DOCUMENTATION IN PSYCHIATRIC NURSING PROBLEM ORIENTED RECORDING Established by Lawrence Weed in 1960s. The data are arranged according to the problems the client has rather than the source of the information. Member of the health team contribute to the problem list, plan of care, and progress notes. FDAR FOCUS CHARTING A method of charting that uses key words or foci to describe what is happening to the client. 3 COLUMNS OF RECORDING are usually used: 1. DATA and time 2.Focus 3.Progress notes The Progress Notes are organized into: DAR DATA ACTION RESPONSE DATA category reflects the assessment phase of the nursing process and consists of observation of client status and behaviors, including data from flow sheet (e.g. Vital signs). The nurse records both subjective and objective data in this section. ACTION Category reflects planning and implementation and includes immediate and future nursing actions. It also include any changes to the plan of care. PROGRESS NOTESRESPONSE: Category reflects the evaluation phase of the nursing process and describes the clients response to any nursing and medical care. Sample Charting:NARRATIVE RECORDING Is a traditional part of the source-oriented record. SOURCE-ORIENTED RECORD: is a traditional client record. Each person or department makes notations in a separate section or sections of the clients chart. Ex. The Admission Department: Admission sheet. The physician: physicians order/Doctors order sheet. The nurses: Nurses notes Narrative Recording In this type of record, information about a particular problem is distributed throughout the record. It consists of written notes that include routine care, normal findings, and client problems. There is no right or wrong order to the information, although chronological order is frequently used. PROCESS RECORDING Is a verbatim (word for- word) account of conversation. It can be taped or written and includes all verbal and nonverbal interactions of both the client and nurse. One method of writing a process recording is to make two columns on a page. First column: list what the nurse and client said along with the associated nonverbal behavior. Second column: contains an analysis about the nurses responses. Once a process recording has been completed, it should analyzed in terms of the content and meaning of the interaction based on communication theory. Each of the nurses statements is interpreted in terms of the communication skill used, with the rationale for and effectiveness of its use. Ex.

NURSE CLIENT RELATIONSHIPNURSE CLIENT INTERACTIONMODULE 4NURSE CLIENT INTERACTION (COMMUNICATION)COMMUNICATION : is the process that people use to exchange information. Is an interaction between two or more people that involves the exchange of information between a sender and a receiverMessages are simultaneously sent and received on two levels: Verbally through the use of words Non- verbally by behaviors that accompany the words.THERAPEUTIC COMMUNICATIONIs an interpersonal interaction between the nurse and client during which the nurse focuses on the clients specific needs to promote an effective exchange of information. therapeutic communication techniques helps the nurse understand and empathize with the clients experience. All nurses need skills in therapeutic communication to effectively apply the nursing process and to meet standards of care for their client.Therapeutic Communication can help Nurses to accomplish Goals:1. Establish a therapeutic nurse- client relationship2. Identify the most important client concern at that moment (client centered goal).3. Assess the clients perception of the problem as it unfolds. (the clients thoughts and feelings about the situation, others and self).4. Facilitate the clients expression of emotions.5. Teach the client and family necessary self-care skills.6. Recognize the clients needs.7. Implement intervention designed to address the clients needs.8. Guide the client toward identifying a plan of action to a satisfying and socially acceptable resolution.To have Effective Therapeutic Communication the nurse must consider:Privacy and Respect of BoundariesUse of TouchActive listening and observation1. PRIVACY AND RESPECT BOUNDARIESPrivacy is desirable but not always possible in Therapeutic Communication. ( delicate information the nurse should know or the patient would revealed)An interview or conference room is optimal, if the nurse believes this setting is not isolative for interaction.The nurse needs to evaluate whether interacting in the clients room is therapeutic.Ex. If the client has difficulty maintaining boundaries or has been making sexual comments, then the clients room is not the best setting.BOUNDARIESPROXEMICS: is the study of distance zones between people during communication.People feel more comfortable with smaller distance when communicating with someone they know rather than strangers.4 Distance Zones:1. Intimate 2. Personal 3. Social4. Intimate 4 Distance Zones: 1. Intimate zone ( 0 to 18 inches between people) : this amount of space is comfortable for parents with young children, people who mutually desire personal contact, or people whispering. invasion of this intimate zone by anyone else is threatening and produces anxiety.2. Personal zone (18 to 36 inches) : this distance is comfortable between family and friends who are talking.3. Social zone (4 to 12 feet): this distance is acceptable for communication in social, work, and business settings.4. Public zone (12 to 25 feet): this is acceptable distance between a speaker and an audience, small groups, and other informal functions. Both the client and the nurse can feel threatened, if one invades the others personal or intimate zone, which can result tension, irritability, fidgeting (uneasy, nervous) , or even flight. When the nurse must invade the intimate or personal zone, the nurse should ask the clients permission.2. touchAS INTIMACY INCREASES, THE NEED FOR DISTANCE DECREASES.5 TYPES OF TOUCH:1. Functional- Professional touch: is used in examination or procedure.2. Social- Polite touch: is used in greetings, such as hand shake3. Friendship- Warmth touch: hug in greeting, back slapping4. Love- intimacy touch: tight hugs and kisses between lovers or close relatives.5. Sexual- Arousal touch: used by lovers, specially the married couple.3. ACTIVE LISTENING AND OBSERVATIONTo receive the senders simultaneous messages, the nurse must use active listening and active observation.Active listening : means refraining from other internal mental activities and concentrating exclusively on what the client says.Active observation : means watching the speakers nonverbal action as he/ she communicates.COMMON MISCONCEPTION OF STUDENTS learning the art of THERAPEUTIC COMMUNICATION = is that they always must be ready with questions the instant the client has finished speaking. They are constantly thinking ahead regarding the next question rather than actively listening to what the client is saying. The result can be that the nurse does not understand the clients concerns, and the conversation is vague, superficial, and frustrating to both participants.Active Listening and ObservationRecognize the issue that is most important to the client at this time.Know what further questions to ask the client.Use additional therapeutic communication techniques to guide the client to describe his /her perceptions fully.Understand the clients perceptions of the issue instead of jumping to conclusions.Interpret and respond to the message objectively.VERBAL COMMUNICATION SKILLS1. USING CONCRETE MESSAGES2. USING THERAPEUTIC COMMUNICATION TECHNIQUES1. USING CONCRETE MESSAGE nurse should use words that are clear as possible when speaking to the client so that the client can understand the message. In concrete message , the words are explicit and need no interpretation. Concrete questions, are clear, direct, and easy to understand. Ex. "what health symptoms caused you to come to the hospital today? or when was the last time you took your antidepressant medications?2. USING THERAPEUTIC COMMUNICATION TECHNIQUES:The choice of technique depends on the intent of the interaction and the clients ability to communicate verbally. Overall , the nurse selects techniques that facilitate the interaction and enhance communication between client and nurse.Techniques such as exploring, focusing, restating, and reflecting encourage the client to discuss his/her feelings or concerns in more depth. THERAPEUTIC COMMUNICATION TECHNIQUES:1. Accepting : indicating receptionEx. yes I follow what you said. Nodding2. Broad opening: allowing the client to take the initiative in introducing the topic.Ex. Is there something youd like to talk about? Where would you like to begin?3. Consensual validation: searching to mutual understanding, for accord in the meaning of the words. Ex. Tell me whether my understanding of it agrees with yours.4. Encouraging comparison: asking that similarities and differences be noted.Ex. Was it something like...? Have you had similar experiences?5. Encouraging description of perceptions: asking the client to verbalize what he/ she perceives.Ex. Tell me when you feel anxious What is happening? What does the voice seem to be saying?6. Encouraging expression: asking the client to appraise the quality of his/her experiences.Ex. What are your feelings in regard to....? Does this contribute to your distress?7. Exploring: delving further into a subject or idea.Ex. Tell me more about that. Would you describe it more fully?8. Focusing: concentrating on a single point.Ex. This point seems worth looking at more closely.9. Formulating a plan of action: asking the client to consider kinds of behavior likely to be appropriate in future situations.Ex. What could you do to let your anger out harmlessly?10. General leads: giving encouragement to continue.Ex. Go on and then? Tell me about it.11. Giving information: making available the facts that the client needs.Ex. My name is.... Visiting hours are... My purpose in being here is.....12. Giving recognition: acknowledging, indicating awareness: Good morning, Mr. S....... I notice that youve combed your hair.13. Making observations: verbalizing what the nurse perceives.Ex. You appear tense. I notice youre biting your lip.14. Offering self: making oneself available.Ex. Ill sit with you awhile.15. Presenting reality: offering for consideration that which is real.Ex. Ill see no one else in the room.16. Reflecting: directing client actions. Thoughts, and feelings back to client.Ex. Client: do you think I should tell the doctor....? Nurse: do you think you should?17. Restating: repeating the main idea expressed.Ex. Client: I cant sleep. I stay awake all the night. Nurse: you have difficulty sleeping.18. Seeking information: seeking to make clear that which is not meaningful or that which is vague.Ex. Im not sure that I follow. Have I heard you correctly?AVOIDING NONTHERAPEUTIC COMMUNICATIONIn contrast, there are many therapeutic techniques that nurses should avoid. These responses cut off communication and make it more difficult for the interaction to continue.Responses such as Everything will work out or May be tomorrow will be a better day may be intended to comfort the client, but instead may impede the communication process.NONTHERAPEUTIC COMMUNICATION TECHNIQUES:1. Advising: telling the client what to do.Ex. I think you should...2. Agreeing: indicating accord with the client.Ex. Thats right.3. Belittling feelings expressed: misjudging the degree of the clients discomfort.Ex. Client: I have nothing to live for... I wish I was dead. Nurse: Everybody gets down in the dumps. or Ive felt that way myself.4. Challenging: demanding proof from client.Ex. But how can you be president of the United State? If youre dead, why is you heart beating?5. Defending: attempting to protect someone or something from verbal attack.Ex. This hospital has a fine reputation. Im sure your doctor has your best interests in mind.6. Disagreeing: opposing the clients ideas.Ex. thats wrong.7. Disapproving: denouncing the clients behavior or ideas.Ex. Thats bad Id rather you wouldnt8. Giving approval: sanctioning the clients behavior or ideas.Ex. Thats good. Im glad that...9. Interpreting: asking to make conscious that which is unconscious; telling the client the meaning of his or her experience.Ex. What you really mean is.... Unconsciously youre saying....10. Probing: persistent questioning of the client.Ex. Now tell me about this problem. You know I have to find out.INTERPRETING SIGNALS OR CUESTo understand what the client means, the nurse watches and listens carefully for cues.CUES: are verbal or nonverbal messages that signal key words or issues for the client.Cue words introduced by the client can help the nurse to know what to ask next or how to respond to the client.INTERPRETING SIGNALS OR CUES (1/2)Ex. Client: I had a boyfriend when I was younger. Nurse: You had a boyfriend? (reflecting, direct the clients actions, thoughts, and feelings back to client) Tell me about you and your boyfriend. (encouraging description) How old were you when you had this boyfriend? (placing events in time or sequences)NONVERBAL COMMUNICATION SKILLSIs behavior that a person exhibits while delivering verbal content. It includes: facial expression, eye contact, space , time, boundaries, and body movements.Nonverbal communicationinvolves the unconscious mind acting out emotions related to the verbal content, the situation, the environment, and the relationship between the speaker and the listener.1. FACIAL EXPRESSIONThe human face produces the most visible, complex, and sometimes confusing nonverbal messages.Facial movements connect with words to illustrate meaning; this connection demonstrates the speakers internal dialogue. Facial expression can be categorized into: Expressive Impassive Confusing Expressive:face portrays the persons moment- by- moment thoughts, feelings and needs.These expression may be evident even when the person does not want to reveal his/her emotions.Impassive:is frozen into an emotionless deadpan expression similar to mask.EX. FLAT AFFECTConfusing:facial expression is one that is the opposite of what the person wants to convey.A person who is verbally expressing sad or angry feelings while smiling is exhibiting a confusing expression. Facial expressionoften affect the listeners response. The nurse should identify the facial expression and ask the client to validate nurses interpretation of it.Ex. youre smiling, but I sense you are very angry.2. BODY LANGUAGEGesture , postures, movements, and body positions.Is a nonverbal form of communication. Closed Body Position Accepting Body PositionCLOSED BODY POSITION such as crossed legs or arms folded across the chest, indicate that interaction might threaten the listener who is defensive or not acceptingACCEPTING BODY POSITION is to sit facing the client with both feet on the floor, knees parallel, hands at the sides of the body, and legs uncrossed or crossed only at the ankle. This open posture demonstrate unconditional positive regard, trust, care and acceptance. The nurse indicates interest in and acceptance of the client by facing and slightly leaning toward him or her while maintaining nonthreatening eye contactVOCAL CUESAre nonverbal sound signals transmitted along with the content: voice volume, tone, pitch, intensity, emphasis, speed, and pauses augment the senders message. Volume : the loudness of the voice, can indicate anger, fear, happiness, or deafness. Tone: can indicate whether someone is relaxed, agitated or bored. Pitch: varies from shrill and high to low and threatening. Intensity: is the power, severity, and strength behind the words, indicating the importance of the message. Emphasis: refers to accents on words or phrases that highlight the subject or give insight on the topic. Speed: is number of words spoken per minute.EYE CONTACTThe eyes have been called the mirror of the soul because they often reflect our emotions.Looking into the other persons eyes during communication, is used to assess the other person and the environment and to indicate whose turn it is to speak it increases during listening but decreases while speaking.Although maintaining good eye contact is usually desirable, it is important that the nurse doesnt STARE at the client.SILENCEOr long pauses in communication may indicate many different things.The client may be depressed and struggling to find the energy to talk.Sometimes pauses indicate the client is thoughtfully considering the question before responding.At times, the client may seem to be LOST IN HIS/HER OWN THOUGHTS and not paying attention to the nurse. It is important to allow the client sufficient time to respond, even if it seems like a long time.To be continue......THERAPEUTIC RELATIONSHIPTherapeutic relationshipThe nurses relationship with the patient consists of a series of goal-directed interactions through which the nurse assesses patients problems, elicits patient input, selects interventions, and evaluates the effectiveness of care.relationship:3 Types : Social Intimate Therapeutic SOCIAL RELATIONSHIP is primarily initiated for the purpose of friendship, socialization, companionship, or accomplishment of task. Communication, w/c may be superficial, Usually sharing of ideas, feelings and experiences and meets basic need for people to interact. Advise is often given. INTIMATE RELATIONSHIP healthy intimate relationship involves two people who are emotionally committed to each other. Both parties are concerned about having their individual needs met and helping each other to meet needs as well. The relationship may include sexual or emotional intimacy as well as sharing of mutual goals.THERAPEUTIC RELATIONSHIP Differs from the social and intimate relationship in many ways because it focuses on the needs, experiences, feelings, and ideas of the client only. The nurse and client agree about the areas to work on and evaluate the outcomes.THERAPEUTIC RELATIONSHIP The nurse uses communication skills, personal strengths, and understanding of human behavior to interact with the client. The nurse should not be concerned about whether or not the client likes him/her or grateful. The nurse must constantly focus on the clients needs not his/her own.COMPONENTS OF A THERAPEUTIC RELATIONSHIPTrust Genuine interestEmpathyAcceptance Positive regard Self-awarenessTherapeutic use of selfTrust Trust develops when the client believes that the nurse will be consistent in his/her words and actions and can be relied on to do what he or she says.Genuine InterestThe client perceives a genuine person showing genuine interest.A client with mental illness can detect when someone is exhibiting dishonest or artificial behavior such as asking a question and then not waiting for the answer, talking over him or her, or assuring him/her everything will be all right.EmpathyIs the ability of the nurse to perceive the meaning and feelings of the client and to communicate that understanding to the client.It is considered one of the essential skills a nurse must develop.Being able to put himself/herself in the clients shoes does not mean that the nurse has had the same exact experiences as the client.Ex. Empathy : I see you are sad.... How can I help you?Ex. Sympathy : I feel so sorry for you.Acceptance The nurse who does not become upset or respond negatively to a clients outbursts, anger, or acting out conveys acceptance to the client.Avoiding judgment s of the person, no matter what the behavior, is acceptance.This does not mean acceptance of inappropriate behavior but acceptance of the person as worthy.The nurse must set boundaries in the nurse- client relationship.Ex. A client puts his arm around the nurses waist. An appropriate response would be for the nurse to remove his hand and say, john, do not place your hand on me. We are working in your relation with your girlfriend and that does not require you to touch me. Now, lets continue.Positive RegardThe nurse who appreciates the client as a simple worth while human being can respect the client regardless of his or her behavior, background, or lifestyle.Calling the client by name, spending time with the client, and listening and responding openly are measures by which the nurse conveys respect and positive regard to the client.Self- AwarenessBefore the nurse can begin to understand clients, the nurse must know himself /herself.Self awareness: is the process of developing an understanding of one owns values, beliefs, thoughts, feelings, attitude, motivations, prejudices, strengths, and limitations and how these qualities affect others.Values: are abstract standards that give a person a sense of right and wrong and establish a code of conduct for living.Sample values: hard work, honesty, sincerity, cleanliness,, and orderliness.Beliefs are ideas that one holds to be true,Ex. if the sun is shining, it will be a good day.Some Beliefs have objective evidence to substantiate them.Ex. People who believe in evolution have accepted the evidence that supports this explanation for the origin of life.Attitudes: are general feelings or a frame of reference around which a person organizes knowledge about world.Attitudes such as: hopeful, optimistic, pessimistic, positive, and negative, color how we look at the world and people.Therapeutic use of SelfBy developing self- awareness and beginning to understand his/ her attitudes, the nurse can begin to use aspects of his/her personality, experiences, values, feelings, intelligence, needs, coping skills, and perceptions to establish relationships with client.Nurses use themselves as therapeutic tool to establish therapeutic relationships with clients and help clients grow, change, and heal.JOHARI WINDOWOne tool that useful in learning more about oneself.Which creates a word portrait of a person in four areas and indicates how well that person knows himself/ herself and communicates with others.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 know 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 by oneself or others.Johari window3 PHASES/ STAGES OF NURSE- CLIENT RELATIONSHIP 1. ORIENTATION STAGE2. WORKING STAGE3. TERMINAL STAGEORIENTATION PHASEBegins when the nurse and client meet and ends when the client begins to identify problems to examine. Before meeting the client: The nurse reads background materials available on the client. Becomes familiar with any medications the client is taking The nurse should consider his/her personal strengths and limitations in working with this client (self assessment). Acceptance is the foundation of all therapeutic relationship.(orientation phase)During the Orientation Phase: The nurse establishes roles The purpose of meeting and parameters of subsequent meetings Identifies the clients problems, and clarifies expectations. Built trust: it is the nurse responsibility to establish a therapeutic environment that foster trust and understanding. The nurse should share appropriate information about himself/herself at this time, including name, reason for being on the unit, and level of schooling. (self- disclosure) The nurse needs to listen closely to the clients history, perceptions and misconceptions. The nurse needs to convey empathy and understanding.Reality testing : is accepting the patients perception, feelings and thoughts as neither right or wrong, but at the same time offering other options or points of view to the client in a non-argumentative manner for the purpose of helping the client arrive at more realistic conclusion.To provide structure: is to intervene when client loses control of his feelings and behaviors by medications, offering self, restrain, seclusion and by assessing client to observe a consistent daily schedule.ORIENTATION PHASE: NURSE- CLIENT CONTRACTSAlthough many clients have had prior experiences in the mental health system, the nurse must once again outline the responsibilities of the nurse and client.Both nurse and client agree on these responsibilities in an informal or verbal contract.ORIENTATION PHASE: CONFIDENTIALITY, DUTY TO WARN MEANS RESPECTING THE CLIENTS RIGHT TO KEEP PRIVATE ANY INFORMATION ABOUT HIS/HER MENTAL AND PHYSICAL HEALTH AND RELATED CASE.DUTY TO WARN: The decision requires the nurse to notify intended victims and police of such threat. Ex. Suicidal threats, threat from the client to harm other person.WORKING PHASEThe phase where issues are addressed,Problems identifiedSolutions exploredNurse and client work to accomplish goalsWorking exploration/identification phaseAt this point the clients problem are identified and solutions are explore, applied and evaluated.The focus of the assessment and of the relationship is the clients behavior and the focus of the interaction is the clients feelings.The nurse should realize that the clients feelings of security are developed by being consistent at all times.Working phasePerception of reality, coping mechanisms and support system are identified.The nurse assists the patient to develop coping skills, positive self concept and independence in order to change the behavior of the client to one that is adaptive and appropriate. The nurse uses the techniques of communication and assumes different roles to help the client.THE SPECIFIC TASKS OF WORKING PHASE INCLUDE THE FF: Maintain 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 independenceTransference : the client unconsciously to transfer to the nurse feelings he or she has for significant others.Countertransferrence: a similar process can occur when the nurse responds to the client based on personal unconscious needs and conflicts.Ex. If the nurse is the youngest in her family and often felt as if no one listened to her when she was a child, she may respond with anger to a client who does not listen or resist her help.TERMINATION PHASE OR RESOLUTION PHASE: is the final stage in the Nurse- client Relationship. It begins when the problems are resolved, and it ends when the relationship is ended. Both nurse and client usually have feelings about ending the relationship; the client especially may feel the termination as an impending loss. Often the clients try to avoid termination by acting angry or as if the problem has not been resolved. The nurse can acknowledge the clients angry feelings and assure the client that this response is normal to ending a relationship. It is appropriate to tell the client that the nurse enjoyed the time spent with the client and will remember him/he, but it is inappropriate for the nurse to agree to see the client outside the therapeutic relationship.Ex. Nurse Jones comes to see Mrs. Cruz for the last time.Mrs. Cruz: is weeping quietly, oh, Ms. Jones, you have been so helpful to me. I just know I will go back to my old self without you here to help me.Nurse Jones: Mrs. Cruz, I think weve had a very productive time together. You have learned so many new ways to have better relationships with your children, and I know you will go home and be able to use those skills. When you come back for your follow-up visit, I will want to hear about how things have changed at home. end

PHARMACOTHERAPEUTICS/PSYCHOPHARCOLOGYPREPARED BY:MARY RUTH V. ENRIQUEZ, RN MANPHARMACOTHERAPEUTICS/PSYCHOPHARCOLOGYDrugs that treat the symptoms of mental illness, and whose actions in the brain provides us with models to better understand the mechanism of mental disorders.1. ANTIPSYCHOTIC DRUGS (NEUROLEPTICS)2. ANTIDEPRESSANTS DRUGS3. MOOD STABLIZING DRUGS4. ANTIANXIETY DRUGS (ANXIOLYTICS)5. STIMULANTS/PSYCHOSTIMULANTSAntipsychotic Drugs (Neuroleptic)Are used to alleviate psychotic symptoms (hallucination, delusions, paranoid thinking, poor reality contact) that may occur in clients with SCHIZOPHRENIA, BIPOLAR DISORDERS and COGNITIVE IMPAIRMENT DISORDERS.ANTIPSYCHOTIC DRUGS CLASSIFIED into:1. Typical 2. Atypical Typical Antipsychotic drugBlock selected dopamine receptors in the striatal and limbic areas of the brain, an action believe to reduce symptoms. Dopamine: is a neuro-Chemical that our bodiesContain naturally.If overproduced or utilizedIncorrectly, it can cause Someone to exhibitPsychotic behavior.Typical Uses : treatment for schizophrenia and other acute or chronic psychotic behavior that is violent or potentially violent.Treat positive symptoms of schizophrenia such as hallucinations, delusions, and suspiciousness.Side effects: AntipsychoticsCertain blood dyscrasiaPhotosensitivity (especially Thorazine)Darkening of the skin from increased pigmentationNeuroleptic malignant syndromeA group of side effects called Extrapyramidal side effects (EPSEs) There is less risk of EPSEs with atypical agents.Neuroleptic Malignant SyndromeIs an uncommon but potentially fatal reaction to treatment with Neuroleptic medications.Symptoms include muscle rigidity, hyperpyrexia, fluctuations in blood pressure, and altered level of consciousness. Early recognition and immediate medical care is important.EXTRAPYRAMIDAL SIDE EFFECTS:Drug -induced Parkinsonism (pseudoparkinsonism): symptoms appear 1 to 8 weeks after patient begins the medication The major symptom is AKINESIA, manifested as shuffling gait, drooling, fatigue, mask like facial expression, tremors, and muscle rigidityEPSEs AKATHISIA: symptoms appear 2 to 10 weeks after patient taking the medication. Symptoms : agitation and motor restlessness, and seem to appear more frequently in women. There is no absolute reason for this, but it is suggested that it may be due to hormonal interaction with the medication.EPSEsDystonia : symptoms appear 1 to 8 weeks after the patient starts taking the medication. Symptoms manifest as bizarre distortions or involuntary movements of any muscle group. Tongue, eyes , face, neck, or larger muscle mass can become tightened into an unnatural position or have irregular spastic movements.TYPES OF DYSTONIA1. TORTICOLLIS: contracted positioning of the neck.2. OCULOGYRIC CRISIS: contracted positioning of the eyes upward.3. WRITERS CRAMP: fatigue spasm affecting a hand.4. LARYNGEAL-PHARYNGEAL :constriction (potentially life-threatening)EPSEsTardive dyskinesia (TD): symptoms appear within 1 to 8 weeks after the patient starts taking the medication. The frequently seen manifestations are rhythmic, involuntary movements that look like chewing, sucking, or licking motions (ex. Beating, spanking). Frowning and blinking constantly are also common. TD is irreversibleATYPICAL ANTIPSYCHOTIC DRUGBlock dopamine receptors in the limbic system and affect serotonin receptors in the cortical areas of the brain.Block both dopamine and Serotonin receptors.ATYPICALIndication, contraindication and interactions are similar to those of typical antipsychotic agents.Advantages over typical agent:1. reduce positive symptoms of schizophrenia ( hallucination, delusions) as well as the negative symptoms (blunted affect, apathy, and social withdrawal).2. these agent cause decreased or no extrapyramidal effects, because they do not affect dopamine in striated areas.ATYPICALAtypical Antipsychotic Agents:RAPID-DISSOLVING PREPARATIONS of : OLANZAPINE (ZYPREXIA) RISPERIDONE (RISPERAL) They begin to dissolve with saliva and can be swallowed without water.Contraindications: Antipsychotics AgentShould be used carefully in patients who are hypersensitive to medications or who have brain damage or blood dyscrasia.Commonly used Antipsychotic AgentsTypical : Thorazine (chlorpromazine) Haldol (haloperidol) Stelazine (trifluoperazine) Mallaril (trioriazine) Loxitane (loxapine) Prolixin (fluphenazine) Atypical Risperdol (risperidone) Clozaril (clozapine Seroquel (quetiapine) Zefprexa (olanzapine) Geodone (ziprasidone) Abilify (aripiprazole)Nursing Considerations:Carefully teaching by doctors and nurses can help the patient to understand that these are very strong medications. The possibility of seizures increases in patients who require antipsychotic medications.Observe for any sign of EPSEs or NMS and carefully monitor blood work for abnormal results. Nursing ConsiderationsCareful instruction to the patient and family regarding wearing a wide-brimmed hat, covering all exposed skin, and using a sunscreen when in the sun , especially if the patient is using Thorazine.Patient should be taught to avoid alcohol.Over -the counter (OTC) products, should not be taken w/out doctor approval.Nursing ConsiderationsInstruct the patient not to alter the dose w/out first discussing it w/ the doctor.This classification of medication should be discontinued slowlyIf medication is ordered once daily, teaching the patients to take the medication 1 to 2 hours before going to bed works well and promotes sleep.Antacid decrease the absorption of antipsychotics, these type of medications should be taken 1 to 2 hours after oral administration of antipsychotics.ANTIDEPRESSANTS (MOOD ELEVATORS)Are group of drugs generally to treat depression, including symptoms of depressed mood, loss of interest in activities or pleasure, altered sleep patterns, and somatic complaints.They are also used to treat anxiety disorders (especially panic attacks), phobic disorders and obsessive-compulsive disordersAntidepressants may be further classified based on their mechanism of action and general usage.Classification of Antidepressants:Tricyclic antidepressantsMonoamine Oxidase InhibitorsSelective Serotonin Reuptake InhibitorsAtypical antidepressantsSerotonin Norepinephrine Reuptake InhibitorsTETRACYCLIC ANTIDEPRESSANT(Heterocyclic Antidepressant)The actions, uses, contraindications, side effect and nursing considerations for the tetracyclic antidepressants are similar for those of SSRIs and tricyclic antidepressants.Commonly used: Ludiomil (maprotiline) , Wellbutrin or Zyban (bupropion), Remeron (mirtazapine), Desyrel (trazodone)MONOAMINE OXIDASE INHIBITORS(MAOIs)ACTION: prevents the metabolism of neurotransmitters by an enzyme, monoamine oxidase. Too much monoamine oxidase can lead to destructive, psychotic behaviors.Uses : generally used for patients with varied types of depression who have not been helped by other depressants.Nursing considerations: teach patient to avoid foods containing the amino acid tyramine, a precursor of Norepinephrine, while taking these medications.MAOIsBlock the metabolism of tyramine, resulting in increased Norepinephrine. A hypertensive crisis may occur.Foods containing significant amount of tyramine: Aged cheese (cheddar) Avocados Yogurt, sour cream Chicken and beef liver, corned beef Bean pods Banana, raisins Smoke and processed meat (salami, pepperoni, and bologna) Chocolate Beer, red wines, caffeine Yeast supplementSELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIs) (Bicyclic Antidepressant)ACTION: increase the availability of serotonin, which is decreased in the brains of depressed individuals.Uses: treatment of depression, anxiety, obsessive disorders, impulse control disorders.Side effects: dependence, suicidal tendencies, sedation, dry mouth, agitation, postural hypotension, headache, arthralgia (joint pain), dizziness, insomnia, confusion, and tremorsSSRIsNursing considerations: do not abruptly discontinue the medications. Caution should be used with driving or activities that require alertness. Alcohol and CNS depressants should be avoided Hard , sugarless candy can be used for dry mouth The patient should change positions slowly to avoid a sudden drop in blood pressure Monitor the patient for suicidal ideationTricyclic AntidepressantsAction: these drugs increase the level of serotonin and norepinephrine, thereby increasing the ability of the nerve cells to pass information to each other. Patients with depressive disorders generally have decreased amounts of these two neurochemicals.Uses : treatment symptoms of depression, includingSleep disturbances, sexual function disturbances, changes in appetite, and cognitive changes.Tricyclic AntidepressantNursing considerations: Patients should not stop using abruptly Medications ( including over the counter medications such as cold preparations) that contain antihistamins, alcohol, sodium bicarbonate, benzodiazepines, and narcotic analgesics can increase the effects of tricyclic antidepressants. Nicotine, barbiturates, and the hypnotic chloral hydrate decrease the effect of the tricyclic antidepressant.SEROTONIN NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIs)ACTION: increases the availability of serotonin and norepinehrine, which are decrease in the brains of depressed individualsThe uses, contraindications, side effects and nursing considerations are similar for those of the SSRIs.MOOD STABILIZERS(antimanic agents)Are a dose of drugs that include antimanic and anticonvulsants.Used to treat bipolar disorder by stabilizing the clients mood, preventing or minimizing the highs and lows that characterize bipolar illness, and treating acute episodes of mania.Ex. Antimanic Agent: Lithium Carbonate (Eskalith, Lithane). Drug of choice for treatment and management of bipolar mania.Anticonvulsants Agents: Gabapentin (Neurontin), Carbamazepine (Tegretol)ANTIANXIETY DRUGS (ANXIOLYTIC)They are generally prescribed to treat anxiety and symptoms associated with anxiety disorders.BENZODIAZEPINES (BZAs): drug of choice for treatment of anxiety and sleep disordersThey are also used in ACUTE ALCOHOL, WITHDRAWAL, PREOPERATIVE SEDATION, SEIZURE DISORDERS, SHORT-TERM TREATMENT OF ACUTE MANIA and MUSCLE RELAXANTS.Additional, BENZODIAZEPINES are used to treat agitation and hyperactivity in Cognitive Impairment Disorders. Anxiolytic Benzodiazepines Medications: Alprazolam (Xanax) Chlordiazepoxide (Librium) Clonazepam (Klonopin) Diazepam (Valium)PsychostimulantsHyperactivity :ADHD: ATTENTION DEFICIT HYPEACTIVITY DISORDER (CHILDREN)RADD: RESIDUAL ATTENTION DEFICIT DISORDER (ADULT)STIMULANTSAre readily available over the counter as well by prescription. They are found over the counter in diet preparations, pills to prevent sleep, in cigarettes, and in beverages such as coffee and soda. They are used medically to combat narcolepsy and attention deficit disorder in children.Amphetamines are one type of stimulant, can be abused, and they have street names, including uppers, speed, and bennies.STIMULANTS/PSYCHOSTIMULANTSAre commonly used to treat children and adult with ADHD, they also may be used to treat NARCOLEPSY in adult.NARCOLEPSY: a condition characterized by sudden attacks of sleep occurring repeatedly during the day.Excessive sleepiness characterized by repeated, irreversible sleep attacks. After 10 to 20 minutes, the person is briefly refreshed until the next asleep attack.Psychostimulant Detroamphetamine (Dexedrine)Methylphenidate (Ritalin, Concerta, Addreral,)Pemoline (Cylert)Methamphetamine (Desoxyn)

THERAPEUTIC MODALITIES, PSYCHOSOCIAL SKILLS AND NURSING STRATEGIESprepared by:Mary Ruth V. ENRIQUEZ, rn man

Therapeutic ModalitiesTreatment receive by mentally ill client in variety of settings. Biophysical/Somatic Intervention Supportive Psychotherapy Counseling Assertive Training Stress Management Behavior Modification Cognitive Restructuring Milieu therapyBiophysical /Somatic InterventionSomatic Intervention: is a tool used by psychologist to influence nervous system regulation and therapy.Somatoforms Disorders: characterized by multiple, recurrent physical symptoms in a variety of bodily system that have no organic or medical basis.ECT (ELECTRO CONVULSIVE THERAPY)ECT (Electro Convulsive Therapy)= shock therapy Is used primarily for treating Depression but has been used to treat MANIA, CATATONIA, and SCHIZOPRENIA that is unresponsive to medications.ECTIt requires consent formMay be administered 2 to 3 times per week, for total of 6 to 12 treatments.The procedure involves inducing unconsciousness (short acting anesthesia is used), then passing an electric current through the brain, the clients V/S, oxygenation and cardiac functioning are carefully monitored before and after ECT.An electric current ( 70 to 150 volts) is applied through the brain for 0.5 to 2 seconds, producing a seizure that last for 30 to 60 seconds.ECTFollowing ECT, the client is monitored according to routine post operative protocols.Traditionally the electrodes have been applied BILATERALLY.Alternative electrode placements are routinely used, including: UNILATERAL AND BIFRONTALElectroconvulsive therapySUPPORTIVE PSYCHOTHERAPYIt involves interaction with the patient (not silent listening) and emphasizes a focus on the present (not on the past).Questioning is less challenging and critical, and the approach conveys empathy and understanding.Conduct:Nurse-client relationshipGroup therapyFamily therapyNurse Client Therapy/Individual PsychotherapyIs a method of bringing about change in a person by exploring his/her feelings, attitude, thinking, & behavior.It involves a one-one relationship between therapist and the client.Reason why people seek psychotherapy: to understand themselves and their behavior, To make personal changes To improve interpersonal relationships To get relief from emotional pain or unhappiness.One-on one therapyGROUP THERAPYClient participate in sessions with a group of people.The members share a common purpose and are expected to contribute to the group to benefit others and receive benefit from others in returnBeing a member of a group allows the client to learn new ways of looking at a problem or ways of coping with or solving problems and also helps him/her to learn important interpersonal skills.Group therapyEx. By interacting with other members, client often received feedback on how other perceives and react to them and their behavior.This is extremely important information for many clients with mental disorders, who have difficulty with interpersonal skills.The Therapeutic results of Group Therapy:1. Gaining new information, or learning2. Gaining inspiration or hope3. Interacting with others4. Feeling acceptance and belonging5. Becoming aware that one is not alone and that others share the same problems6. gaining insight into ones problems and behaviors and how they affect others.7. Gaining of oneself for the benefit of others (ALTRUISM)FAMILY THERAPYA form of a group therapy which the client and his/her family members participate.THE GOALS include:1. Understanding how family dynamics contribute to the clients psychotherapy2. Mobilizing the familys interest strengths and functional resources3. Restructuring maladaptive family behavior styles.4. Strengthening family problem-solving behavior. Family TherapyCan be used both to assess and treat various psychiatric disorders. Although one family member usually is identified initially as the one who has problems and needs help, it often becomes evident through the therapeutic process that other family members also have emotional problems and difficulties.COUNSELING COUNSELING PSYCHOLOGY: as a psychological specialty facilitates personal and interpersonal functioning across the life span with a focus on emotional, health-related, developmental and organizational concerns.ex,. Group therapyFamily therapyGroup members can ventilate feelings, try out problem-solving approaches, and resolves conflict in a rational, systematic manner.ASSERTIVE TRAININGIs a form of behavior therapy designed to help people stand up for themselves- to empower themselves, in more contemporary terms.Helps the person take more control over life situations.Techniques help the person negotiate interpersonal situations and foster self-assurance.They involve using I statement s to identify feelings and to communicate concerns or needs to others.Ex. I feel angry when you turn your back while Im talking.dont say yes when you want to say no.Speak up for yourselfSTRESS MANAGEMENTIs techniques intended to equip a person with psychological stress, Stress : as a persons physiological response to an internal and external stimulus that triggers the fight-or- flight response.3 TECHNIQUES OF STRESS MANAGEMENT:1. POSITIVE REFRAMING2. DECASTROPHIZING3.ASSERTIVE TRAININGPOSITIVE REFRAMINGMeans turning negative messages to positive messages.The therapist teaches the person to create positive messages for use during panic episodes.Ex. Instead of thinking, my heart is pounding. I think Im going to die!(NEGATIVE)I can stand this. This is just anxiety. It will go away. (POSITIVE)decastrophyzingThe technique consists of confronting the worst-case scenario of a feared event or object, using mental imagery to examine whether the effects of the event or object have been overestimated (magnified or exaggerated) and where the patients coping kills have been underestimated.Is also called the what if technique" because the worst-case scenario is confronting by asking what if the feared event or object happened, what would occur then?decastrophyzingEx. I would make an absolute fool of myself if I say the wrong thing.what if you say the wrong thing, what would happen then?he might think Im weird.Assertiveness TrainingIt helps the person take more control over life situations and help the person negotiate interpersonal situations.BEHAVIOR MODIFICATIONIs a method of attempting to strengthen a desire behavior or response by reinforcement, either positive or negative.TECHNIQUES OF BEHAVIOR MODIFICATION:1. POSITIVE and NEGATIVE REINFORCEMENTPositive reinforcement = is provided by giving a person attention and positive feedback.Negative reinforcement = is done by removing a stimulus after a behavior occurred to prevent it from occurring again.Positve and negative reinforcementEx. Operant conditioning (reward & punishment)Techniques of Behavior Modification:2. Systematic Desensitization: it is used to help clients overcome irrational fears and anxiety associated with a phobia. The client is asked to make list of situations involving the phobic object, from the least to the most anxiety- provoking. The client learns and practices relaxation techniques to decrease and manage anxiety.COGNITIVE RESTRUCTURINGIs a technique useful in changing patterns of thinking by helping client to recognize negative thoughts and feelings and to replace them with positive pattern of thinking.TECHNIQUES OF COGNITIVE RESTRUCTURING:1. THOUGHT-STOPPING: is a technique to alter the process of negative or self critical thought patterns. Ex. Splashing the face with cold water.2. POSITIVE SELF TALK: client reframes negative thoughts to positive onesMILIEU THERAPYRefers to the physical and social environment in which an individual is receiving treatment.Uses a safe environment to meet the individual clients treatment needs.Safety is the most important priority in managing milieu.All treatment team members are viewed as significant and valuable to the clients successful treatment outcomes.Elements of the Treatment EnvironmentFor the treatment environment to managed be effectively, we consider several interrelated elements essential.These elements, which provide the foundation necessary for the nurse to manage the environment effectively, include: Safety Structure Norms Limit setting Balance Safety Is the primary to all other aspects of the environment.Safety includes both physical and psychological protection.Physical protection: refers to safety from physical harm through the management of risks in the environment, such as the prevention of physical aggression and the requirement of staff supervision for patients when using potentially unsafe grooming items ( e.g. Sharps, glass items, and plastic bags). Safety Psychological safety: involves the nurses active intervention to prohibit verbal abuse, ridicule, or harassment of patients.Structure Refers to the physical environment, rules, and daily schedules of treatment activities.Is an essential component of psychiatric treatment because , without it, there is no justification for the patient being in a treatment environment, particularly if custodial care is outmoded.Nurses lead activities such as patient education and social skills training groups.Teaching about medications, side effects, and after care support for both patients and families is an important function of the psychiatric nurse in minimizing patient noncomplianceNorms Are specific expectations of behavior that permeate the treatment environment; they are intended to promote safety and trust in the environment through the sanctioning of socially acceptable behaviors and consistency about what to expect.For ex. A norm of nonviolence provides physical and emotional security in the environment.Limit SettingIs an important element of the treatment environment and is related to norms.Limits should be set on acting-out behavior such as self destructive acts, physical aggressiveness, and sexual behavior.It is also sometimes necessary to set limits on behaviors such as excessive requests, attempts to overly personalize the therapeutic relationship, and refusal to participate in treatment activities.Closely related to limit setting are rules.Balance Involves the process of gradually allowing independent behaviors and in a dependent situation.It might be necessary to make specific judgments about a patients readiness to assume certain responsibilities for his/her own care versus providing assistance when the patient might not be able to act on his/her own behalf.Focus of Milieu TherapyTo use the physical and social environment to affect a positive change directed toward accomplishing the clients goals.To empower the clients through involvement in setting his/her own goals and development purposeful relations with the staff to assist in meeting these goals.One on one relationships with the staff are used to examine client behaviors, feelings and interactions with the context of the therapeutic group activities.To use community meetings, activity groups, social skills group and physical exercise programs to accomplish treatment goalsPlay therapyPlay Therapy (ADHD)Treatment modality in which the therapist engages in play with the child. Therapeutic play, PLAY techniques are used to understand the childs thoughts and feelings and to promote communication. This should not be confused with play therapy.PLAY THERAPY: a psychoanalytic technique used by therapist.Therapeutic PlayDramatic Play: is acting out an anxiety-producing situation such as allowing the child to be a doctor or use a stethoscope or other equipment to take care of a patient (a doll).Play Techniques: to release energy could include: pounding pegs, running, or working with modelling clay.Creative Play: techniques can help the children to express themselves, ex. By drawing pictures of themselves, their family, and peers. These techniques are especially useful when children are unable or unwilling to express themselves verbally. Psychosocial InterventionAre nursing activities that enhance the clients social and psychological functioning and improve social skills, interpersonal relationships, and communication.Nurses often use psychosocial intervention to help meet clients needs and achieve outcomes in all practices settings, not just mental health.Ex. Medical-surgical nurse might need to use interventions that incorporate behavioral principles such as limits with manipulative behavior or giving positive feedbackEx. A client with diabetic tells the nurse, I promise to have just one bite of cake. Please! Its my grandsons birthday cake (manipulative behavior) GENERAL ASSESSMENT CONSIDERATIONMODULE 3 PREPARED BY: MARY RUTH V. ENRIQUEZ, RN MAN General Assessment considerations1. Principles and Techniques of the Psychiatric Nursing Interview2. Mental Status Examination (MSE)3. Diagnostic Examination Specific to Psychiatric Patient PRINCIPLES and TECHNIQUES OF PSYCHIATRIC NURSING INTERVIEW ASSESSMENT: Is the first step of the nursing process and involves the collection , organization, and analysis of information about the clients health. PSYCHOSOCIAL ASSESSMENT: Which includes a Mental Status Examination Purposes of Psychosocial Assessment: is to construct a picture of the clients current Emotional state, Mental capacity, and Behavioral function. This assessment serves as the basis for developing a plan of care to meet clients needs. Clinical baseline used to evaluate the effectiveness of treatment and interventions or a measure of the clients progress. FACTORS INFLUENCING ASSESSMENT1) Client Participation/ Feedback2) Clients Health Status3) Clients Previous Experiences/Misconceptions about Health Care4) Clients Ability to Understand5) Nurses Attitude and Approach HOW TO CONDUCT THE INTERVIEW ENVIRONMENT1) The nurse should conduct the psychosocial assessment in an environment that is comfortable, private, and safe for both the client and the nurse.2) An environment that is fairly quiet with few distractions allows the client to give his or her full attention to the interview.3) Conducting the interview in a place such as a conference room ensures the client that no one will overhear what is being discussed.4) The nurse should not choose an isolated location for interview, particularly if the client is unknown to the nurse or has a history of any threatening behavior. INPUT FROM FAMILY AND FRIENDS if family members, friends, or caregivers have accompanied the client, the nurse should obtain their perceptions of the clients behavior and emotional state. The nurse should then be aware that friends or family may not feel comfortable talking about the client in his or her presence and may provide limited information. The client may not feel comfortable participating in the assessment without family or friends. This may limit the amount or type of information the nurse obtains. HOW TO PHRASE QUESTIONS OPEN ENDED QUESTIONS : allows the client to begin as he or she feels comfortable and also gives the nurse an idea about the clients perception of his or her situation.Ex. Of an Open- ended questions: What brings you here today? Tell me what has been happening to you. How can we help you? CLOSED- ENDED QUESTIONS The nurse may need to use more direct questions to obtain information. Questions need to be clear, simple, and focused on one specific behavior or symptom; they should not cause the client to remember several things at once.Ex. Questions that can confuse to the client, How are your eating and sleeping habits and have you been taking any over- the counter medications that affect your eating and sleeping? Ex. Closed-Ended Questions: How many hours did you sleep last night? Have you been thinking about suicide? How much alcohol have you been drinking? How well have you been sleeping? What over-the counter medications are you taking? The nurse should use a nonjudgmental tone and language, particularly when asking about sensitive information such as drugs or alcohol use, sexual behavior, abuse or violence, and childrearing practices. Using nonjudgmental language and a matter-of-fact tone avoids giving the client verbal cues to become defensive or to not tell the truth. Ex. When asking a client about his or her parenting role. The nurse should ask,what types of discipline do you use? rather than How often do you physically punish your child? The first question is more likely to elicit honest and accurate information; the second question give wrong impression that physical discipline is wrong, and it may cause the client to respond dishonestly. MENTAL STATUS EXAMINATION CONTENT OF THE ASSESSMENT: History General Appearance and Motor Behavior Mood and Affect Thought Process and Content Sensorium and Intellectual Processes Judgmental and Insight Self-concept Roles and Relationships Physiologic and Self-care concerns 1. History Includes: clients history, age and developmental stage, cultural and spiritual beliefs, and beliefs about health and illness. The history of client , as well as his or her family, may provide some insight on current situation. Ex. Has the client experienced similar difficulties in the past? Has the client been admitted to the hospital, and if so, what was that experience like? A family history that is positive for alcoholism, bipolar disorder, or suicide is significant because it increases the clients risk for these problems. Age and developmental stage: are important factors in the psychosocial assessment. The nurse evaluates the clients age and developmental level for congruence with expected norms. Ex. A client may be struggling with personal identity and attempting to achieve independence from his or her parents. If the client is 17 years old, these are two of the primary developmental tasks for adolescent. If the client is 35 years old and still struggling with these issues of self-identity and independence, the nurse need to explore the situation. the clients age and developmental level also may be incongruent with expected norms if the client has a developmental delay or mental retardation. Cultural and Spiritual beliefs : the nurse must be sensitive, avoid making inaccurate assumptions about clients psychosocial functioning. Many cultures have beliefs and values about a persons role in society or acceptable social or personal behavior differ from those of the nurses. Ex. People from other cultures, such as Japan, consider such as eye contact to be sign of disrespects.While Western cultures consider good eye contact to be a positive characteristic indicating self-esteem and paying attention. 2. GENERAL APPEARANCE AND MOTOR BEHAVIOR The nurse assesses the clients overall appearance, including: Hygiene and grooming Appropriate dress Posture Eye contact Unusual movements or mannerism Speech (rate of the speech fast or slow, responses a minimal yes or no without elaboration, tone audible or loud) Specific terms used in making assessments of general appearance and motor behavior: Automatisms: repeated purposeless behaviors often indicative of anxiety, such as drumming fingers, twisting locks of hair, or tapping the foot. Psychomotor retardation: overall slowed movements Waxy flexibility: maintenance of posture or position over time even when it is awkward or uncomfortable. Neologism : invented words that have meaning only for the client. 3. MOOD AND AFFECT MOOD : refers to the clients pervasive and enduring emotional state. EXPRESSED EMOTIONS AFFECT : is the outward expression of the clients emotional state. FACIAL EXPRESSION The nurse assesses for consistency among the clients mood, affect, and situation .Ex. The client may have an angry facial expression but deny feeling angry or upset in any way. Or the client may be talking about the recent loss of a family member while laughing and smiling. COMMON TERMS USED IN ASSESSING AFFECT: BLUNTED AFFECT: showing little or a slow-to-respond facial expression. BROAD AFFECT: displaying a full range of emotional expression. FLAT AFFECT: showing no facial expression. INAPPROPRIATE AFFECT: displaying a facial expression that is incongruent with mood or situation; often silly or giddy regardless of circumstances. RESTRICTED AFFECT: displaying one type of expression, usually serious or somber. MOOD May be described as: happy, sad, depressed, euphoric, anxious, or angry. LABILE: when client exhibits unpredictable and rapid mood swings from depressed and crying to euphoria with no apparent stimuli. 4.THOUGHT PROCESS AND CONTENTThought process: refers to how the client thinks. The nurse can infer a clients thought process from speech and speech patterns.Thought Content: is what the client actually says. The nurse assesses whether or not the clients verbalizations make sense, that is, if ideas are related and flow logically from one to the next. The nurse also must determine whether the client seems preoccupied, as if talking or paying attention to someone or something else. When the nurse encounters clients with marked difficulties in thought process and content, the nurse may find it helpful to ask focused questions requiring short answers. COMMON TERMS RELATED TO THOUGHT PROCESS AND CONTENT: Circumstantial thinking: a client eventually answer a question but only after giving excessive unnecessary detail. Delusion : a fixed false belief not based in reality. Flight of ideas : excessive amount and rate of speech composed of fragmented or unrelated ideas. Ideas of reference: clients inaccurate interpretation that general events are personally directed to him or her, such as hearing a speech on the news and believing the message had personal meaning. Loose associations: disorganized thinking that jumps from one idea to another with little or no evident relation between the thoughts. Tangential thinking: wandering off the topic and never providing the information requested. Thought blocking: stopping abruptly in the middle of a sentence or train of thought; sometimes unable to continue the idea. Thought broadcasting: a delusional belief that others can hear or know what the client is thinking. Thought insertion: a delusional belief that others are putting ideas or thoughts into the clients head- that is, the idea are not those of the client. Thought withdrawal: a delusional belief that others are taking the clients thoughts away and the client is powerless to stop it. Word salad: flow of unconnected words that convey no meaning to the listener. Assessment of suicide or Harm toward others The nurse must determine whether the depressed or hopeless client has suicidal ideation or lethal plan. The nurse does so by asking the client directly Do you have thoughts of suicide? or what thoughts of suicide have you had? If the client is angry, hostile, or making threatening remarks about a family member, spouse, or anyone else, the nurse must ask if the client has thoughts or plans about hurting that person. The nurse does so by questioning the client directly: What thoughts have you had about hurting (persons name)? What is your plan? What do you want to do to (persons name)? When a client makes specific threats or has a plan to harm another person, health providers are legally obliged to warn the person who is the target of the threats or plan. Duty to warn: legal term used. 5. SENSORIUM AND INTELLECTUAL PROCESSES ORIENTATION MEMORY ABILITY TO CONCENTRATE ABSTRACT THINKING & INTELLECTUAL ABILITIESORIENTATION: Refers to the clients recognition of person, place, and time- that is , knowing who and where he or she is and the correct day, date , and year. This is documented as: Oriented x 3 : oriented Oriented x1 : disoriented (person only) Oriented x2 : disoriented (person and place) When a person is disoriented: first loses track of time, then place, and finally person. Orientation returns in reverse order: person, place, timeMEMORY: The nurse directly assesses memory, both recent and remote by asking questions with verifiable answers. Ex. What is the name of the current president? Who was the president before that? In what country do you live? What is the capital of this state? What is your social security number? Verifiable answers : give accurate answers.ABILITY TO CONCENTRATE: The nurse assesses the clients ability to concentrate by asking the client to perform certain tasks: Spell the word WORLD backward: DLROW Serial 7: begin with 100 subtract 7, subtract 7, again and so on. Repeat the days of the week backward: Sunday, Saturday, Friday, Thursday, Wednesday, Tuesday, Monday . Perform a THREE-PART TASK, such as take a piece of paper in your right hand, fold it in half, and put it on the floor. ( The nurse should give the instructions at one time)ABSTRACT THINKING AND INTELLECTUAL ABILITIES: When assessing the intellectual functioning, the nurse must consider the clients level of formal education. Lack of formal education could hinder performance in many tasks in this section. The nurse assesses the clients ability to use ABSTRACT THINKING, which is associations or interpretations about a situation or comment. The nurse ask the client to interpret a common proverb. If the client can explain the proverb correctly, his or her abstract thinking abilities are intact. If the client provides a literal explanation of the proverb and cannot interpret its meaning, abstract thinking abilities are lacking. When the client continually gives literal translations, this is evidence of concrete thinking. Ex. Proverb : A STITCH IN TIME SAVES TIME ABSTRACT meaning: If you take the time to fix something now, youll avoid bigger problems in the future. LITERAL translation: Dont forget to sew up holes in your clothes (Concrete thinking) SENSORY- PERCEPTUAL ALTERATIONS Some clients experience HALLUCINATIONS (false sensory perceptions or perceptual experiences that do not really exist), Hallucinations = can involve the five senses and bodily sensations. Auditory hallucination: hearing voices, are the most common Visual hallucination = seeing things dont really exist, are second most common. Clients perceive hallucinations as real experiences, but later in the illness, they may recognize the as hallucination. 6. JUDGMENT AND INSIGHT JUDGMENT: refers to ability to interpret ones environment and situation correctly and adapt ones behavior and decisions accordingly. Problems with judgment may be evidenced as the client describes recent behavior and activities that reflect a lack of reasonable care for self or others. Ex. The client may spent large sums of money on frivolous items when he or she cannot afford basic necessities such as food or clothings. INSIGHT : is the ability to understand the true nature of ones situation and accept some personal responsibility for that situation. The nurse frequently can infer insight from the clients ability to describe realistically the strengths and weaknesses of his or her behavior. Ex. Poor insight : a client who places all blame on others for his own behavior, saying its y wifes fault that i drink and get into fights, because she nags me all the time. This client is not accepting responsibility for his drinking and fighting. SELF- CONCEPT Is the way one views oneself in terms of personal worth and dignity. To assess clients self-concept, the nurse can ask the client to describe himself or herself and what characteristics he or she likes and what he or she would change. Description of self in term of Physical characteristics gives the nurse information about the clients body image. Emotions that client frequent experiences, such as sadness or anger, and whether or not the client is comfortable with those emotions. The nurse also must assess the clients coping strategies. Ex. Questions : What do you do when you have a problem? How do you solve it? ROLES AND RELATIONSHIP People functioning in their community through various roles such as mother, wife, son, daughter, teacher, secretary, or volunteer. The nurse assesses the roles the client occupies, client satisfaction with those roles, and whether the client believes he or she is fulfilling the roles adequately. Relationships with other people are important to ones social and emotional health. Relationships vary in terms of significance, level of intimacy or closeness, and intensity. The inability to sustain satisfying relationships can result from mental health problems or can contribute to the worsening of some problems. The nurse must assess the relationships in the clients life, the clients satisfaction with those relationships, or any loss of relationship. Common questions: Do you feel close to your family? Do you have or want a relationship with a significant other? Are your relationships meeting your needs for companionship or intimacy? Can you meet your sexual needs satisfactorily? Have you been involved in any abusive relationship? PHYSIOLOGIC AND SELF-CARE CONSIDERATION When doing psychosocial assessment, the nurse must include physiologic functioning. Although a full physical health assessment may not be indicated, emotional problems often affect some areas of physiologic function. Emotional problems can greatly affect eating and sleeping patterns: under stress, people may eat excessively or not at all, and may sleep up to 20 hours a day or may be unable to sleep more than 2 or 3 hours a night. SELF CARE CONSIDERATION: The nurse also ask the client if he or she has any major or chronic health problems and if he or she takes prescribed medications as ordered and follows dietary recommendations. Noncompliance with prescribed medication is an important area. The nurse must help the client feel comfortable enough to reveal this information. DIAGNOSTIC PROCEDURE SPEIFIC TO PSYCHIATRIC PATIENTS