastered after resolution, thus each needs to be mastered enough to effectively cope with conflicts of later stages. **Stage I: Orally-Sensory (birth- 1 year) Infancy** Nuclear Conflict - Trust vs. Mistrust - Drive and Hope - Religion - Ability to trust others and a sense of one's own trust worthiness; a sense of hope - Withdrawal and estrangement **Stage II: Muscular-Anal (1-3 years) Early Childhood** Nuclear Conflicts - Autonomy vs. Shame and doubt - Self-control and will power - Law and Order **Stage III: Locomotors-genital (3-5 years) Late Childhood** - Initiative vs. Guilt - Direction and purpose Institution - Education and economic Concepts/Basic Attitude - Realistic sense of purpose, ability to evaluate one's behaviour - Self denial and self restriction **Stage IV: Latency (6-11 years) School age** Nuclear Conflict - Industry vs. Inferiority Strengths - Method and competence Institution - Technology - Realization of competence, perseverance - Feeling that one will never be "any good" withdrawal from school and peers. **Stage V: Adolescence (12-18 years)** Nuclear Conflict - Identity v. Role confusion Strengths - Devotion and Fidelity Institution - Ideology Concepts/Basic Attitude - Coherent sense of self, plans to actualize one's abilities - Feelings of confusion, indecisiveness, possibly antisocial behaviour. **Stage VI: Young Adulthood (19-35 years)** Nuclear Conflict - Intimacy vs. Isolation Strengths - Devotion and fidelity Institution - Ethics Concepts/Basic Attitude - Capacity for love as mutual devotion, commitment to work and relationship - Impersonal relationships, prejudice possessive **Stage VII: Adulthood (35-50 years)** Nuclear Conflict - Generatively vs. Stagnation Strengths - Production and care Institution - Generative succession Concepts/Basic Attitudes - Creativity, productivity, concerns for others - Self-indulgence, impoverishment of self. **Stage VIII: Maturity (50 + years) Old Age** Nuclear Conflict - Ego integrity vs. Despair Strengths - Renunciation or letting go and wisdom Concepts/Basic Attitudes - Acceptance of the worth and uniqueness of one's life, accepts death with dignity - Sense of loss contempt for others - Levels on past failures, inability to adjust to aging process. ***Carl Jung (1967)*** - From his study of international myths, arts and folklore, he discovered repeated images that he called "archetypes". An archetype can be a mythical figure, hero, powerful father, nurturing mother, the wicked witch. **Persona** - "a powerful archetype" which is a public personality, the aspect of a self that one's reveals to others. The role that society expects one to play. **Shadow Archetype** - Contains the opposite of what we feel ourselves to be. - Reflects the prehistoric fear of wild animals and represents the animal side of human nature. - Recognizes that humans are psychologically bisexual, that is "masculine" and "feminine" qualities are found in both sexes. **Anima** is the feminine archetype in men. **Animus** is the masculine archetype in women. - Views motivation comes not only from past conflicts but also from future goals and the need for self-fulfilment. **The Two Basic Personality Orientations:** **Introversion** - The inward, cautions, shy, timid and reflective. **Extroversion** - The outgoing, sociable, assertive and energetic. He believes that the healthy personality maintains a balance in all spheres-male and female, introversion and extroversion, conscious and unconscious and has the ability to accept the past and strive for the future. Application to Nursing - Jung emphasized the importance of symbolism, rituals, and spirituality. - We have to be aware as we enter in our client's environment, the symbols of importance to that person. Thus rituals of self-care and the conflicts and anxiety when those rituals interfere with growth and health. **INTERPERSONAL SOCIAL THEORY** - Emphasizes the importance of social forces or what one does in relation to others than internal or biological factors. - Asserts that the adult mental disorder stem from impaired interpersonal relationship of childhood. **Alfred Adler** - Emphasizing the conscious as the core of personality. - Believed that one's social environment shape personality and interactions and that people actively guide their own growth and development. - Proposed that inferiority feelings are stimulates for growth. - Inferiority complex is a exaggeration of feelings of inadequacy and insecurity resulting in defensive and neurotic behaviour. - The creation of a unique pattern of striving for superiority is learned from early parent child interaction. - 3 Categories of Problems in a Person's Life Time 1. Problems involving behaviour toward others 2. Problems of occupation 3. Problems of love - 4 Basic Styles in Working through Problems 1. Avoiding 2. Expecting to get anything from others 3. Dominating others 4. Cooperating with others - Healthy people are characterized by self-reliance and cooperatively working with others within the culture. **Harry Stack Sullivan (1940)** - Cultural environment greatly shapes personality and that personality development does not end at 5 of age but continues until young adulthood. - Emphasized in the development of the self-concept which be called personification. - The persona is what one talking about when one refers to "I or me". This starts to develop from infancy. - The persona, or self- concept begins with the idea of "good me", "bad me", and "not me". - The "good me" is perceived when the mother is rewarding the infant. - The "bad me" arises in response to the negative experiences with the mother. - The "not me" arises out of extreme anxiety that the child rejects as part of the self. - As development proceeds, the child integrates these persons into a realistic view of self. - Emphasized the importance of peers and reciprocal relationships to the developing child and adolescent. Sullivan's Sages of Healthy Interpersonal Development from Birth to Maturity Phases / Levels of Interacting, Communicating and Comprehending Infancy - Experiences maternal tenderness and intuits maternal anxieties, struggles to achieve feelings of security and to avoid anxiety. Childhood - Modifies actions to suit social demands in sex-role training, peer play and family events. Uses movement and language to avoid anxiety. Juvenile - Learns to accept subordinate to authority figures outside the family. More concepts of self-status and role. Preadolescence - Capable of participating in genuine love relationship with others. - Develops consideration and concerns outside the self. Early adolescence - Heterosexual contacts enter into personal relationship. - Attempts to integrate sex with other personal relationship. Late adolescence - Masters expression of sexual impulses. Forms satisfying and responsible associations. Uses communication skills to protect self from conflicts with others. **Karen Horney (1937)** - Believed that people are dependent on each other. - Often in a state of anxious conflict when others do not treat they well. - People/children may become aggressive as a way of protecting what little security they do have. - Or become too submissive, selfish, self-pitying as a way of gaining attention or sympathy. - 3 Ways People Relate with each other: 1. Move toward others -- seeking love support and cooperation. 2. Move away from others -- to be independent, self-sufficient. 3. Against each other's -- to be competitive, critical and domineering. **COGNITIVE THEORIES** - The person's perceptions and interpretations influence subsequent biological and behavioural responses. - If the person consistently misinterprets or generalizes an event, emotional and physiological distress and mal adaptation are likely to occur and require interventions that restore homeostasis. **Aaron Beck (1991)** - Emphasizes the mental processes involved in knowing. - Cognitive theorists look at how people direct their attention, perception, thinking etc. - Believes that Schemata shape personality patterns that consist of a person's beliefs, values, and assumptions. - Schemata develop early in life form experience and response to stressful stimuli. - Cognitive distortions produce the symptoms of various psychological disturbances and mediate psychological responses that contribute to anxiety and mood disorder. - Clients in cognition themes of loss or defeat are likely to be depressed. - Clients in anxiety disorder interprets situation as dangerous. - In paranoid condition, the person selecting interprets themes of abuse or interference. - Exaggerated interpretations of personal gain characterize the client with mania. **Beck's six common cognitive distortions that result in maladoptive behaviours:** 1. **Arbitrary interference:** the process of drawing a specific conclusion in the absence of evidence to support the conclusion: the evidence may be contrary to the conclusion. 2. **Selective abstraction:** Focusing on a detail taken out of context, ignoring more salient features of the situation, and conceptualizing the whole experience on the one detail. 3. **Overgeneralization:** the pattern of drawing a general rule or conclusion from one or more isolated incidents and applying the concepts across the board to related and unrelated situation. 4. **Magnification and Minimization:** errors in evaluating the significance or magnitude of an event that is as gross as to constitute a distortion. 5. **Personalization:** the productivity to relate external events to oneself when there is no basis for making such a connection. 6. **Absolutist (dichotomous) thinking**: places all experiences in one of two opposite categories, e.g. saint or sinner, flawless or defective. In describing himself, the patient selects the extreme negative categorization. **Jean Piaget (1958)** - Proposed a sequence of cognitive development that emphasized the relationship between action and thought. - Identified stages that are characterized by distinctive features in the pattern of a person's reasoning. **First Stage -- sensor motor** - Characteristic of child's thinking from birth to about 2 years of age. - The young infant appears to think that the only object that exist are the objects that can be seen. - Information is obtained through the senses and motor action. **Second Stage -- preoperational stage (2-7 years)** - Moves through three periods - First period - Children can differentiate an image or a word from what it stands for. - Children to develop representational thought and can grasp several events as they begun to speak. - Can differentiate image and language from action and reality, but they lack casual reasoning. - Second period (4-5 ½ years) - Children are more able to examine and set about a specific task, adopt their intelligence to it, and reason about more difficult everyday problems. - Reasoning has a tendency to centre on some striking feature of the object in the exclusion of other relevant aspect resulting in distorted reasoning. - Situation is viewed egotistically from a personal point of view. **Third stage (5-6 years)** - The rigid and irreversible intellectual structures begin to become more flexible, and children begin the transition of the 3^rd^ stage of through. 3^rd^ stage Concrete operational (7-11 years) - Operations are mental actions that have a definite and strong structure. - Logical thoughts extend only to objects and events of first-hand reality. - Able to consider two contrasting features e.g. height and width. - At 7-8 years they begin to look at their own thinking and monitor it. - Starts to look at alternative actions that will achieve the same outcome. 4^th^ stage Formal operational (11 adulthood) - Logically solves all types of problems - Stage of formal reasoning - Thinks scientifically - Reflects on their own reasoning to look for inconsistencies. Application to Nursing - Piaget's theory of cognitive development helps nurses recognize impaired development. - Assessing knowledge level of client and family education needs is an integral part of nursing care. **NEUROBIOLOGICAL THEORIES** - All behaviours are a reflection of brain function and all thought processes represents a range of functions mediated by nerve cells in the brain. **Dopamine (DA)** - Is primarily responsible for fine motor movement, sensory integration, cognition, memory, and emotional behaviour. - DA is metabolized by monoamine oxidize (MAO). - DA has 5 receptors D1-D5 and carries out different degrees of stimulation or inhibition of the post synaptic response. D4 receptors have a greater affinity for "a typical antipsychotic agents". - Hyperactivity of the dopaminergic system is implicated in schizophrenia and mania, where as hypoactive dopamine systems are believed to contribute to depression and Parkinson's disease. - Plays a major role in addiction because drugs such as cocaine, opiates, and alcohol increase the amount of dopamine to act on D2 receptors and stimulates the reward system in the brain. **Norepinephrine (NE)** - Is the precursor of adrenaline, the main ingredient in the sympathetic "fight or flight" response. - NE transmission and reuptake are impaired in a variety of mental illness, but primarily in the anxiety and substance- related disorder. **Serotonin** - Secreted in the raphe nuclei and hypothalamus. - They modulate wakefulness and alertness. - Influence the transmission of sensory pain. - Controls the temperature, sleep, hunger. - Alternation to the serotonergic system or serotonin (5-HT) function a long with NE has been implicated in the pathogenesis of depressive syndrome. - The restoration of the normal function of 5-HT and NE has been targeted by antidepressant medication. **Gamma -- amino butyric acid (GABA)** - Is an inhibitory neurotransmitter that serves as the brain's modulator - Counteracts the effects of the excitory neurotransmitter NE and DA, preventing disorganize frenzied responses to stimuli and dampening emotional arousal. - Persons in GABA or fewer GABA receptors are more vulnerable to anxiety disorder and panic symptoms. **Glutamate and N-methyl-D-asparate (NMDA)** - Glutamate is the main excitory neurotransmitter - Hypo function in glutametergic function, specifically involving the neurotransmission of NMDA-type glutamate receptors play a vital role in the pathogenesis of negative symptoms of schizophrenia and anxiety. **HUMAN NEEDS THEORY** Needs motivates the behavior of a person If basic needs are not met, illness is likely to follow. **Defense Mechanism** **Ego Defense Mechanism** - Are considered protective barriers used to manage instinct and affect in stressful situations. - They may be used to resolve a mental conflict, to reduce anxiety or fear, to protect one's self-esteem, or to protect one's sense of security. - Depending upon their use, they 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 behaviour. 1. Compensation unconscious use of a specific behaviour to make up for a real or imagined in ability or deficiency, thus maintaining self-respect or self-esteem. 2. Conversion unconscious expression of a mental conflict as a physical symptom to relieve tension or anxiety. 3. Denial unconscious refusal to face thoughts feeling, wishes, needs, or reality factors that is intolerable. 4. Displacement unconscious shifting of feelings such as hostility or anxiety from one idea, person, or object to another. 5. Dissociation separation and detachment of a strong emotionally charged conflict from ones consciousness. 6. Identification unconscious attempt to identity with personality traits or actions of another to preserve one's self-esteem or to reach a specific goal. 7. Introjections unconscious application of the philosophy, ideas, customs, and attitudes of another person to one's self. 8. Projection unconscious assignment of unacceptable thoughts or characteristics of self to others. 9. Rationalization unconscious justifications of one's ideas, actions, or feelings to maintain self-respect, prevents feelings of guilt, or obtain social approval 10. Reaction -- formation unconscious demonstration of the opposite behaviour, attitude, or feeling of what one would normally show in a given formation. 11. Regression retreat to past developmental stages to meet basic needs. 12. Restitution negation of a previous consciously intolerable action or experiences. 13. Sublimation unconscious rechanneling of intolerable or socially unacceptable impulses or behaviours into activities that are personally or socially acceptable. 14. Substitution unconscious replacement of unacceptable impulses, attitudes, needs, or emotions with those that are more acceptable. 15. Suppression voluntary rejection of unacceptable thoughts and feelings from conscious awareness. 16. An engagement ring symbolizes love and a commitment to another person. 17. Undoing act or communication that partially negates previous ones, a primitive defense mechanism. **THERAPEUTIC COMMUNINCATION AND RELATIONSHIP** **COMMUNICATION** refers to the giving and receiving of information involving three elements. 1. The sender, 2. The message, 3. The receiver. the feedback is message sent by the receiver to the sender. Factors Influencing Communication 1\. Attitude Attitudes are developed in various ways. They maybe the result of interaction with the environment; assimilation of others' attitude; life experiences; intellectual processes, or traumatic experience. Can be described as accepting, caring, prejudiced, judgmental, or open or closed mended. Ex. A negative and or close minded attitude may respond with "It won't work", "It's no use trying" a positive or an open minded attitude may state "Why not try it?" , We have nothing to lose". 2. Sociocultural or Ethnic Background Various cultures and ethnic groups display different communication patterns. Ex. Southeast Asian are reserved French and Italian are talkative and aggressive. 3. Past Experiences Previous positive or negative experiences influence one's ability to communicate. Ex. Teenagers who have been criticized by parents whenever attempting to express any feelings may develop a disturbed self-concept and feel that their opinions are not worthwhile. 4\. Knowledge of Subject Matter A person who is well educated or knowledgeable about certain topics may communicate with others at a high level of understanding. The receiver of the message may be unable to comprehend the message or may consider the sender to be a "know-it-all expert". 5\. Ability to Relate to Others Some are "natural-born talkers" 6\. Interpersonal Perceptions Are mental processes by which intellectual, sensory, and emotional data are organized logically or meaningfully. Satir (1995) warns of looking without seeing, listening without hearing, touching without feeling moving without awareness and speaking without meaning. - How we perceive others or assume what they think. Inattentiveness, disinterest, or lack of use of one's senses during communication can result in distorted perception. 7\. Environmental Factors Time, place, number of people present, and the worse level can influence communication. Types of Communication 1\. Verbal Communication Usually takes place through the spoken words but sometimes involves written communication. **Factors that can influence verbal communication.** Past experiences Feelings Cultural and religious background Sociocultural States To overcome these potential obstacles, you must learn about -- and how to show sensitivity to your patient's experiences, beliefs and background. Be sure to listen intently as the patient speaks. This will allow you not only to hear and analyze what he says but also to interpret his communication pattern 2\. Non-Verbal Communication Includes eye contact, facial expression, posture, gait, gestures, touch, physical appearance or attributes, dress or grooming, affect and even silence. Eg. Vocal Clues - note for pausing or hesitating while conversing, talking in a tense or flat tone, or speaking tremulously. Gestures -- pointing, finger tapping, winking, hand clapping, eyebrow raising, palm rubbing, hand wringing and beard/ hair stroking. They may betray feelings of insecurity; anxiety, apprehension, power, enthusiasm, eagerness or genuine interest. Distance or Spatial Territory Zones of distance awareness 1\. Intimate Zone body contacts, for intimate relationships 2\. Personal Zone 1 ½ to '4 feet "arms length" to include holding hands, Zone for therapeutic communication. 3\. Social Zone 4 feet -- 12 feet, for formal business and social discourse. 4\. Public Zone 12 -- 25 no physical contact, minimal eye contact, people remain strangers. Social Communication vs. Therapeutic Communication Social Communication occurs daily as the nurse greets the client. Also referred as small talk. may be referred to as doing a favor for another person. A person or intimate relationship occurs. The identification of needs may not occur Person goals may or may not be discussed Constructive or destructive depending may occur A variety of resources may be used during socialization Therapeutic Communication promotes the functional use of one's latent inner resources. Encouraging verbalization of feelings or exploring ways to cope with increased stress A personal but not intimate, relationship occurs Needs are identified by the client with the help of the nurse. Personal goals are set by the client Constructive dependency, interdependency, and independence are promoted Specialized professional skills are used while () **The Therapeutic Communication Techniques** 1\. Using Silence Allows the patient time to think and gain insights, slows the pace of the interaction, and encourages the patient to initiate conversation, while conveying the nurse's support, understanding, and acceptance Threat Questioning the patient; asking for "why" responses; failure to break a () silence 2\. Listening an active process of receiving information and examining reaction to the message received. Eg Maintaining eye contact and receptive nonverbal communication Value Nonverbally communicates to the patient the nurse's interest and acceptance Threat failure to listen 3\. Broad Opening or Open ended Questionings Encouraging the patient to select topics for discussion Eg "What are you thinking about?' Value Indicates acceptance by the nurse and the value of the patient's initiative Threat Domination of the interaction by the nurse; rejecting responses 4\. Restating repeating the main thought the patient expressed. Eg "You say that your mother left you when you were 5 y.o." Value Indicates that the nurse s' listening and validates, reinforces, or calls attention to something important that has been said. Threat lack of validation of the nurse's interpretation of the message, being judgmental, reassuring, defending 5\. Clarification / Clarifying attempting to put into words vague ideas or unclear thoughts of the patient to enhance the nurse's understanding or asking the patient to explain what he means Eg "I'm not sure what you mean. Could you tell me about that again?" Value Helps clarifying feelings, ideas and perception of the patient and provide an explicit correlation between them and the patient's action Threat Failure to probe, assumed understanding 6\. Reflection / Reflecting Directing back the patient's ideas, feelings, questions, or comment Eg "You're feeling tense and anxious, and it's related to a conversation you had with your husband. Last night?" Pt. "I think I should take my medication" Nurse. "You think you should take your medication?" Value Validates the nurse's understanding of what the patient is saying and signifies empathy, interest and respect for the patient. Threat Stereotyping the patient's responses, inappropriate timing of reflections; inappropriate depth of feeling of reflection 7\. Humor The discharge of energy through the comic enjoyment of the imperfect Eg. 'That gives a whole new meaning to the word nervous." Value Can promote insight by making conscious repressed material resolving paradoxes, tempering aggression, and revealing new options; a socially acceptable form of sublimation. Threat Indiscriminate use; belittling patient; screen to avoid therapeutic intimacy 8\. Giving information / informing the skill of information giving Eg. I think you need to know more about how your medication works Value helpful in health teaching or patient education about relevant aspect of patient's well-being and self-care. Threat Giving advice 9\. Focusing / focusing on specifics Questions or statements that help the client expand on a topic of importance Eg. "Tell me more about your job." Value Allows the patient to discuss central issues and keeps the communication process goal-centered or goal-directed Threat Allowing abstractions and generalizations, changing topics. 10\. Sharing Perception Asking the patient to verify the nurse's understanding of what the patient is thinking or feeling. Eg. "You're smiling, but I sense that you are really very angry with me." Value Conveys the nurse's understanding to the patient and has the potential for clearing up confusing communication Threat Challenging the patient; accepting literal responses, reassuring; testing; defending. 11\. Theme Identification Identifying underlying issues or problems experienced by the patient that emerge repeatedly during the course of the nurse-patient relationship Eg. "I've noticed that in all of the relationship that you have described, you've been hurt or rejected. Do you think this is the underlying issue?" Value Allows the nurse to best promote the patient's exploration and understanding of important problems. Threat Giving advice, reassuring; disapproving 12\. Suggesting Presentation of alternative ideas for the patient's consideration relative to problem solving Eg "Have you thought of responding to your boss in a different way? "For example... " Value Increases the patient's perceived options or choices. Treat Giving advice, inappropriate timing, being judgmental Other forms or Examples of Therapeutic Communication 1\. Accepting Ex. Yes. That must have been difficult for you 2\. Giving recognition or Acknowledging "I've notice you comb you hair and you look neat today." 3\. Offering self I will walk with you. 4\. Offering general leads or Door openers "go on" 5\. Making Observations You appear angry 6\. Placing the evens in time or sequence when did your nervousness begin? 7\. Encouraging description of perception "how does you feel when you take your medication." - "What does the voice seem to be saying?" 8\. Restating Client: "I can't sleep. I stay awake all night" 9\. Reflecting Client: "I think I should take my medication." - Nurse:"You think you should take your medication." 10\. Presenting Reality or confronting this is a hospital not a hotel - There is no elephant in this room. 11\. Encouraging formulation of a place of action if this situation occurs again, what options would you have? 12\. Asking direct questions how does your wife feel about your hospitalization? **Self Awareness** - Is a key part of the psychiatric nursing experience. The nurse goal is to achieve authentic, open, and personal communication - A good understanding and acceptance of self allows the nurse to acknowledge a patient's differences and uniqueness. Increasing Self-Awareness Johari's Window +-----------------------------------+-----------------------------------+ | 1 | 2 | | | | | Known to self and others | Known only to others | +===================================+===================================+ | 3 | 4 | | | | | Known only to self | Known neither to self nor to | | | others. | +-----------------------------------+-----------------------------------+ The following three principles help explain how the self-functions. 1\. A change in any one quadrant affects all other quadrants. 2\. The smaller quadrant 1, the poorer the communication 3\. Interpersonal; earning, means that a change has taken place, so quadrant 1 is larger and one or more quadrants are smaller - The goal of self-awareness is to enlarge the area of quadrant 1, while reducing the area of the 3 other quadrants - To increase self-knowledge, it is necessary to listen to the self by means of allowing genuine emotions to be experienced, identifies and accepts personal needs, and moves the body in a free, joyful, and spontaneous ways. - It includes exploring personal thoughts, feelings, memories, and impulses - To reduce the size of quadrant 2, one must engage in listening to and listening from others. This requires active listening and openness to the feedback others provide. - To reduce the size of quadrant 3, you should learn to reveal to others the important aspect of self- this is what you called self-disclosure which is a sign of personality health and a means of achieving a healthy personality. **PHASES OF THE RELATIONSHIP** I. Preinteraction Phase begin before the nurse's first contact with the patient. - The nurse's initial task is one of self-exploration - Identification of prejudices and misconceptions - Feeling and fears - Overriding anxiety or nervousness II\. Introductory or Orientation Phase - The first meeting - Primary concerns is to find out why the patient sought help - The task on this phase: 1\. Establishing a climate of trust 2\. Understanding 3\. Acceptance 4\. Open Communication 5\. Formulation of contract - Element of a Nurse-Patient contract - Names of individuals - Roles of nurse and patient - Responsibilities of nurse and patient - Expectations of nurse and patient - Purpose of the relationship - Meeting location and time - Conditions for termination - Confidentiality - Other task of the nurse in the orientation phase - Explore the patient's perceptions, thoughts, feelings, and action - Identify pertinent patient's problems - Define mutual, specific goals with the patient N.B be flexible in anticipating the length of time required Working phase - Therapeutic work is carried out during the working phase - Exploration of stressors and promotion of insight - Actual behavioral change is the focus of this phase - Patient often display resistance behaviors - Greater part of the problem solving process - Patient may feel close to the nurse and may responds by clinging to old defenses and may resist the nurse attempt to move forward - A plateau or impasse in the relationship may develop Termination Phase - The most difficult but the most important phase - Learning is maximized for both the nurse and the patient - Is a time to exchange feelings and memories and to evaluate mutually the patient's progress and goal attainment - Levels of trust of intimacy are heightened - Feeling of sense of loss may be experienced by both the nurse and the client - Other feelings that may be experienced/ explored, anger, rejection, sadness. - Criteria for determining patient readiness for termination - Experiences relief from the presenting problem - Level of functioning has improved - Increased self-esteem and a stronger sense of identity - Uses more adoptive coping skills - Achieved the planned treatment outcomes - An impasse or plateau has been reached in the nurse-patient relationship that cannot be resolved Tips in Preparation for termination 1\. Reduce the number of visit 2\. Incorporate others into the meeting 3\. Changing the location of the meeting - Successful termination requires that the patient work through feelings related to separation from emotionally significant person Responsive dimensions - Are crucial in a therapeutic relationship to establish trust and open communication - Genuineness means that the nurse is an open, honest, sincere person who is actively involved in the relationship - Means that the nurse response is sincere, that the nurse is not thinking and feeling one thing and saying something different - Respect is also called nonpossesive warmth or unconditional positive regard - The patient is regarded as a person of worth, regardless of who they are - The nurse's attitude is nonjudgmental, () criticism, ridicule, or reservation. - Emphatic Understanding - Empathy is the ability to enter into the life of another person, to accurately perceive his/her current feelings and their meanings, and to communicate this understanding to the patient - To sense the client's private world as if it were your own, but without losing the 'as if' quality - Concreteness involves using specific terminology rather than abstraction when communicating with the patient - It avoids vagueness and ambiguity - It is high on orientation and termination phase and low on the working phase **Therapeutic Impasses** - Are blocks in the progress of the nurse-patient relationship - Provokes intense feelings in both the nurse and the patient, which may range from anxiety to apprehension, to frustration, love, or intense anger 1\. **Resistance** is the patient's reluctance or avoidance of verbalizing or experiencing troubling aspect of oneself - Is often caused by the patient's unwillingness to change when the need for change is recognized - Usually happens during the working phase, because the greater part of the problem-solving process occurs during this phase - Secondary gains may be another cause of resistance 2\. **Transference** is an unconscious response in which the patient experiences feelings and attitudes toward the nurse that were originally associated with other significant figures in his/her life - This is a reaction which the patient develops to reduce anxiety - Reduces self-awareness by allowing the patient to maintain an inaccurate view of the world in which all people are seen in similar terms - Hostile transference happens when the patient internalizes anger and hostility - May be expressed as depression and discouragement Ex. patient may ask to terminate the relationship or the ground that there is no chance of getting well; may become critical, defiant and imitable. May express doubts about the nurse competence. May attempt to compete with the nurse by reading psychology books and be bate using intellectual issue - Detachment, forgetfulness, irrelevant chatter, preoccupation with childhood experiences - Prolong silence. (An extreme form of uncooperativeness.) - Dependent Reaction Transference characterized by patients who are submissive, subordinate, and ingratiating and who regard the nurse as a godlike figure - This jeopardize the relationship because the patient views the relationship as magical - The nurse must live-up the patient overwhelming expectation and patient continues to demand more of the nurse. Overcoming Resistance and Transference - Contract must be set on the orientation phase - Listen carefully and use clarification and reflection of feelings Clarification given the nurse a more focused idea of what is happening Reflection may help patient becomes aware of what has been going on in their own minds - Reflection of feelings acknowledges resistance and mirrors it to the patient **3. Counter transference** - Is a therapeutic impasse' created by the nurse's specific emotional response to the qualities of the patient - Is transference applied to the nurse - The nurse identify the patient with individuals from their past, and personal needs interfere with their therapeutic effectiveness Types - Reaction of intense love or caring - Reaction of intense disgust or hostility - Reaction of intense anxiety, often in response to resistance by the patient Other forms - Ignoring patient behavior - Joking about or criticizing a patient - Overreaction to a patients aggressive behavior Overcoming Counter transference - Self-examination/Self-awareness Ex. Ask some of the following questions - How do I feel about my patient? - Am I afraid of the patient? - Am I impressed by or try to impress my patient? - Do I feel sorry for or overly sympathetic toward the patient? Next ask yourself - What is the patient doing to provoke these feelings? - Who does the patient remind me of? The nurse must discover the source of the problem because counter transference can be harmful to the patient **4. Boundary Violations** - Occurs when the nurse goes outside the boundaries of the therapeutic relationship and establishes a social, economic, or personal relationship with a patient Remember: Whenever the nurse is doing or thinking of doing something special, different, or unusual for a patient, often a boundary violation is involved. A nurse should consider the possibility of a boundary violation if encounters the following: - Receives feedback that his/her behavior is intrusive () patients or their families - Has difficulty setting limits with a patient - Relates to a patient like a family member or friend - Has sexual feelings toward a patient - Feels that he/she is the only one who understands the patient - Receive feedback that he/she is too involved with a patient or family - Feels that other staff are too critical of a particular patient - Believes that other staff members are jealous of his/her relationship () a patient Specific boundaries violation - Role boundaries : Related to psychiatric nurse's role - Time boundaries : Odd and unusual treatment hours that have no therapeutic necessity - Place and space boundaries: related to where the treatment takes place. Treatment outside of the office usually merits special scrutiny - Money boundaries : Bartering or seeing an indigent patient for free should be carefully reviewer - Gifts and service boundaries - Clothing boundaries : to dress in an appropriate therapeutic manner - Language boundaries : too familiar, sexual, off-color, or leading language - Self-disclosure boundaries : inappropriately timed self-disclosure and lacking of therapeutic value - Post discharge social boundaries - Physical contact boundaries : sexual contact **Legal and Ethical Issues** Clients receiving mental health care retain all civil rights afforded to all people except the right to leave the hospital in the case of involving commitment - Any restrictions must be made by a court or a physicians order for a verifiable documented reason - Involuntary hospitalization - Clients who do not wish to hospitalized and treated but poses a threat or danger to themselves and others - Clients under this category have no right to leave the hospital whenever he wishes to all other right remain intact - A person can be detained in a psychiatric facility for 48-72 hours on an emergency basis until a hearing can be conducted to determine whether or not he/she should be committed to a facility for treatment for a specific period. (same for substance abuse cases) - Release from hospital - Only clients who were hospitalize voluntarily have the right to leave, provided they don't present any danger to self or others - These committed clients can sign request for discharge - Mandatory outpatient treatment - Is the requirement that client continue to participate in treatment on an involuntary basis () their release from the hospital to the community e.g medications, treatments, group therapies, -appointment etc. - Also called conditional release or outpatient commitment - Court-ordered outpatient treatment is most common among persons with severe and persistent mental illness who have had multiple contact and mental institutions social welfare and justice system - The court concern is that -- patient still have civil rights - Communities concern -- protection against dangerous people () Hx of not taking their medication and who may became threats - **Conservatorship** - Conservator or legal guardian are given to people who are gravely disabled, incompetent, cannot provide food, clothing and shelter for themselves, and cannot act in their own best interest - Clients with guardians losses the right to enter into legal contracts or agreements that require a signature - Conservators speaks for the clients the nurse must obtain consent from them - Least restrictive environment - The client have the right to treatment in the least restrictive environment to appropriate to meet their needs - The client must be free of restraints or seclusion unless it is necessary - It means that a client does not have to be hospitalized if he/she can be treated in an outpatient setting 6\. **Restraint** -- is the direct application of physical force to a person, without his/her permission, to restrict his/her freedom of movement Types -- human restraints Mechanical restraints Chemical restraints Seclusion is the involuntary confinement of a person in a specially constructed, locked room equipped with a security window or camera for direct visual monitoring - Any sharp or potentially dangerous objects are removed as safety precaution - Decreases stimulation, protects others from the client, prevents property destruction, and provides privacy Goal is to give the client the opportunity to regain physical and emotional self control Use of restrain or seclusion is permitted only when the client is imminently aggressive and dangerous to self of to others. requires a face to face evaluation by a licensed independent practitioner within 1 hour; a physician's order every 4 hours, a proper documentation every 1-2 hours and close supervision of 1;1 basis for the first hour Restraints can be remove by 2 staff members for a time Criteria for removing seclusion and restraints - Verbalization of feelings, less/decrease muscle tension and demonstration of self-control Other duty of the nurse - Support to clients family members - On orientation phase, client must sign a document about seclution and restraints after explanation to the client or to their legal guardian - Provide family with information -- legal or ethical difficulties Confidentiality Duty to warn the third party Based on: - Is the client dangerous to others - Is the danger the result of serious mental illness - Is the danger serious - Are the means to carry out the threats available - Is the danger targeted at identifiable victims - Is the victim accessible Insanity Defense - The argument that a person accused of a crime is not guilty because that person cannot control his/her actions or cannot understand the wrongfulness of the act - Being used in 33% to 45% of major criminal cases (public perception) as get away - 0.9% in actuality Nursing liability Torts- a wrongful act that results in injury, loss or damage - Either unintentional or intentional Unintentional Torts - Negligence involves causing harm by failing to do what a reasonable and prudent person would do in similar circumstances - Malpractice a type of negligence that refers specifically to professionals Four Elements of Malpractice 1\. Duty 2\. Breach of duty 3\. Injury or damage 4\. Causation the breach of duty was the direct cause of loss or damage or injury Intentional Torts - Assaults any action that causes a person to fear being touch in a way that is offensive, insulting, or physically injurious without consent or authority - Battery involves harmful or unwarranted contact with a client; actual harm may or may not occurred - False imprisonment unjustifiable detention of client such as the inappropriate use of restraints and seclusion 3 Elements of proving liability for an intentional tort 1\. The act was willful and voluntary on the part of the defendant 2\. The nurse intended to bring about consequences or injury to the person. 3\. The act was a substantial factor in causing injury or consequences Steps to avoid liability - Practice within the scope of law and nurse practice act - Collaborate with colleagues to determine the best course of action - Use established practice standards to guide decisions and actions - Always put the client's rights and welfare first - Develop effective interpersonal relationships with clients and families - Good documentation Ethical Issues Utilitarianism the greatest good for the greatest number Deontology decisions should be based on principles Principles used as guides - Autonomy the right to self-determination - Beneficence duty to promote good for others - Nonmaleficence to do no harm to others either intentionally or unintentionally - Justice fairness- treating all people fairly and equally without regard for sex, race, etc. - Veracity the duty to be honest or truthful - Fidelity obligation to honor commitment and contracts **Anger, Hostility and Aggression** Anger a normal human emotion - Is a strong, uncomfortable, emotional response to a real or perceived provocation - Energizes the body for self-defense by activating the "fight-or-flight" emotional response Hostility a verbal aggression - Emotional expressed through verbal arouse, lack of cooperation, violation of rules on warms, or threatening behavior - Intended to cause emotional harm or intimidate another Physical Aggression a behavior in which a person attacks or injuries another person or that involves destruction of property Anger is normal and healthy reaction when circumstances are unfair, unjust etc. - Must be express assertively = problem solving or resolution be possible - Becomes negative when it is denied, suppress, or express inappropriately = to hostility and aggression = possible physical problem e.g. migraine headaches, ulcers, depression, and self-esteem Nurses can help clients to express appropriate by becoming or serving as role model by role-playing Assertive communication techniques - It uses the "I" statements that express feelings and are specific to the situation - Others engage in activities called catharsis Note: Catharsis can increase rather than alleviate angry feelings Catharsis = release for anger Activities that are not aggressive is more effective in decreasing anger Hostility = increase risk for coronary artery disease and HPN Anger suppression is especially common in women 'coz it labeled as unfemine emotion Offenders are not strangers but usually intimate acquaintances Related disorder - Paranoid delusions - Dementia, Delirium - Head injuries - Alcohol/ Drug abuse - Antisocial/borderline personality disorder - Depressions Etiology : Neurobiologic Theories Serotonin level Activity of dopamine and NE = () impulsively violent behavior Structural damage to the limbic system, frontal, temporal lobe = alteration to modulate Aggression = aggressive behavior Psychosocial Theories Infants-Toddlers -- express loudly and intensely Toddlers Temper Tantrums - Impulse control are expected as the child matures Children in dysfunctional families with poor parenting - Who receive inconsistent responses to their behavior - On lower economic status Rejection can lead to anger and aggression Cultural Consideration Asian and Native American -- see expressing anger as rude or disrespectful and to avoid it. Bouffeé delirante- from West Africa and Haiti Characterized by a sudden outburst and psychomotor excitement, marked confusion, aggressive behavior and auditory and visual hallucinations and paranoid ideation Amok -- Malaysia, Laos, Phil, Papua New Guinea, Polynesia, Puertorico, Navajo. Period of brooding, outburst of violent, aggressive or homicidal behavior seen only in men Treatment - Treatment focus on underlying or comorbid psychiatric disorder - Rapid tranquilization (for psychoses) to decrease agitation and aggression and provide sedation Assessment assess for Privacy , Nurse' Roles Rest , Patient's Roles Activity pattern , Past Hx of violence and aggressive behavior Past Hx of being abused/drug dependency or substance abuse Nsg. Dx - Risk for other-directed violence - Ineffective coping Outcome Identification 1\. Will not harm or threaten others 2\. Will refrain from behaviors that are intimidating or frightening to others 3\. Will verbalize feelings and concerns S aggression 4\. Will comply c treatment **Managing aggressive behavior** Triggering Phase An event or circumstances in the environment that initiates the client's response, which is often anger or hostility S/S Restlessness, anxiety, irritability, pacing, muscle tension, rapid breathing, loud voice anger Management Approach client in a nonthreatening, calm manner in order to de-escalate the client's emotion and behavior - Convey empathy - Encourage client to express angry feelings and suggest that client is still in control and can maintain that control - Decrease stimulation (moves other clients or put patient in a quiet area0. - Give medication PRN - Use relaxation technique - Problem solving () the client - Engage client in physical activity such as walking = helping client to relax If the above management is unsuccessful Client may progress to. Escalation Phase: - Indicate movement toward a loss of control - Pale or frustrated face, yelling, swearing, agitation, threatening, demanding, drenched fist, threatening gestures, hostility, loss of ability to think clearly = loss of ability to solve the problem Management: - The nurse must take control of the situation - Use kind firmness approach - Advice client to take a time out and cool-off an a quiet area - E.g. Tell client that aggressive behavior is not acceptable - Reoffer PRN Rx - Ask for help (if the client will not take a cool off) at least 4 members of the staff = "show of force' -- ready but not near to nurse. Crisis Phase - Period of emotional and physical crisis, the client loses control - Becomes physically aggressive S/S Loss of emotional and physical control, throwing objects, kicking, hitting, spitting, biting, scratching, shrieking, screaming, inability to communicate clearly Management - Take charge for the safety of the client, staff and other clients - Obtain a DI's order for restraint or seclusion - Give Rx IM PRN - Document all actions taken - Perform close assessment during seclusion and restraints Recovery phase - Regaining of control both physical and emotional S/S lowering of voice, decrease muscle tension, clear and rational communication, physical relaxation Management - Encourage to talk of or about the situation or triggers that led to aggressive behavior - Helps client relax, perhaps sleep, and return to a calmer state - Help client explore alternatives on what to do when next time to avoid aggressive episode - Assess other clients/staff members for injury - Talk to the other staff about the situation and evaluate what needs to improve and to be done next time - Give time and encourage client to talk about incident/situation Post Crisis Phase - Client attempts reconciliation with others and returns to the level of functioning before the aggressive incident and it's antecedents S/S Remorse, apologies, crying, quiet withdrawn behavior Management: - Remove from restrain and seclusion - Do not lecture or chastise the client - Discuss behavior in a calm and rational manner - Give expectation that he/she will be able to control or handle feelings or events in a non aggressive manner in the future - Reintegrate client in the activity ASAP when he/she can participate Evaluation: - Care is most effective when the client's anger is defused in earlier stage - The goal is to teach angry, hostile and potentially aggressive client to express their feelings verbally without threats or harm to others or destruction of property.