33496209 psychiatric nursing
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Concerned with the promotion of mental health, prevention of mentaldisorders, and the nursing care of patients
during mental illness and rehabilitation.
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Core of Psychiatric Nursing Interpersonal Process – human to human relationship (NPI)
where by the professional nurse practitioner uses of therapeutic Self
Psychiatric Nursing as Science & Art Knowledge, Skills & Attitude (KSA)
• Science – use of different theories in the practice of nursing
• Arts –
Therapeutic use of self Clientele in Psychiatric Nursing
• Individual, Family and the Community
• Mentally ill and Mentally Healthy Person
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WHO definition: state of complete physical, mental,and social wellness, not merely absence of disease orinfirmity
State of emotional, psychological, and social wellnessevidenced by:
Satisfying interpersonal relationships
Effective behavior and coping
A positive self-concept
Emotional stability
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Individual factors: Biologic make-up, autonomy, independence, self-esteem,
capacity for growth, vitality, ability to find meaning in life,emotional resilience or hardiness, a sense of belonging,
reality orientation, and coping or stress managementabilities Interpersonal factors: Effective communication, ability to help others, intimacy,
and a balance of separateness and connectedness Social/cultural factors: A sense of community, access to adequate resources,
intolerance of violence, support of diversity among people,mastery of the environment, and a positive, yet realistic,
view of one’s world
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Historically viewed as possession by demons,punishment for religious or social transgressions,weakness of will or spirit, violation of socialnorms
Today seen as a medical problem, although somestigma from previous beliefs remains
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Mental disorder is “a clinically significant
behavioral or psychological syndrome or
pattern that occurs in an individual andthat is associated with distress ordisability or with a significantly increased
risk of suffering death, pain, disability, oran important loss of freedom” (APA)
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Individual factors include biologic
makeup, anxiety, worries and fears, a sense of disharmony in life, and a loss of meaning in one’s life
(Seaward, 1997) Interpersonal factors
include ineffective communication, excessive dependencyor withdrawal from relationships, and loss of emotional
control. Social and cultural factors
include lack of resources, violence, homelessness, poverty,and discrimination such as racism, classism, ageism, and
sexism.
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The DSM-IV-TR® is a taxonomy published by APA
and used by all mental health professionals thatdescribes all mental disorders according tospecific diagnostic criteria
The DSM-IV-TR is based on multiaxialclassification system:
A multi-axial classification system that involvesassessment on several axes, or domains of
information, allows the practitioner to identify all the
factors that relate to a person’s condition:
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► Axis I : Major psychiatric disorders except mentalretardation and personality disorders
► Axis II : Mental retardation, personality disorders,maladaptive personality features, and defensemechanisms
► Axis III : Current medical conditions
► Axis IV: Psychosocial and environmentalproblems
► Axis V: Global Assessment of Functioning (GAF)score
DSM-IV-TR (cont’d)
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The ability to establish therapeuticrelationships with clients is one of themost important skills a nurse can
develop
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Components include:
Trust
Genuine interest
Empathy (not sympathy)
Acceptance of person, not necessarily his orher behavior
Unconditional positive regard
Self-awareness and therapeutic use of self
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Nurse Client Interaction
Direct interaction
Establishing Rapport to patient Working & Communicating to patient
Nurse Patient Relationship
Therapeutic nurse–patient relationship,which includes four phases: orientation,identification, exploitation, and resolution
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Self-awareness: process of understanding one’s own
values, beliefs, thoughts, feelings, attitudes, motivations,
strengths, and limitations and how one’s thoughts and
behaviors affect others
Therapeutic use of self: the nurse uses aspects of his or her
personality, experience, values, feelings, intelligence,
needs, coping skills, and perceptions to establish
relationships with clients that are beneficial to clients
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Tool that is useful in learning more aboutoneself is the Johari window (Luft, 1970),
which creates a “word portrait” of a person infour areas and indicates how well that personknows himself or herself and communicateswith others.
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The Johari window is aself-awareness toolthatcategorizes qualitiesof self as:
Open/public
Blind/unaware
Hidden/private
Unknown
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The four areas evaluated are as follows:
Quadrant 1: Open/public self: qualities one
knows about oneself and others also know Quadrant 2: Blind/unaware self: qualities known
only to others Quadrant 3: Hidden/private self: qualities known
only to oneself Quadrant 4: Unknown: an empty quadrant to
symbolize qualities as yet undiscovered byoneself or others
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Social Relationship A social relationship is primarily initiated for
the purpose of friendship, socialization,companionship, or accomplishment of a task.Communication, which may be superficial,usually focuses on sharing ideas, feelings, andexperiences and meets the basic need forpeople to interact.
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Intimate Relationship A healthy intimate relationship involves two
people who are emotionally committed toeach other. Both parties are concerned abouthaving their individual needs met and helpingeach other to meet needs as well. Therelationship may include sexual or emotionalintimacy as well as sharing of mutual goals.
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Therapeutic Relationship
The therapeutic relationship focuses on the
needs, experiences, feelings, and ideas of theclient only. The nurse and client agree aboutthe areas to work on and evaluate theoutcomes. The nurse uses communicationskills, personal strengths, and understandingof human behavior to interact with the client.
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Therapeutic relationships
are focused on the needs,
experiences, feelings, and
ideas of the client, not the
nurse The therapeutic
relationship
consists of three phases:
Orientation
Working
Termination
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ORIENTATION The orientation phase begins when the nurse
and client meet and ends when the clientbegins to identify problems to examine.During the orientation phase, the nurseestablishes roles, the purpose of meeting,and the parameters of subsequent meetings;identifies the client’s problems; and clarifiesexpectations.
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Nurse task is to:
Build trust
Reads background materials available on the client Becomes familiar with any medications the client is
taking
Gathers necessary paperwork
Arranges for a quiet, private, comfortable setting
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Outline the responsibilities of the nurse and client. both nurse and client should agree on these
responsibilities in an informal or verbal contract. formal or written contract may be appropriate if a written contract has been necessary in the past
with the client or if the client “forgets” the agreed-on verbal contract.
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The contract should state: Time, place, and length of sessions When sessions will terminate Who will be involved in the treatment plan (family
members, health team members) Client responsibilities (arrive on time, end on
time) Nurse’s responsibilities (arrive on time, end on
time, maintain confidentiality at all times,
evaluate progress with client, document sessions
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Respecting the client’s right to keep private anyinformation about his or her mental and physicalhealth and related care.
The nurse must clearly state information aboutwho will have access to client assessment data andprogress evaluations.
He or she should tell the client that members of the
mental health team share appropriate informationamong themselves to provide consistent care andthat only with the client’s permission will theyinclude a family member
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Revealing personal information such asbiographical information and personal ideas,
thoughts, and feelings about oneself toclients (Deering, 1999). The nurse can use self-disclosure to convey
support, educate clients, demonstrate that aclient’s anxiety is normal, and even facilitateemotional healing (Deering, 1999).
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Divided into two sub phases
Problem identification
▪ the client identifies the issues or concerns causingproblems
▪ Examination of the client’s feelings and responses
Exploitation (exploration)
▪ the nurse guides the client to examine feelings andresponses and to develop better coping skills and a morepositive self-image; this encourages behavior changeand develops independence.
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The specific tasks of the working phase include the following: Maintaining the relationship
Gathering more data
Exploring perceptions of reality
Developing positive coping mechanisms Promoting a positive self-concept
Encouraging verbalization of feelings
Facilitating behavior change
Working through resistance Evaluating progress and redefining goals as appropriate
Providing opportunities for the client to practice new behaviors
Promoting independence
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In the working phase, the nurse must beacutely aware of 2 common elements canarise:
Transference: when clients unconsciously transfer feelings they have for significant persons in their life onto the nurse▪ Patient to nurse
Countertransference: when the nurse responds tothe client based on his or her own unconsciousneeds and conflicts▪ Nurse to patient
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Begins when the client’s problems are
resolved
Ends when the relationship is ended
Deals with feelings of anger or abandonment that may occur
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Inappropriate boundaries (relationshipbecomes social or intimate)
Feelings of sympathy and encouragingdependency
Nonacceptance of the client as a person
because of his or her behaviors, leading toavoidance of the client
Nurse self-awareness is the way to avoid such
problems
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Teacher the nurse may teach the client new methods of coping and
solving problems. Caregiver
role in mental health settings is the implementation of thetherapeutic relationship to build trust, explore feelings, assistthe client in problem solving, and help the client meetpsychosocial needs.
Advocate In the advocate role, the nurse informs the client and then
supports him or her in whatever decision he or she makes(Kohnke, 1982).
Parent surrogate Assume the parental role as evidenced in choice of words and
nonverbal communication.
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