Treatment Modalities - PDF

Treatment Modalities ELECTROCONVULSIVE THERAPY INTRODUCTION TO ELECTROCONVULSIVE THERAPY Electroconvulsive therapy (ECT): is a treatment for severe mental illness in which a brief application of electrical stimulus is used to produce a generalized seizure. ECT Initially done without musc...

Treatment Modalities ELECTROCONVULSIVE THERAPY INTRODUCTION TO ELECTROCONVULSIVE THERAPY Electroconvulsive therapy (ECT): is a treatment for severe mental illness in which a brief application of electrical stimulus is used to produce a generalized seizure. ECT Initially done without muscle blocker or anesthetic INTRODUCTION TO ECT ❑ECT has changed substantially during the past decades. The use of general anesthesia has promoted the interest in ECT. ❑ECT become more complex, more precise, and safer procedure. INTRODUCTION TO ECT ❑Generalized seizures for 30-60 seconds in duration are required for therapeutic effects. ❑75-90% of patients exhibit a dramatic and sustained improvement.  Mechanism ECT producesofa deliberate action , artificially induced grand mal seizure of the brain This affects a wide range of neurotransmitters and neurohormones Increase slow wave activity Reduces regional cerebral blood flow and glucose metabolism Increase the blood – brain permeability  Indications The most common for ECT indication for ECT are major depression disorder and bipolar disorder. Its indicated for clients in the following situations: 1. Failure to respond to medication 2. Severe symptoms, such as severe psychosis or dangerously suicidal or homicidal behaviors 3. Adverse reactions to psychotropic medication 4. Medical condition such as heart disease or glaucoma, that could be worsen by medication 5. Previous successful respond to ECT Indications for ECT ECT is sometimes employed in the treatment of people with schizophrenia.it is primarily used in clients experiencing catatonia. ECT is safe in all trimesters of pregnancy and may be less harmful to the fetus than psychotropic medication.  Informed consent Informed consent - adequate mental capacity, understand procedure, risks, side effects, benefits, alternatives. The treatments are usually given two to three times per week in a series of 6 to 12 treatments. ECT is given after careful medical screening and in a very controlled environment with an anesthesiologist or healthcare practitioner. Contraindications for ECTvascular accident (CVA), Brain tumor, recent cerebral subdural hematoma, recent myocardial infarction, congestive heart failure, angina pectoris, retinal detachment, acute or chronic respiratory disease. Client 1. The preparation client should ingest nothing by mouth for at least 8 hours prior to the treatment. 2. Thirty minutes prior to the treatment the client is given atropine sulfate IM to control secretion and to prevent bradycardia, which sometime occur with ECT.  Client Short acting barbiturate is administer IV as anesthesia preparation Sodium thiopental (Pentothal), and muscle relaxant Succinylcholine (Scoline). Electrodes are placed on either one side of the temple or on both sides, through which the current is delivered.  Side The client usually awakes -10-15 min after the effects procedure. Memory often affected by ECT. Headache. ADVERSE EFFECTS can result in fractures and ❑Muscle contractions: dislocations; prevented by small doses of muscle relaxants ❑Injury to teeth, tongue or lips: stimulus causes intense contraction of the masseter muscles and forceful movement of the jaw; prevented by using a bite block ❑Electrical injury to the staff or patient ADVERSE EFFECTS ❑Short-term memory loss and cognitive deficits ❑Anesthesia related problem: i.e. air way issue; aspiration Nursing Care in ECT Therapy Emotional support and education: allow the pt and family to express feelings. Teaching should be individualized and the nurse should respond to questions about misconceptions.  Physical A physicalRestraint restraint is any manual method, physical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely. Drug ororChemical A drug medication,Restraint or a combination, when it is used as a restriction to manage the patient’s behavior, restrict the patient’s freedom of movement, or to impair the patient’s ability to appropriately interact with their surroundings and is not standard treatment or dosage for the patient’s condition. Legal/Administrative/Forensic Restraint Corrective restraints used for security reasons and administered by forensic personnel. (Use of handcuffs, manacles, shackles, other chain-type devices, or other restrictive devices). Seclusion Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self- destructive behavior.  Restraint “Seclusionor andSeclusion Interventions restraint when used properly, can be life- saving and injury-sparing interventions. These emergency measures aim to protect patients in danger or harming themselves or others and to enable patients to continue in treatment successfully and effectively” Patient Rights All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. Patient Rights Least restrictive interventions must be implemented or at least considered prior to initiation of restraint or seclusion Restraint or seclusion use can not be based solely on the patient’s diagnosis or history of dangerous behavior The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient, a staff member, or others from harm. Asking the patient who is demonstrating the behavior “what would help you right now at this moment?” Restraint or Seclusion Order Must Never Be Written as PRN Choose Restraint or Seclusion Include Duration (hours or minutes) Include Duration Unit (number of hours or minutes) Include least restrictive interventions attempted or considered/not attempted and why not attempted Include clinical justification for use Include type of restraint Include behavioral criteria that must be demonstrated for discontinuation and this information is also shared with the family when authorized by the patient  Monitoring Staff will be assigned to monitor of Restraint orthe patient one to one Seclusion In seclusion, the staff member will remain outside the locked door to observe the patient In restraint, the staff member will remain in the room with the patient Documentation must be done every 15 minutes on the assessment section of the restraint form Restraint or Seclusion Assessments Document every 15 minutes Vital signs Based on the patient’s condition Circulation and range of motion Checking skin color and temperature Complaints of numbness, tingling Asking how extremities feel Repositioning and release of restraints Which restraints have been released Patient was repositioned Restraint or Seclusion Assessments Offer and document every 2 hours Hygiene and elimination With assistance, loosen restraints and assist patient to commode for elimination needs and or hygiene needs Nutrition and hydration Increased calories being used related to behaviors Increased risk for dehydration and or electrolyte imbalance related to increased perspiration  Treatment modalities Psychotherapy The word psychotherapy comes from the Greek words psychē ,meaning breath, spirit, or soul and therapeia to nurse or cure, Its use was first noted around 1890.It is defined as the relief of distress or disability in one person by another, using an approach based on a particular theory or paradigm, and that the agent performing the therapy has had some form of training in delivering it. Individual therapy When people think of psychotherapy, more often than not they will imagine lying on a leather couch while an intimidating psychologist takes notes on everything they say in order to “repressed” childhood experiences that will provide insight into their present psychological condition. Individual therapy is a psychotherapy implemented by a trained professional, usually a therapist or psychologist to help a client work through a problem. Individual therapy Individual therapy refers to therapy sessions with one client and one therapist. Individual sessions with a therapist average about 45 minutes to one hour long. Individual therapy An alternative to group therapy, individual therapy is offered in many different types or branches of psychology. Therapy strives to help people better understand themselves and their problems in order to cope with the demands of their daily lives. Individual therapy Individual therapy is effective to deal with such condition: General anxiety and stress Difficult childhood and family experiences (past and present) Relationship struggles Depression Homesickness Eating and body image issues Individual therapy The first session will usually involve the patient and the psychologist “getting to know” one another. The therapist will ask questions about The patient himself Past experiences, Current situation, Family, Job and Friends Individual therapy In the first session it is important to: Build therapeutic trust so patient can begin to express and work through his/her feelings related to the condition. During the first session, encouragement and support should be given to the patient Individual therapy The other session should: encourage the patient to learn how to deal with his/her feelings. The child patient will learn about old and new feelings. Encourage the patient to develop a list of safe places as well as a list of supportive people whom he/ she can turn to for support, guidance and affirmation Therapy goals In every type of psychotherapy, the psychologist will help the patient to develop specific goals for the therapy. This will include a broad overall goal as well as more focused goals that may change from session to session. Breaking the overall goal into session objectives helps to focus on specific parts of the program and make sure all aspects are properly covered. Therapy goals Identify coping strategies :These may be coping strategies that have helped the patient in the past. the psychologist will teach the patient to adapt these strategies to his current situation. Therapy goals Rearrange life priorities: Sometimes people have psychological problems because they have an irrational expectation of themselves and others. This increases the pressure on everyone and can lead to stress, anxiety and depression. By rearranging the expectations and priorities they may be able to avoid unnecessary stress.  Therapy Identify goalsstrengths: personal Psychologists will draw the patient attention to positive aspects about himself, and help him rediscover and bring him out again. This will help the patient to believe in himself. Advantages with individual therapy versus other therapies Confidentiality provide more time to handle the patient particular problems The patient do not have to listen to other people The patient can arrange a time which suits to him and he does not have to co-ordinate his calendar with other people and available group therapy slots Conclusion Individual therapy is therapeutic conversation between the patient and the therapist in order to release their tension associated with major events in their entire life Individual therapy can be in many forms and the combination between them is more effective Individual therapy help the patient to identify the positive and negative points Individual therapy help the patient to develop more strategies in order to deal with their tensions Conclusion First session contributed to be the most important session in order to develop trust relationship between the patient and the therapist Individual therapy could be effective to deal with depression, anxiety, eating disorders, sexual abuse and drug abuse Somatic Therapies Somatic Therapies Phototherapy Complementary and alternative therapy Phototherapy Indications: Seasonal Affective Disorder (also called SAD) 60-90% response rate. Consists of exposing a patient to artificial light that is 5-20 times brighter than indoor lighting. The “light visor” shaped like a baseball cap is worn on the head suspended in front of the eyes.  Mechanism Phototherapy isofbased action on biological rhythms that are related to light and darkness. The therapeutic effect appears to be mediated primarily by the eyes not the skin. Positive and Adverse Most patients Effects feel relief after of Light 3-5 days; Therapy however they relapse equally rapidly if light treatment is stopped. Patients should continue treatments throughout the winter months. Adverse effects: headache, fatigue, nausea, dry eyes and nasal passages. Complementary and Alternative Therapies A broad range of healing philosophies and approaches that focus on holistic therapies. Herbal Products Used to treat mild depression, anxiety, seasonal affective disorder, and sleep disorders. Mechanism: serotonin- reuptake inhibition. Acupuncture Involves the insertion of needles into acupoints or energy channels for the purpose of restoring energy balance. It is used in treating depression and anxiety. Auricular acupuncture used in treating substance abuse disorders. Massage There are a few studies that have evaluated the effects of massage therapy for the treatment of depression. Effects may be short term. Yoga (breathing control stretching, and meditation) Found to have efficacy in treating OCD and substance abuse disorders. Group Therapy  Introduction Group therapy become one of the most popular therapy in the treatment of mental illness. It is came out after World War II. Group therapy Group therapy provides treatment in a format where there is one therapist and six to eight participants with related problems. The participants improve not only from the interventions of the therapist, but also from observing others in the group and receiving feedback from group members. Group therapy The therapeutic group deferent than social group because its goal to assist individual to alter their behavioral patterns and to developed new and more effective way of dealing with the stressor of daily living Group sessions Group must be homogeneous 9 sessions 60 – 90 min. each These sessions include: -development of personality -development of the disorders -identification of treatment needs Group therapy The advantages of group therapy include: Less expense — By treating several patients simultaneously, the therapist can reduce the usual fee. In most cases the cost of group therapy is about one-third that of individual therapy. Group therapy The advantages of group therapy include: Increased feedback — Group therapy can provide the patient with feedback from other people. Getting different perspectives is often helpful in promoting growth and change. Group therapy The advantages of group therapy include: Modelling — By seeing how others handle similar problems, the patient can rapidly add new coping methods to his or her behaviours. This is beneficial in that it can give the patient a variety of perspectives on what seem to work and when. Group therapy Example — Mary listens to Joan talk about how telling her husband that he hurt her feelings was more productive than simply getting angry at him and not speaking. As she listens, Mary thinks of how she might try this same strategy with her husband. She can then try out this new behaviour by practicing with the men in the group. Types of Groups Task Groups: A group that comes together to perform a task that has a goal (e.g. community organizations, committees, planning groups, task force). Guidance/Psychoeducational Group: Preventative and educational groups that help group members learn information about a particular topic or issue and might also help group members cope with that same issue (e.g. support group for a suicide). Types of Groups (continued) Counseling/Interpersonal Problem- Solving Groups: These groups help participants resolve problems of living through interpersonal support and problem solving. Psychotherapy Groups: These groups focus on personality reconstruction or remediation of deep-seated psychological problems. Types of Groups (continued) Support Groups: These deal with special populations and deal with specific issues and offer support, comfort, and connectedness to others (e.g. Addiction). Self-help Groups: These have no formal or trained group leader. (e.g. Alcoholics Anonymous or Gamblers Anonymous). Group Counseling Advantages of Groups It provides a social atmosphere that is similar to the real world. Members can test out and practice new behaviors. Members can practice new interpersonal skills. They are cost effective. Groups help members see that they are not the only one who has that particular problem or issue. Groups provide members with support. Group Counseling Disadvantages of Groups Less individualized attention from the counselor. Confidentiality is more difficult to maintain. There are concerns with conformity and peer pressure. Not everyone can be in a group (e.g. those with issues too severe or those with poor interpersonal skills.) Group Counseling Stages of Groups Stage One (Orientation/Forming): Group members become oriented to the group and to each other. Stage Two (Transition/Storming): Anxiety and ambiguity become prevalent as group members struggle to define themselves and group norms. This stage is often characterized by conflict. Group Counseling Stages of Groups (continued) Stage Three (Cohesiveness/Norming): A therapeutic alliance forms between group members. Trust between members has been established. Stage Four (Working/Performing): Group members experiment with new ideas, behaviors or ways of thinking. Egalitarianism develops. Stage Five (Adjourning/Terminating): This is the time when the group disbands. ” Therapeutic Groups A group is a collection of people who have a relationship with one another, are interdependent, and may have common norms. Group therapy Therapist or cotherapists meet and interact with 5-10 people who have a shared purpose Purpose: creating a supportive atmosphere Recommended: when achieving results on one´s own is diffucult. Particularly effective in emotional disturbances and substance abuse disorders Function: sharing experiences and insights and getting feedback Group Development Pre-group phase: what are the goals of the group? Initial phase: group begins to settle down to work. Conclusion Group therapy is one of multiple method to deal and treat patient with mental illness when we are in the right way. Milieu Therapy – The Therapeutic Community  Introduction The psychiatric-mental health nurse provides structures, and maintains a therapeutic environment in collaboration with the patient and other health care clinicians. Milieu, Definition Milieu therapy, or therapeutic community, is defined as “a scientific structuring of the environment to affect behavioral changes and to improve the psychological health and functioning of the individual”. Milieu therapy Within the therapeutic community setting, the patient is expected to learn adaptive coping, interaction, and relationship skills that can be generalized to other aspects of his or her life. The Goal of Milieu Therapy Manipulate the environment so that all aspects of the client’s hospital experience are considered therapeutic. Within the therapeutic environment, patients are expected to learn adaptive coping, interaction, and relationship skills that can be generalized to other aspects of their life. Achieving client autonomy.  Basis of Milieu Therapy Basis of Milieu Therapy is the belief that all human beings are affected by their physical, social, and emotional climate. So the use of the environment considered the therapeutic tool in milieu therapy, because factors such as social interactions, the physical structure of the setting, and scheduled activities may generate stress and resistance for some patients – these “stressful experiences” are used to help them learn to manage stress adaptively in the real world.  Milieu Therapy Characteristics The client physical needs are met. The client is respected as an individual with rights, needs and opinions and is encouraged to express them. Decision making authority is clearly defined. Milieu Therapy Characteristics Protection of the client from being injured from self and others and only those restrictions are necessary to afford such protection are imposed. Programming is structured but flexible. Milieu Therapy Characteristics The environment provides a testing ground for the establishment of new patterns of behaviors.  Team Members The treatment plan is directed by an interdisciplinary team. Team members of all disciplines sign the plan and meet regularly to update the plan as needed. Disciplines may include psychiatry, psychology, nursing, social work, occupational therapy. Critique *Advantages:- Milieu therapy creates a different type of attitude and behaviour in the patient because the environment is like home. Instead of adopting a sick role, the patient makes decisions in the ward management and cares for other patients. In other words, he becomes less dependent and passive. Critique *Advantages:- The patient learns to make decisions which improves his self confidence. Milieu includes safe physical surroundings, all the treatment team members, and other clients, which is supported by clear and consistently maintained limits and behavioral expectations. Critique *Disadvantages - Low client- to- staff ratio. - Requires continuous open communication among all staff and clients. - Milieu therapy is limited to only hospitalized patients. - Individual needs and concerns may not be met.  Role of the nurse Through use of the nursing process, nurses manage the therapeutic environment on a 24-hour basis. Nurses have the responsibility for ensuring that the client’s physiological and psychological needs are met. Role of the nurse Nurses are also responsible for medication administration. Development of a one-to-one relationship. Setting limits on unacceptable behavior. Client education. Summary Milieu therapy is the use of the environment as a therapeutic tool depending on the belief that human beings are affected by physical, social, and emotional climate. The responsibility of the psychiatric mental health nurse is to provide structures and to maintain a therapeutic environment in collaboration with the patient and other health care clinicians. Conclusion The therapeutic environment is a type of milieu therapy, restore their self-confidence by providing many opportunities for decision making, increase their self-awareness, and focus their attention and concern away from the self and toward the needs of others. Family Therapy Family definition A group of people connected emotionally or by blood or both that has emotionally patterns of interaction and relationships.  Family definition Families comprise people who have a shared history and shared future.  Form of family units Nuclear -two or more people living together and related by blood , marriage or adoption. Extended -several nuclear families whose members may or may not live together and function as one group.  Comprehensive family assessment Collection of all relevant data related to family health, psychological well-being and social functioning to identify problems for which the nurse can generate nursing diagnosis. Genogram Genogram A diagram or map of multiple generation of a family indicating family relationships, life events, family functioning, and significant development events. Includes ages, date of marriage, death, geographic location. Analysis of genogram Family composition Relationship problems Mental health illness pattern Family mental health Members live in harmony among themselves and within society, and support their members throughout their lives. Family mental health In a dysfunctional family, interactions, decisions or behaviors interfere with the positive development of the family and its individual members. Family mental illness Mental illness is a stressful event in family’s life. Effect of mental illness on the family The diagnosis of a mental illness in a family member can bring out feelings of guilt over possible genetic transmission of the disease to the ill family member by parents. Family mental illness Shame or embarrassment in the family about how people out side the family will view the family and ill member. Family mental illness The ill family member might experience feelings of sadness anger about being ill or about the intervention of other family members. Family mental illness When a family member experience a mental illness , the family is likely to be the major source of assistance for mentally ill member. Which approach is best? Individual therapy when the social relationships are stable, and the person is in distress Family therapy when the social relationships are unstable, and the person is in distress Family therapy Is method of treatment in which all family members gain insight into problems improve communication and improve functioning of individual members as well as the family as a whole.  Family therapy Is a form of group therapy in which the client’s family members participate the goal include understanding how family dynamics contribute to the client psychopathology mobilizing the family inherent strength and functional recourses, restructuring maladaptive family behaviors. Conclusion Family therapy is a branch of psychotherapy that works with families in intimate relationships to nurture change and development. It tends to view change in terms of the systems of interaction between family members. It emphasizes family relationships as an important factor in psychological health. The Psychiatric Nursing Assessment  Introduction A comprehensive, holistic psychiatric assessment examines the physical, psychological, intellectual, social, and spiritual aspects of the individual. 2  Holistic Psychiatric Nursing Assessment 1) Biopsychosocial history. 2) Mental status examination. 3) Psychological tests. 4) Physical assessment. 3 1) Biopsychosocial history -Identifying data. -Chief complaint. -History of present illness. -Psychiatric history. -Alcohol and substance use history. -Medical history. -Family history. -Developmental history. 4  1) Biopsychosocial history -Social history. -Occupational/educational history. -Culture. -Spirituality. -Coping skills. 5  2) Mental status examination The mental status examination is a description of all the areas of the client’s mental functioning. The acronym BEST PICK can assist in the recall of the elements of the mental status examination. -Behavior and appearance. -Emotions: mood and affect. -Speech. -Thought process and content. 6 2) Mental status examination -Perceptual disturbances. -Impulse control. -Cognition and sensorium. -Knowledge, insight, and judgment. 7  3) Psychological tests Multiple tools, including rating scales. 8  4) Physical assessment -Physical examination. -Assessment of activities of daily living. -Laboratory tests. -CT scan/other diagnostic tests. 9  Identifying data 1. Name 2.Gender 3.Age 4.Marital status 5. Ethnicity 6.Education 7. Religion 8.Current living situation 9.Occupation 10  Chief complaint The client’s chief complaint is the reason for current contact with the mental health system. The chief complaint should be obtained in the client’s own words. 11  History of present illness The history of present illness is a chronologic account of the events leading up to the current contact with the mental health professional. 12  Psychiatric history Information concerning past psychiatric illness must be obtained to understand the current episode, to make an accurate diagnosis, and to make a prognosis. 13 Alcohol and substance use history Studies have shown high co-morbidity of mental illness and alcohol or substance abuse. 14  Medical history The nurse should ascertain significant illnesses, injuries, and treatments received. The client must be assessed for allergies and past and present side effects from medication. Women should be questioned concerning their menstrual cycles, pregnancies, and menopause. 15  Cont’ Medical history The nurse should evaluate the client’s risk for falling and skin break down and take note of assistive devices the client requires (e.g. eyeglasses, hearing aides, dentures, and walkers). 16  Family history Families are taught about the condition of mental illness and engaged in the treatment process. Obtaining a family history of mental illness is important, because many of these disorders are hereditary. 17  Developmental history The developmental history is an account of the client’s infancy, childhood, and adolescence. It may provides clues to the origin of current behaviors and aid in the diagnosis. 18  Social history A client’s ability to make and sustain relationships indicates the ability to utilize the therapeutic relationship and aids in the diagnosis. The client’s living situation is also integral to the assessment, because many of the client’s stressors are environmental in origin. Homelessness, for example, is a sever social stressor. 19  Occupational and educational history It is essential to establish a client’s past and present level of function in work and school. Work or school-related stress may have precipitated the illness. The client’s level of education partially determines how the nurse can most effectively communicate with and educate the client. Low socioeconomic status has been correlated with a relatively high rate of symptoms of mental illness. 20  Culture Culture can significantly influence the development, expression, and reporting of mental disorders; thereby affecting diagnosis. 21  Spirituality and values A client’s lack of or sense of spirituality may have impact on illness or treatment. Some clients feel that spirituality decreases their sense of aloneness and despair. Spirituality and religiosity may deter suicide and violence. Conversely, some clients may become angry with God for having caused their suffering and may lose faith. 22  Coping skills Coping skills are mechanisms people use to manage internal and external stressors. Coping behaviors can enable an individual to alter a stressful situation by controlling, or at least minimizing, the stress resulting from the situation. 23 Behavior and general appearance Appearance 1. Grooming and dress 2.Hygiene 3.Posture 4.Height and weight 5.Level of eye contact 6.Hair color and texture 24 Behavior and general appearance Appearance 7.Evidence of scars, tattoos, or other distinguishing skin marks 8.Evaluation of client’s appearance compared with chronological age 25 26 Behavior and general appearance Motor Activity 1. Tremors 2.Tics (involuntary, spasmodic motor movement) 3.Gestures (A motion of the limbs or body made to express or help express thought or to emphasize speech) 4.Mannerisms (habitual gesture or way of speaking or behaving) 4.Hyperactivity 27 Gestures 28 Behavior and general appearance Motor Activity 5. Restlessness or agitation 6. Aggressiveness 7. Rigidity 8.Gait patterns 9.Echopraxia (pathological imitation of movements of one person by another) 10. Psychomotor retardation 11. Freedom of movement (range of motion) 29  Behavior and general appearance Motor Activity 12. Catatonia (holding a position for hours without moving) 13. Waxy flexibility (when limbs can be moved by the interviewer into positions that the client then maintains) 30 Tics 31 Catatonia 32 Waxy flexibility 33 Behavior and general appearance Some antipsychotic medications may cause akathisia (motor restlessness), dystonia (stiffness), or dyskinesia (involuntary muscle movement). 34  Emotions: mood and affect Mood (the pervasive subjective emotional state) Affect (the visible expression of this state) Both mood and affect can be described as euthymic (normal), labile (rapidly changing from one mood state to another), depressed, irritable, anxious, angry, euphoric (excessively happy), frightened, or empty. 35  Emotions: mood and affect Variability in the client’s affect should be noted ranging from flat (no variability or absence of emotional expression) to labile (rapid fluctuation in affect). It is important to note congruity or incongruity of mood and affect. For example, some depressed clients look depressed, whereas others who are depressed appear euthymic. 36  Emotions: mood and affect Blunted affect (a disturbance in affect manifested by a severe reduction in the intensity of affect) Restricted affect (reduction in the intensity of affect but less severe than blunted affect) 37  Speech Speech may range from: Pressured to hesitant. Loud to inaudible. Spontaneous to nonspontaneous. Slurred to clear. The client may be described as talkative depending on quantity of speech. 38  Speech Dysarthria (physical difficulty in vocalizing) Echolalia (the repetition of the interviewer’s words) Perseveration (the repetition of the same words) Aphasia (difficulties in understanding or producing speech) 39 Thought process and content Thought content Obsession (intrusive thoughts or ideas that the client recognizes as crazy but acts in accordance with anyway e.g. compulsive hand washing from an obsessive fear of germs) 40 Thought process and content Thought content Delusions (false beliefs e.g. Persecutory, Grandiose, Reference, Control or influence, Somatic, Nihilistic, Bizarre, Self accusation, Thought withdrawal, Thought insertion, Thought broadcasting, Thought control, Jealous, Erotomania) Suicidal and homicidal thoughts 41  Thought process and content The presence of active suicidal or homicidal thoughts constitutes a psychiatric emergency and immediate action is necessary. 42  Thought process and content Thought process Neologism (new word created by the patient) Word Salad (incoherent mixture of words and phrases) Tangentiality (the person frequently digress and forgets his initial reason for beginning a discussion) Circumstantiality (the person frequently digress but reaches a conclusion) 43 Thought process and content Thought process Flight of idea (rapid, continuous verbalizations or plays on words produce constant shifting from one idea another; the ideas tend to be connected, and in the less severe from a listener may be able to follow them) 44 Thought process and content Thought process Clang association (association of word similar in sound but not in meaning; words have no logical connection) Thought blocking (abrupt interruption in train of thinking before a thought or idea is finished; after a brief pause; the person indicates no recall of what was being said or was going to be said) 45 Thought process and content Thought process Loose associations Confabulation (fabrication of information to fill in for memory gaps, often indicating dementia) Concrete thought (only able to understand the conversations literally) 46 Thought process and content Thought process A client’s ability to think abstractly may be ascertained by assessing the client’s interpretation of a proverb or the client’s ability to describe similarities. 47  Perceptual Disturbances Hallucinations (sensations experienced by the client without real external stimuli, e.g. Auditory, Visual, Tactile, Olfactory, Gustatory) Illusions (misinterpretations of true stimuli) Depersonalization (altered perception of the self) Derealization (altered perception of the environment) 48  Impulse control Impulse control is the ability to delay, modulate, or inhibit the expression of behaviors and feelings. Assessing the client’s ability to control impulses is an integral part of determining potential for acting on suicidal and violent thoughts. 49  Cognition and sensorium Level of consciousness Orientation (to time, place, and person) Concentration (assessed by asking the client to count backward from 100 by 7s) Memory (immediate, recent, and remote) Intellectual functioning (below average, average, and superior) 50  Knowledge, insight, and judgment Knowledge. Judgment (the capacity to identify possible courses of action, anticipate their consequences, and choose the appropriate behavior) Insight (the extent of the client awareness of illness and maladaptive behaviors) 51 52 Schizophrenia and Other Psychotic Disorders  Outlines Objectives Introduction Nature of The Disorder Etiological Implications Types of Schizophrenia And Other Psychotic Disorders Application of The Nursing Process Treatment Modalities for Schizophrenia and Other Psychotic Disorders  Learning Objectives After reading this chapter, the student will be able to: 1. Discuss the concepts of schizophrenia and related psychotic disorders. 2. Identify etiological implications in the development of these disorders. 3. Describe various types of schizophrenia and related psychotic disorders. 4. Identify symptomatology associated with these disorders and use this information in client assessment.  Learning Objectives After reading this chapter, the student will be able to: 5. Formulate nursing diagnoses and outcomes of care for clients with schizophrenia and other psychotic disorders. 6. Identify topics for client and family teaching relevant to schizophrenia and other psychotic disorders. 7. Describe appropriate nursing interventions for behaviors associated with these disorders.  Learning Objectives After reading this chapter, the student will be able to: 8. Describe relevant criteria for evaluating nursing care of clients with schizophrenia and related psychotic disorders. 9. Discuss various modalities relevant to treatment of schizophrenia and related psychotic disorders.  Introduction The term schizophrenia was coined in 1908 by the Swiss psychiatrist Eugen Bleuler. The word was derived from the Greek “skhizo” (split) and “phren” (mind).  Introduction Over the years, much debate has surrounded the concept of schizophrenia. Various definitions of the disorder have evolved, and numerous treatment strategies have been proposed, but none have proven to be uniformly effective or sufficient.  Introduction Two general factors appear to be gaining acceptance among clinicians. The first is that schizophrenia is probably not a homogeneous disease entity with a single cause but results from a variable combination of genetic predisposition, biochemical dysfunction, physiological factors, and psychosocial stress.  Introduction The second factor is that there is not now and probably never will be a single treatment that cures the disorder. Instead, effective treatment requires a comprehensive, multidisciplinary effort, including pharmacotherapy and various forms of psychosocial care, such as living skills and social skills training, rehabilitation, and family therapy.  ‫‪Schizophrenia in Palestine‬‬ ‫ اما عن االحصائيات الخاصة بالمركز الفلسطيني لالرشاد‬ ‫فقد بينت النتائج الخاصة بالمتوجهين للطب النفسي خالل‬ ‫الثالث سنوات االخيرة ( ‪ ) 2007،2008،2009‬ما يلي‪:‬‬ ‫‪ %25‬من المتوجهين يعانون من القلق بانواعه و ‪%22‬‬ ‫اضطراب مزاج اما الفصام واالضطرابات الذهانية تشكل‬ ‫‪ % 18‬من المتوجهين ‪ %11‬اضطراب تكيف و‪%8‬‬ ‫اضطراب بالشخصية‪.‬‬  NATURE OF THE DISORDER Perhaps no psychological disorder is more crippling than schizophrenia. Characteristically, disturbances in thought processes, perception, and affect invariably result in a severe deterioration of social and occupational functioning.  NATURE OF THE DISORDER Symptoms generally appear in late adolescence or early adulthood, although they may occur in middle or late adult life (American Psychiatric Association [APA], 2000). Some studies have indicated that symptoms occur earlier in men than in women.  NATURE OF THE DISORDER The premorbid personality often indicates social maladjustment or schizoid or other personality disturbances (Ho, Black, & Andreasen, 2003). This premorbid behavior is often a predictor in the pattern of development of schizophrenia, which can be viewed in four phases. NATURE OF THE DISORDER  NATURE OF THE DISORDER Phase I: The Schizoid Personality. The DSM-IV-TR (APA, 2000) describes individuals in this phase as – indifferent to social relationships – having a very limited range of emotional experience and expression. – They do not enjoy close relationships and prefer to be “loners.” – They appear cold and aloof. Not all individuals who demonstrate the characteristics of schizoid personality will progress to schizophrenia. However, many individuals with schizophrenia show evidence of having had these characteristics in the premorbid condition.  NATURE OF THE DISORDER Phase II: The Prodromal Phase. Characteristics of this phase include – social withdrawal. – impairment in role functioning; – behavior that is peculiar or eccentric; – neglect of personal hygiene and grooming; – blunted or inappropriate affect; – disturbances in communication; – bizarre ideas; – unusual perceptual experiences; – lack of initiative, interests, or energy. The length of this phase is highly variable, and may last for many years before deteriorating to the schizophrenic state.  NATURE OF THE DISORDER Phase III: Schizophrenia. In the active phase of the disorder, psychotic symptoms are prominent.  NATURE OF THE DISORDER Phase III: Schizophrenia. The DSM-IV-TR (APA, 2000) diagnostic criteria for schizophrenia: Characteristic Symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period: – Delusions – Hallucinations – Disorganized speech – Grossly disorganized or catatonic behavior – Negative symptoms (i.e., affective flattening, alogia, or avolition).  Negative Symptoms Affective flattening (facial expression immobile, masklike, and unresponsive with poor eye contact), alogia (poverty of speech), avolition (unable to initiate goal directed activities may have problems in engaging in activities and completing tasks), anhedonia (inability to find joy in usually enjoyable activities), and attentional problems.  NATURE OF THE DISORDER Phase III: Schizophrenia. The DSM-IV-TR (APA, 2000) diagnostic criteria for schizophrenia: Social/Occupational Dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relationships, or self-care are markedly below the level achieved before the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement).  NATURE OF THE DISORDER Phase III: Schizophrenia. The DSM-IV-TR (APA, 2000) diagnostic criteria for schizophrenia: Duration: Continuous signs of the disturbance persist for at least 6 months.  NATURE OF THE DISORDER Phase IV: Residual Phase. Schizophrenia is characterized – by periods of remission and exacerbation. – A residual phase usually follows an active phase of the illness. – Symptoms during the residual phase are similar to those of the prodromal phase, with flat affect and impairment in role functioning being prominent. – Residual impairment often increases between episodes of active psychosis.  Prognosis A return to full premorbid functioning is not common (APA, 2000). several factors have been associated with a more positive prognosis. These include good premorbid adjustment, later age at onset, female gender, abrupt onset of symptoms precipitated by a stressful event (as opposed to gradual insidious onset of symptoms), associated mood disturbance, brief duration of active-phase symptoms, good interepisode functioning, minimal residual symptoms, absence of structural brain abnormalities, normal neurological functioning, a family history of mood disorder, and no family history of schizophrenia (APA, 2000). ETIOLOGICAL IMPLICATIONS The cause of schizophrenia is still uncertain. Most likely no single factor can be implicated in the etiology; rather, the disease probably results from a combination of influences including biological, psychological, and environmental factors. ETIOLOGICAL IMPLICATIONS – Genetics * Studies show that relatives of individuals with schizophrenia have a much higher probability of developing the disease than does the general population. – Twin Studies *The rate of schizophrenia among monozygotic (identical) twins is four times that of dizygotic twins and approximately 50 times that of the general population (Sadock & Sadock, 2003). ETIOLOGICAL IMPLICATIONS – Adoption Studies * The children who were born of schizophrenic mothers were more likely to develop the illness than the comparison control groups (Ho, Black, & Andreasen, 2003). ETIOLOGICAL IMPLICATIONS – The Dopamine Hypothesis This theory suggests that schizophrenia (or schizophrenia- like symptoms) may be caused by an excess of dopamine- dependent neuronal activity in the brain. This excess activity may be related to increased production or release of dopamine at nerve terminals, increased receptor sensitivity, too many dopamine receptors, or a combination of these mechanisms (Sadock & Sadock, 2003). ETIOLOGICAL IMPLICATIONS – Physiological Influences * A number of physical factors of possible etiological significance have been identified in the medical literature. However, their specific mechanisms in the implication of schizophrenia are unclear. ETIOLOGICAL IMPLICATIONS – Viral Infection * Sadock and Sadock (2003) report that epidemiological data indicate a high incidence of schizophrenia after prenatal exposure to influenza. – Anatomical Abnormalities * Ventricular enlargement is the most consistent finding; however, sulci enlargement and cerebellar atrophy are also reported. ETIOLOGICAL IMPLICATIONS – Histological Changes * A “disordering” of the pyramidal cells in the area of the hippocampus has been suggested (Jonsson et al, 1997). – Physical Conditions * Some studies have reported a link between schizophrenia and epilepsy (particularly temporal lobe), birth trauma, head injury in adulthood, alcohol abuse, cerebral tumor (particularly in the limbic system), cerebrovascular accidents, systemic lupus erythematosus, myxedema, parkinsonism, and Wilson’s disease. ETIOLOGICAL IMPLICATIONS – Psychological Influences * These early theories related to poor parent child relationships and dysfunctional family systems as the cause of schizophrenia. ETIOLOGICAL IMPLICATIONS Environmental Influences – Sociocultural Factors * Many studies have been conducted that have attempted to link schizophrenia to social class. Indeed epidemiological statistics have shown that greater numbers of individuals from the lower socioeconomic classes experience symptoms associated with schizophrenia than do those from the higher socioeconomic groups (Ho, Black, & Andreasen, 2003). ETIOLOGICAL IMPLICATIONS – Stressful Life Events * Studies have been conducted in an effort to determine whether psychotic episodes may be precipitated by stressful life events. There is no scientific evidence to indicate that stress causes schizophrenia.  TYPES OF SCHIZOPHRENIA Disorganized Schizophrenia. In this variation of schizophrenia, the individual doesn’t have hallucinations or delusions. Instead, they experience disorganized behavior and speech. This can include: flat affect speech disturbances disorganized thinking inappropriate emotions or facial reactions trouble with daily activities  TYPES OF SCHIZOPHRENIA Catatonic Schizophrenia Catatonic schizophrenia is characterized by marked abnormalities in motor behavior and may be manifested in the form of stupor or excitement.  TYPES OF SCHIZOPHRENIA Paranoid Schizophrenia Paranoid schizophrenia is characterized mainly by the presence of delusions of persecution or grandeur and auditory hallucinations related to a single theme. The individual is often tense, suspicious, and guarded, and may be argumentative, hostile, and aggressive. Onset of symptoms is usually later (perhaps in the late 20s or 30s  TYPES OF SCHIZOPHRENIA Undifferentiated Schizophrenia Sometimes clients with schizophrenic symptoms do not meet the criteria for any of the subtypes, or they may meet the criteria for more than one subtype. These individuals may be given the diagnosis of undifferentiated schizophrenia.  TYPES OF SCHIZOPHRENIA Residual Schizophrenia This diagnostic category is used when the individual has a history of at least one previous episode of schizophrenia with prominent psychotic symptoms. Residual schizophrenia occurs in an individual who has a chronic form of the disease and is the stage that follows an acute episode (prominent delusions, hallucinations, incoherence, bizarre behavior, and violence).  TYPES OF SCHIZOPHRENIA Residual Schizophrenia Residual symptoms may include social isolation, eccentric behavior ‫غريب االطوار‬, impairment in personal hygiene and grooming, blunted or inappropriate affect, poverty of or overly elaborate speech, illogical thinking, or apathy.  TYPES OF SCHIZOPHRENIA Schizoaffective Disorder This disorder is manifested by schizophrenic behaviors, with a strong element of symptomatology associated with the mood disorders (depression or mania). The client may appear depressed, with psychomotor retardation and suicidal ideation, or symptoms may include euphoria, grandiosity, and hyperactivity.  TYPES OF SCHIZOPHRENIA Brief Psychotic Disorder The essential feature of this disorder is the sudden onset of psychotic symptoms that may or may not be preceded by a severe psychosocial stressor. These symptoms last at least 1 day but less than 1 month, and there is an eventual full return to the premorbid level of functioning.  TYPES OF SCHIZOPHRENIA Schizophreniform Disorder The essential features of this disorder are identical to those of schizophrenia, with the exception that the duration, including prodromal, active, and residual phases, is at least 1 month but less than 6 months.  TYPES OF SCHIZOPHRENIA Delusional Disorder The essential feature of this disorder is the presence of one or more nonbizarre delusions that persist for at least 1 month. Erotomanic Type ‫معبود الجماهير‬ Grandiose Type Jealous Type Persecutory Type Somatic Type  TYPES OF SCHIZOPHRENIA Shared Psychotic Disorder The essential feature of this disorder is a delusional system that develops in a second person as a result of a close relationship with another person who already has a psychotic disorder with prominent delusions.  TYPES OF SCHIZOPHRENIA Psychotic Disorder Due to a General Medical Condition The essential features of this disorder are prominent hallucinations and delusions that can be directly attributed to a general medical condition.  TYPES OF SCHIZOPHRENIA Substance-Induced Psychotic Disorder The essential features of this disorder are the presence of prominent hallucinations and delusions that are judged to be directly attributable to the physiological effects of a substance (i.e., a drug of abuse, a medication, or toxin exposure). APPLICATION OF THE NURSING PROCESS  TREATMENT MODALITIES FOR SCHIZOPHRENIA Psychological Treatments – Individual Psychotherapy – Behavior Therapy – Group Therapy – Social Skills Training  TREATMENT MODALITIES FOR SCHIZOPHRENIA Social Treatment – Milieu Therapy: Milieu therapy is a form of psychotherapy that involves the use of therapeutic communities. Patients join a group of around 30, for between 9 and 18 months. – Family Therapy – Assertive Community Treatment (ACT)  TREATMENT MODALITIES FOR SCHIZOPHRENIA Organic Treatment – Psychopharmacology The End  Relationship Development and Therapeutic Communication  Outlines ◼ Objectives. ◼ Introduction. ◼ The therapeutic nurse–client relationship. ◼ Conditions essential to development of a therapeutic relationship. ◼ Phases of a therapeutic nurse–client relationship. ◼ Boundaries in the nurse–client relationship. ◼ Interpersonal communication. 2  Objectives ◼ Describe the relevance and dynamics of a therapeutic nurse–client relationship. ◼ Identify goals of the nurse–client relationship. ◼ Identify and discuss essential conditions for a therapeutic relationship to occur. ◼ Describe the phases of relationship development and the tasks associated with each phase. ◼ Identify types of pre-existing conditions that influence the outcome of the communication process. ◼ Define territoriality, density, and distance as components of the environment. ◼ Identify components of nonverbal expression. ◼ Describe therapeutic and nontherapeutic verbal communication techniques. ◼ Describe active listening. ◼ Discuss therapeutic feedback. 3  Introduction ◼ The nurse–client relationship is the foundation on which psychiatric nursing is established. ◼ It is a relationship in which both participants must recognize each other as unique and important human beings. ◼ It is also a relationship in which mutual learning occurs. 4  Introduction ◼ Peplau (1991) stated: ◼ Shall a nurse do things for a patient or can participant relationships be emphasized so that a nurse comes to do things with a patient as her share of an agenda of work to be accomplished in reaching a goal health. ◼ It is likely that the nursing process is educative and therapeutic when nurse and patient can come to know and to respect each other, as persons who are alike, and yet, different, as persons who share in the solution of problems. 5  Introduction ◼ Hays and Larson (1963) ◼ “To relate therapeutically with a patient, it is necessary for the nurse to understand his or her role and its relationship to the patient’s illness.” ◼ They describe the role of the nurse as: ◼ providing the client with the opportunity to: Identify and explore problems in relating to others. Discover healthy ways of meeting emotional needs. Experience a satisfying interpersonal relationship. 6  Introduction ◼ The therapeutic interpersonal relationship is the process by which nurses provide care for clients in need of psychosocial intervention. ◼ Therapeutic use of self is the instrument for delivery of that care. ◼ Interpersonal communication techniques (both verbal and nonverbal) are the “tools” of psychosocial intervention. 7  The Therapeutic Nurse- Client Relationship ◼ Therapeutic Relationship :An interaction between two people (usually a caregiver and a care receiver) in which input from both participants contributes to a climate of healing, growth promotion, and/or illness prevention. 8  The Therapeutic Nurse- Client Relationship ◼ Therapeutic relationships are goal oriented. Ideally, the nurse and client decide together what the goal of the relationship will be. ◼ Most often the goal is directed at learning and growth promotion in an effort to bring about some type of change in the client’s life. ◼ In general, the goal of a therapeutic relationship may be based on a problem-solving model. 9  The Therapeutic Nurse- Client Relationship ◼ Example ◼ Goal ◼ The client will demonstrate more adaptive coping strategies for dealing with (specific life situation). ◼ Interventions ◼ Identify what is troubling the client at this time. ◼ Encourage the client to discuss changes he or she would like to make. ◼ Discuss with the client which changes are possible and which are not possible. ◼ Have the client explore feelings about aspects that cannot be changed and alternative ways of coping 10 more adaptively.  Therapeutic Use of Self ◼ The ability to use one’s personality consciously and in full awareness in an attempt to establish relatedness and to structure nursing interventions. ◼ Use of the self in a therapeutic manner requires that the nurse have a great deal of self-awareness and self understanding, having arrived at a philosophical belief about life, death, and the overall human condition. 11  Conditions Essential To Development Of A Therapeutic Relationship ◼ Several characteristics that enhance the achievement of a therapeutic relationship have been identified. ◼ These concepts are highly significant to the use of self as the therapeutic tool in interpersonal relationship development. ◼ Rapport ◼ Trust ◼ Respect ◼ Empathy ◼ Genuineness 12  Rapport ◼ Rapport ‫العالقه‬implies special feelings on the part of both the client and the nurse based on acceptance, warmth, friendliness, common interest, a sense of trust, and a nonjudgmental attitude. ◼ Establishing rapport may be accomplished by discussing non-health-related topics. 13  Trust ◼ Trust is the initial developmental task described by Erikson. ◼ If the task has not been achieved, this component of relationship development becomes more difficult. ◼ That is not to say that trust cannot be established, but only that additional time and patience may be required on the part of the nurse. 14  Trust ◼ It is imperative for the nurse to convey an aura of trustworthiness, which requires that he or she possess a sense of self-confidence. ◼ Confidence in the self is derived from knowledge gained through achievement of personal and professional goals and the ability to integrate these roles and to function as a unified whole. 15  Trust ◼ Trust cannot be presumed; it must be earned. Trustworthiness is demonstrated through nursing interventions that convey a sense of warmth and caring to the client. ◼ These interventions are initiated simply and concretely, and directed toward activities that address the client’s basic needs for physiological and psychological safety and security. 16  Trust ◼ Many psychiatric clients experience concrete thinking, which focuses their thought processes on specifics rather than generalities. ◼ Examples of nursing interventions that would promote trust in an individual who is thinking concretely include the following: ◼ Providing a blanket when the client is cold ◼ Providing food when the client is hungry ◼ Keeping promises ◼ Being honest (e.g., saying “I don’t know the answer to your question, but I’ll try to find out”) and then following through 17  Trust ◼ Examples of nursing interventions that would promote trust in an individual who is thinking concretely include the following: ◼ Simply and clearly providing reasons for certain policies, procedures, and rules. ◼ Providing a written, structured schedule of activities. ◼ Attending activities with the client if he or she is reluctant to go alone. ◼ Being consistent in adhering to unit guidelines. ◼ Taking the client’s preferences, requests, and opinions into consideration when possible in decisions concerning his or her care ◼ Ensuring confidentiality; providing reassurance that what is discussed will not be repeated outside the boundaries of the health care team. 18  Respect ◼ To show respect is to believe in the dignity and worth of an individual regardless of his or her unacceptable behavior. ◼ The attitude is nonjudgmental, and the respect is unconditional in that it does not depend on the behavior of the client to meet certain standards. ◼ The nurse, in fact, may not approve of the client’s lifestyle or pattern of behaving. 19  Respect ◼ Many psychiatric clients have very little self-respect because, as a result of their behavior, they have been rejected by others in the past. ◼ The nurse can convey an attitude of respect by: ◼ Calling the client by name (and title, if the patient prefers) ◼ Spending time with the client ◼ Allowing for sufficient time to answer the client’s questions and concerns ◼ Promoting an atmosphere of privacy during therapeutic interactions with the client, or when the client may be undergoing physical examination or therapy 20  Respect ◼ The nurse can convey an attitude of respect by: ◼ Always being open and honest with the client, even when the truth may be difficult to discuss ◼ Taking the client’s ideas, preferences, and opinions into consideration when planning care ◼ Striving to understand the motivation behind the client’s behavior, regardless of how unacceptable it may seem 21  Genuineness ◼ The concept of genuineness ‫ الصدق‬refers to the nurse’s ability to be open, honest, and, “real” in interactions with the client. ◼ To be “real” is to be aware of what one is experiencing internally and to allow the quality of this inner experiencing to be visible in the therapeutic relationship. 22  Genuineness ◼ When one is genuine, there is congruence between what is felt and what is being expressed. ◼ The nurse who possesses the quality of genuineness responds to the client with truth and honesty, rather than with responses he or she may consider more “professional” or ones that merely reflect the “nursing role.” 23  Genuineness ◼ Genuineness may call for a degree of self-disclosure on the part of the nurse. This is not to say that the nurse must disclose to the client everything he or she is feeling or all personal experiences that may relate to what the client is going through. ◼ Indeed, care must be taken when using self-disclosure, to avoid transposing the roles of nurse and client. When the nurse uses self disclosure, a quality of “humanness” is revealed to the client, creating a role for the client to model in similar situations. 24  Genuineness ◼ The client may then feel more comfortable revealing personal information to the nurse. ◼ Most individuals have an uncanny ‫خارق للطبيعه‬ability to detect other peoples’ artificiality. When the nurse does not bring the quality of genuineness to the relationship, a reality base for trust cannot be established. ◼ These qualities are essential if the actualizing potential of the client is to be realized and for change and growth to occur. 25  Empathy ◼ Empathy is a process wherein an individual is able to see beyond outward behavior and sense accurately another’s inner experience at a given point in time. ◼ With empathy, the nurse can accurately perceive and understand the meaning and relevance of the client’s thoughts and feelings. ◼ The nurse must also be able to communicate this perception to the client. 26  Empathy ◼ This is done by attempting to translate words and behaviors into feelings. ◼ It is not uncommon for the concept of empathy to be confused with that of sympathy. ◼ The major difference is that with empathy the nurse “accurately perceives or understands” what the client is feeling and encourages the client to explore these feelings. 27  Empathy ◼ With sympathy the nurse actually “shares” what the client is feeling, and experiences a need to alleviate distress. ◼ Empathy is considered to be one of the most important characteristics of a therapeutic relationship. ◼ Accurate empathetic perceptions on the part of the nurse assist the client to identify feelings that may have been suppressed or denied. Positive emotions are generated as the client realizes that he or she is truly understood by another. As the feelings surface and are explored, the client learns aspects about self of which he or she may have been unaware. 28 Empathy 29  Phases of A Therapeutic Nurse-client Relationship ◼ The therapeutic interpersonal relationship is the means by which the nursing process is implemented. ◼ Through the relationship, problems are identified, and resolution is sought. Tasks of the relationship have been categorized into four phases: 1. Pre -interaction phase 2. Orientation (introductory) phase 3. Working phase 4. Termination phase 30 Phases of A Therapeutic Nurse-client Relationship 31  The Pre-interaction Phase ◼ The pre-interaction phase involves preparation for the first encounter with the client. ◼ Tasks include: ◼ Obtaining available information about the client from his or her chart, significant others, or other health team members. From this information, the initial assessment is begun. This initial information may also allow the nurse to become aware of personal responses to knowledge about the client. 32  The Pre-interaction Phase ◼ Tasks include: ◼ Examining one’s feelings, fears, and anxieties about working with a particular client. # For example, the nurse may have been reared in an alcoholic family and have ambivalent feelings about caring for a client who is alcohol dependent. All individuals bring attitudes and feelings from prior experiences to the clinical setting. The nurse needs to be aware of how these preconceptions may affect his or her ability to care for individual clients. 33  The Orientation Phase ◼ During the orientation phase, the nurse and client become Familiar. ◼ Tasks include: ◼ Creating an environment for the establishment of trust and rapport. ◼ Establishing a contract for intervention that details the expectations and responsibilities of both the nurse and client. ◼ Gathering assessment information to build a strong client database. 34  The Orientation Phase ◼ Tasks include: ◼ Identifying the client’s strengths and limitations ◼ Formulating nursing diagnoses. ◼ Setting goals that are mutually agreeable to the nurse and client. ◼ Developing a plan of action that is realistic for meeting the established goals. ◼ Exploring feelings of both the client and nurse in terms of the introductory phase. ◼ Introductions often are uncomfortable, and the participants may experience some anxiety until a degree of rapport has been established. Interactions may remain on a superficial level until anxiety subsides. Several interactions may be required to fulfill the tasks associated with this phase. 35  The Working Phase ◼ The therapeutic work of the relationship is accomplished during this phase. ◼ Tasks include: ◼ Maintaining the trust and rapport that was established during the orientation phase ◼ Promoting the client’s insight and perception of reality ◼ Problem-solving using. ◼ Overcoming resistance behaviors on the part of the client as the level of anxiety rises in response to discussion of painful issues ◼ Continuously evaluating progress toward goal attainment 36  The Working Phase ◼ Transference and Counter-transference ◼ Transference and counter-transference are common phenomena that often arise during the course of a therapeutic relationship. ◼ Transference ◼ Transference occurs when the client unconsciously attributes (or “transfers”) to the nurse feelings and behavioral predispositions formed toward a person from his or her past. ◼ Example: Anger toward the nurse can be manifested by uncooperativeness and resistance to the therapy. 37  The Working Phase ◼ Transference can also take the form of overwhelming affection for or excessive dependency on the nurse. ◼ The nurse is overvalued and the client forms unrealistic expectations of the nurse. ◼ When the nurse is unable to fulfill those expectations or meet the excessive dependency needs, the client may become angry and hostile. 38  The Working Phase ◼ Interventions For Transference. ◼ In cases of transference, the relationship does not usually need to be terminated, except when the transference poses a serious barrier to therapy or safety. ◼ The nurse should work with the patient in sorting out the past from the present, and assist the patient into identifying the transference and reassign a new and more appropriate meaning to the current nurse-patient relationship. ◼ The goal is to guide the patient to independence by teaching them to assume responsibility for their own behaviors, feelings, and thoughts, and to assign the correct meanings to the relationships based on present circumstances instead of the past. 39  The Working Phase ◼ Counter-transference ◼ Counter-transference refers to the nurse’s behavioral and emotional response to the client. ◼ These responses may be related to unresolved feelings toward significant others from the nurse’s past, or they may be generated in response to transference feelings on the part of the client. 40  The Working Phase ◼ These feelings can interfere with the therapeutic relationship when they initiate the following types of behaviors: ◼ The nurse over identifies with the client’s feelings because they remind him or her of problems from the nurse’s past or present. ◼ The nurse and client develop a social or personal relationship. ◼ The nurse begins to give advice or attempts to “rescue” the client. ◼ The nurse encourages and promotes the client’s dependence. ◼ The nurse’s anger engenders feelings of disgust (hate) toward the client. 41  The Working Phase ◼ These feelings can interfere with the therapeutic relationship when they initiate the following types of behaviors: ◼ The nurse feels anxious and uneasy in the presence of the client. ◼ The nurse is bored and apathetic in sessions with the client. ◼ The nurse has difficulty setting limits on the client’s behavior. ◼ The nurse defends the client’s behavior to other staff members. 42  The Working Phase ◼ Interventions For Counter-transference. ◼ The relationship usually should not be terminated in the presence of counter-transference. ◼ Rather, the nurse or staff member experiencing the counter-transference should be supportively assisted by other staff members to identify his or her feelings and behaviors and recognize the occurrence of the phenomenon. 43  The Working Phase ◼ Interventions For Counter-transference. ◼ It may be helpful to have evaluative sessions with the nurse after his or her encounter with the patient. ◼ In which both the nurse and other staff members (who are observing the interactions) discuss and compare the exhibited behaviors in the relationship. 44  The Termination Phase ◼ Termination of the relationship may occur for a variety of reasons: the mutually agreed-on goals may have been reached; the client may be discharged from the hospital; or, in the case of a student nurse, it may be the end of a clinical rotation. ◼ Termination can be a difficult phase for both the client and nurse. The main task involves bringing a therapeutic conclusion to the relationship. 45  The Termination Phase ◼ This occurs when: ◼ Progress has been made toward attainment of mutually set goals. ◼ A plan for continuing care or for assistance during stressful life experiences is mutually established by the nurse and client. 46  The Termination Phase ◼ This occurs when: ◼ Feelings about termination of the relationship are recognized and explored. Both the nurse and the client may experience feelings of sadness and loss. ◼ The nurse should share his or her feelings with the client. Through these interactions, the client learns that it is acceptable to have these feelings at a time of separation. Through this knowledge, the client experiences growth during the process of termination. 47  Boundaries In The Nurse–client Relationship ◼ Material boundaries are physical property that can be seen, such as fences ‫سياج‬that border land. ◼ Social boundaries are established within a culture and define how individuals are expected to behave in social situations ◼ Personal boundaries are those that individuals define for themselves. They include physical distance boundaries, or just how close individuals will allow others to invade their physical space; and emotional boundaries, or how much individuals choose to disclose of their most private and intimate selves to others. ◼ Professional boundaries limit and outline expectations for appropriate professional relationships with clients. 48  Interpersonal Communication The Impact of Pre-existing Conditions ◼ Values, attitudes, and beliefs ◼ Culture or religion ◼ Social status ◼ Age or developmental level ◼ Gender ◼ Environment in which the transaction takes place 49  Nonverbal Communication ◼ Physical Appearance and Dress. ◼ Body Movement and Posture. ◼ Touch ◼ Facial Expressions ◼ Eye Behavior ◼ Vocal Cues, or Paralanguage 50  Therapeutic Communication Techniques ◼ Therapeutic Communication : Caregiver verbal and nonverbal techniques that focus on the care receiver’s needs and advance the promotion of healing and change. ◼ Therapeutic communication encourages exploration of feelings and fosters understanding of behavioral motivation. It is nonjudgmental, discourages defensiveness, and promotes trust. 51 Nontherapeutic Communication Techniques ◼ The nurse should recognize and eliminate the use of these patterns in his or her relationships with clients. ◼ Avoiding these communication barriers will maximize the effectiveness of communication and enhance the nurse client relationship. 52  Process Recordings ◼ Process recordings are written reports of verbal interactions with clients. ◼ They are verbatimp ‫( حرفي‬to the extent that this is possible) accounts, written by the nurse or student as a tool for improving interpersonal communication techniques. ◼ The process recording can take many forms, but usually includes the verbal and nonverbal communication of both nurse and client. 53  Process Recordings ◼ The interaction provides a means for the nurse to analyze both the content and pattern of the interaction. ◼ The process recording is not documentation in and of itself, but should be used as a learning tool for professional development. ◼ An example of one type of process recording is presented in Table 6–5. 54  Active Listening ◼ To listen actively is to be attentive to what the client is saying, both verbally and nonverbally. Attentive listening creates a climate in which the client can communicate. ◼ With active listening the nurse communicates acceptance and respect for the client, and trust is enhanced. ◼ A climate is established within the relationship that promotes openness and honest expression. ◼ Several nonverbal behaviors have been designated as facilitative skills for attentive listening. 55  Active Listening ◼ Those listed here can be identified by the acronym SOLER: ◼ S—Sit squarely facing the client. This gives the message that the nurse is there to listen and is interested in what the client has to say. ◼ O—Observe an open posture. Posture is considered “open” when arms and legs remain uncrossed. This suggests that the nurse is “open” to what the client has to say. With a “closed” position, the nurse can convey a somewhat defensive stance, possibly invoking a similar response in the client. 56  Active Listening ◼ Those listed here can be identified by the acronym SOLER: ◼ L—Lean forward toward the client. This conveys to the client that you are involved in the interaction, interested in what is being said, and making a sincere effort to be attentive. ◼ E—Establish eye contact. Direct eye contact is another behavior that conveys the nurse’s involvement and willingness to listen to what the client has to say. The absence of eye contact, or the constant shifting of eye contact, gives the message that the nurse is not really interested in what is being said 57  Active Listening ◼ Those listed here can be identified by the acronym SOLER: ◼ R—Relax. Whether sitting or standing during the interaction, the nurse should communicate a sense of being relaxed and comfortable with the client. ◼ Restlessness and fidgetiness communicate a lack of interest and a feeling of discomfort that are likely to be transferred to the client. 58 59 Psychiatric mental health nursing in acute care settings  Introduction Acute mental illness: Acute mental illness is a general term which can be used to describe a range of symptoms involving problems with feelings, behaviors, emotions and thoughts.  Psychiatric mental health nursing in acute care settings Treatment and care for mental health-related issues is provided in a variety of settings. The environment, and level or type of care, will depend on multiple factors: the nature and severity of the person’s mental condition, their physical health, and the type of treatment prescribed or indicated.  Acute Mental Illness Acute mental illness is characterized by significant and distressing symptoms of a mental illness requiring immediate treatment. This may be the person's first experience of mental illness, a repeat episode or the worsening of symptoms of an often continuing mental illness.  Acute Mental Illness The onset of acute mental illness is sudden or rapid and the symptoms usually respond to treatment. In view of this, admission to the Acute Wards can be voluntary or else compulsory. The latter normally takes place when the person's behavior and actions indicate being at risk of causing serious harm to the self or to others. In this regard, receiving immediate treatment becomes a priority.  Acute Mental Illness When a person becomes an in-patient at Mental hospital due to his/her acute mental illness, a care plan is drawn by the multi disciplinary team. Routine tests, medical tests and medication assessment and intervention are carried out.  Acute Mental Illness As the person's mental health becomes more stable, the person is first sent ‘on leave'', meaning that s/he would still be on the medical records of Mental hospital, and is eventually discharged. Follow-up visits with the consultant and/or the multi disciplinary team can be offered, either at Mental hospital or else within the community services.  In-patient treatment In-patient treatment: (sometimes referred to as hospitalization) is a type of treatment in which the patient is provided with 24 hour care at a live-in facility. How long the person's stay would be, depends on the individual's needs. One important difference between in- patient and out-patient treatment is the amount of medical attention received by a patient.  In-patient treatment In in-patient treatment, constant medical supervision is placed over each patient. Such care is effective because it offers a very structured and defined atmosphere. Such a setting helps a person to forget about the distractions of life and allows them to focus on healing physically and psychologically.  Out-patient treatment In psychiatric health, if the person suffers from mild mental illness and is coping with every day activities, the person may simply need out-patient treatment. This treatment may be received by using the mental health service/s offered within his/her community.  In-patient treatment When however, the person's mental illness becomes acute and he/she finds it extremely difficult to carry on with everyday life, or the person's life or that of other's may be at risk due to the illness, it is important to enter Mental hospital (In-Patient Unit for in-patient treatment). As the person begins to recover and become more stable, s/he may be referred for out-patient treatment at the Psychiatric Out-Patient clinic or at the various other Community Services.  Out-patient treatment Out-patient treatment: involves periodic visits to a clinician, where assessment and interventions are carried out. The frequency with which a practitioner sees people varies widely, from days to months, depending on the type, severity and stability of each person's condition.  Out-patient treatment Out-patient treatment allows the person to receive the necessary medical support while living within the community and getting on with everyday life. The person can keep working, spending time with the family, socializing with friends and living at home.  Out-patient treatment Outpatient mental illness treatment is best suited for those with: Mild to moderate symptoms. A solid support system. The ability to function outside of the treatment environment.  Out-patient treatment Many different types of mental health treatment options are offered on an outpatient basis. These include: Individual therapy. Group therapy. Family therapy. Support groups. Intensive outpatient care. Psychiatric medications and outpatient medical management.  Psychiatric in-patient treatment Psychiatric in-patient treatment has changed over the past several decades. In the past, patients were “hospitalized” for a very long time to the extent that some lost the skills which they previously had and became fully dependent on the hospital context.  Psychiatric in-patient treatment Today, this is very different. People receiving psychiatric treatment are more likely to be seen as outpatients. If the person needs to enter hospital, the average stay is around one to two weeks, with only a small number receiving long-term treatment in hospital.  Psychiatric in-patient treatment When a person is admitted to hospital s/he is closely monitored to provide an accurate diagnosis. This can help to administer, adjust or stabilize medications and to provide the necessary treatment. The duration of the stay would depend on how severe the mental illness is.  Psychiatric in-patient treatment There are times when a person becomes so ill that there may be a risk of severely hurting oneself or others. In this case entering hospital may become a necessity even if the individual does not agree. While seeking help voluntarily is always preferable, if that is at all possible, the decision to be admitted to hospital involuntarily can in the long run be more caring and helpful than it seems – especially if this is the only way in which the right care can be given.  Psychiatric in-patient treatment Being admitted to hospital may sometimes be daunting for some people and may give rise to several questions and worries. In view of this, it may be helpful for the patient and his/her relatives to prepare a few questions that may be asked prior to, or when admitted to hospital. The following are a few such questions that may be asked: Questions related to the patient's general treatment program:  Psychiatric in-patient treatment When can we talk to the doctor/team? Will we be able to discuss treatment with the doctor/team? When? How often? Are there activities for patients and is there a daily schedule for this? How long will the patient be at the facility? What can we expect when the patient is discharged?​ The role of the registered nurse in an acute mental health inpatient setting delivering care from a crisis management perspective, which covers aspects such as assessment, stabilization of symptoms and discharge planning. Participants also believed that the therapeutic relationship was a fundamental role in inpatient care.  Symptoms Signs and symptoms of mental illness can vary, depending on the disorder, circumstances and other factors. Mental illness symptoms can affect emotions, thoughts and behaviors. Examples of signs and symptoms include:  Symptoms Feeling sad or down Confused thinking or reduced ability to concentrate Excessive fears or worries, or extreme feelings of guilt Extreme mood changes of highs and lows Withdrawal from friends and activities Significant tiredness, low energy or problems sleeping Detachment from reality (delusions), paranoia or hallucinations  Symptoms Inability to cope with daily problems or stress Trouble understanding and relating to situations and to people Alcohol or drug abuse Major changes in eating habits Sex drive changes Excessive anger, hostility or violence Suicidal thinking  Symptoms Sometimes symptoms of a mental health disorder appear as physical problems, such as stomach pain, back pain, headache, or other unexplained aches and pains.  Causes Mental illnesses, in general, are thought to be caused by a variety of genetic and environmental factors: Inherited traits. Mental illness is more common in people whose blood relatives also have a mental illness. Certain genes may increase your risk of developing a mental illness, and your life situation may trigger it.  Causes Environmental exposures before birth. Exposure to environmental stressors, inflammatory conditions, toxins, alcohol or drugs can sometimes be linked to mental illness. Brain chemistry. Neurotransmitters are naturally occurring brain chemicals that carry signals to other parts of your brain and body. When the neural networks involving these chemicals are impaired, the function of nerve receptors and nerve systems change, leading to mental illness.  Risk Factors Certain factors may increase your risk of developing mental health problems, including: Having a blood relative, such as a parent or sibling, with a mental illness Stressful life situations, such as financial problems, a loved one's death or a divorce An ongoing (chronic) medical condition, such as diabetes Brain damage as a result of a serious injury (traumatic brain injury), such as a violent blow to the head Traumatic experiences, such as military combat or being assaulted Use of alcohol or recreational drugs Being abused or neglected as a child Having few friends or few healthy relationships A previous mental illness Examples of acute mental diseases Psychosis Confusion Acute stress reaction Adjustment disorders Delirium Organic mental disorders Organic brain syndrome  Psychiatric hospitalization treatment Psychiatric hospitalization treatment typically consists of stabilization, close monitoring, medication, administration of fluids and nutrition, and other necessary emergency care. People may be voluntarily or involuntarily hospitalized. A person may be involuntarily hospitalized when they either are gravely disabled or are a danger to themselves or others.  Psychiatric hospitalization A person is a candidate for psychiatric hospitalization when they have: Severe mental health symptoms. Hallucinations or delusions. Suicidal or homicidal ideation. Not slept or eaten for days. Lost the ab