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MODULE 1

INTRODUCTION TO PSYCHIATRIC NURSING

OBJECTIVES

1. Survey the history of psychiatric care. Distinguish roles of the interdisciplinary team members in the

delivery of psychiatric care.y Psychiatrist

o Diagnoses mental disorders, conducts psychotherapy and prescribes somatic therapies.

y Clinical psychologisto Conducts group and family therapies and administers and evaluates psychological tests that assist

in the diagnostic process

y Psychiatric social workero Locates halfway house and arranges living conditions for client being discharged from the

hospital

y Psychiatric clinical nurse specialist

o Conducts group therapies and provides consultation and education to staff nurses.y Psychiatric nurse

o Manages the therapeutic milieu on a 24-hour basis.

y Mental health techniciano Assists staff nurses in the management of the milieu.

y Occupational therapisto Helps clients plan, shop for and cook a meal.

y Recreational therapisto Accompanies clients on community trip to the zoo.

y Music therapist

o Helps clients get to know themselves better by having them describe what they feel when theyhear a certain song.

y Art therapisto Encourages clients to express painful emotions by drawing pictures on paper.

y Psychodramatisto Directs a group of clients in acting out a situation that is otherwise too painful for a client to

discuss openly.

y Dietitiano Assesses needs, establishes, monitors and evaluates a nutritional program for a client with

anorexia nervosa.

y Chaplaino Helps clients to recognize their own beliefs so that they may draw comfort from those beliefs in

time of spiritual need.

2. Define personality and investigate the contributions from the following theories:a. Psychoanalytic theory Freud

y Ido The id is the locus of instinctual drives: the pleasure principle.o Present at birth, it endows the infant with instinctual drives that seek to satisfy needs and

achieve immediate gratification.

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o Id-driven behaviors are impulsive and may be irrational.

y Egoo The ego, also called the rational self or the reality principle, begins to develop between

the ages of 4 and 6 months.

o The ego experiences the reality of the external world, adapts to it and responds to it.o The primary function of the ego is one of mediator, that is to maintain harmony among

the external world, the id and the superego.y Superego

o Might be referred to as the perfection principle.o Which develops between ages 3 and 6 years, internalizes the values and morals set forth

by primary caregivers.

o Superego becomes rigid and punitive, problems with low self-confidence and low self-esteem arise.

o Composed of two major components: Ego-ideal Conscience

b. Interpersonal theory Peplaus Model of Nursing

Age Stage Major Developmental Tasks

Infancy Learning to count on others Learning to communicate in various ways with theprimary caregiver in order to have needs fulfilled

Toddlerhood Learning to delay satisfaction Learning the satisfaction of pleasing others by delayingself-gratification in small ways

Early childhood Identifying oneself Learning appropriate roles and behaviors by acquiringthe ability to perceive the expectations of others

Late childhood Developing skills in participation Learning the skills of compromise, competition andcooperation with other; establishment of a more realistic

view of the world and a feeling of ones place in it

c. Review the theories of Erikson, Age Stage Major Developmental Tasks

Infancy

Birth 18 m

Trust vs. mistrust To develop a basic trust in the mothering figure and learn to

generalize it to others

Early childhood18 m 3 years

Autonomy vs. shame & doubt To gain some self-control and independence within theenvironment

Late childhood3 6 years

Initiative vs. guilt To develop a sense of purpose and the ability to initiate anddirect own activities

School age6 12 years

Industry vs. inferiority To achieve a sense of self-confidence by learning,competing, performing successfully and receivingrecognition from significant others, peers and acquaintances

Adolescence

12 20 years

Identity vs. role confusion To integrate the tasks mastered in the previous stages into a

secure sense of selfYoung adulthood

20 30 years

Intimacy vs. isolation To form an intense, lasting relationship or a commitment to

another person, cause, institution or creative effort

Adulthood

30 65 years

Generatively vs. stagnation To achieve the life goals established for oneself, while also

considering the welfare of future generations

Old age

65 years - death

Ego integrity vs. despair To review cones life and derive meaning from both

positive and negative events, while achieving a positive

sense of self-worth

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d. Piaget Age Stage Major Developmental Tasks

Birth 2 years Sensorimotor With increased mobility and awareness, development of a sense ofself as separate from the external environment; the concept of object

permanence emerges as the ability to form mental images evolves

2 6 years Preoperational Learning to express self with language; development of understanding

of symbolic gestures; achievement of object permanence6 12 years Concrete operations Learning to apply logic to thinking; development of understanding of

reversibility and spatiality; learning to differentiate and classify;

increased socialization and application of rules

12 15+ years Formal operations Learning to think and reason in abstract terms; making and testinghypotheses; capability of logical thinking and reasoning expand and

are refined; cognitive maturity achieved

e. Maslow

3. Examine mental health and mental illness.

4. Identify cultural elements that influence attitudes toward mental health and mental illness.

y Incomprehensibility

y Cultural relativity

5. Identify the two major psychological response patterns to stress.

y Anxiety

y Grief

6. Describe the levels of anxiety and distinguish between examples of each.Mild Anxiety

y Prepares people for action

y Sharpens the senses, increases motivation for productivity, increases the perceptual field andresults in a heightened awareness of the environment.

y Associated with the tension experienced in response to the events of day-to-day living.

y Learning is enhanced and the individual is able to function at his or her optimal level.

Moderate Anxiety

y Level of anxiety increases, the extent of the perceptual field diminishes

y Moderately anxious individual is less alert to events occurring in the environment.

y Individuals attention span and ability to concentrate decrease, although he or she may still attendto needs with direction.

y Assistance with problem solving may be required

y Increased muscular tension and restlessness are evident.

Severe Anxiety

y Perceptual field of the severely anxious individual is so greatly diminished that concentrationcenters on one particular detail only or on many extraneous details.

y Attention span is extremely limited and the individual has much difficulty completing even thesimplest task.

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y Physical symptoms headaches, palpitations, insomnia

y Emotional symptoms confusion, dread, horror

y Discomfort is experienced to the degree that virtually all overt behavior is aimed at relieving theanxiety

Panic Anxiety

y Most intense state of anxiety

y Individual is unable to focus on even one detail in the environment.

y Misperceptions are common and a loss of contact with reality may occur

y Individual may experience hallucinations or delusions

y Behavior may be characterized by wild and desperate actions or extreme withdrawal

y Human functioning and communication with others is ineffective

y Associated with a feeling of terror and individuals may be convinced that they have a life-threatening illness or fear that they are going crazy

y Can lead to physical and emotional exhaustion and can be a life-threatening situation

7. Distinguish adaptive coping strategies from ego defense mechanisms in behavioral responses to anxiety.Mild Anxiety

y Employ coping behaviors that satisfy their needs for comfortExamples:

Sleeping Drinking Eating Daydreaming

Physical exercise Laughing Smoking CursingCrying Nail biting Pacing Finger tapping

Foot swinging Fidgeting YawningTalking to someone with whom one feels comfortable

Mild-to-Moderate Anxiety

y The strength of the ego is tested and energy is mobilized to confront the threaty Defense mechanisms are used

o CompensationIs the covering up of a real or perceived weakness by emphasizing a trait one considers more

desirable.o Denial

Is the refusal to acknowledge the existence of a real situation or the feelings associated withit.

o DisplacementIs the transferring of feelings from one target to another that is considered less threatening or

neutral.

o IdentificationIs an attempt to increase self-worth by acquiring certain attributes and characteristics of anindividual one admires.

o IntellectualizationIs an attempt to avoid expressing actual emotions associated with a stressful situation by using

the intellectual processes of logic, reasoning, and analysis.

o IntrojectionIs the internalization of the beliefs and values of another individual such that they symbolically

become a part of the self to the extent that the feeling of separateness or distinctness is lost.

o Isolation

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Is the separation of the thought or a memory from the feeling tone or emotions associated with

it sometimes called emotional isolation.

o ProjectionIs the attribution of feelings that impulses unacceptable to ones self to another person. The

individual passes the blame for these undesirable feelings or impulses to another, thereby

providing relief from the anxiety associated with them.o Rationalization

Is the attempt to make excuses or formulate logical reasons to justify unacceptable feelings or

behaviors.

o Reaction formationIs the prevention of unacceptable or undesirable thoughts or behaviors from being expressed by

exaggerating opposite thoughts or types of behaviors.

o RegressionIs the retreating to an earlier level of development and the comfort measures associated with

that of functioning.

o RepressionIs the involuntary blocking of unpleasant feelings and experiences from ones awareness.

o SublimationIs the rechanneling of drives or impulses that are personally or socially unacceptable

(aggressiveness, anger, sexual drives) into activities that are more tolerable and constructive.

o SuppressionIs the voluntarily blocking of unpleasant feelings and experiences from ones awareness.

o UndoingIs the act of symbolically negating or canceling out a previous action or experience that onefinds intolerable.

Moderate-to-Severe Anxiety

y Remains unresolved over an extended period of time can contribute to a number of physiologicaldisorders

y DSM-IV describes these as the presence of one or more specific psychological or behavioralfactors that adversely affect a general medical condition.

y Psychological factors may exacerbate symptoms of, delay recovery from, or interfere withtreatment of the medical condition.

Severe Anxiety

y Extended periods of repressed severe anxiety can result in psychoneurotic patterns of behaving.

y Anxiety Disorderso Characteristic features are symptoms of anxiety and avoidance behavior (phobias, obsessive-

compulsive disorder, panic disorder, generalized anxiety disorder, and post-traumatic stress

disorder)

y Somatoform Disorderso Characteristic features are physical symptoms for which there is no demonstrable organic

pathology.

o Psychological factors are judged to play a significant role in the onset, severity, exacerbationor maintenance of the symptoms (hypochondriasis, conversion disorder, somatizationdisorder, pain disorder)

y Dissociative Disorders

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o Characteristic feature is a disruption in the usually integrated functions of consciousness,memory, identity or perception of the environment (dissociative amnesia, dissociative fugue,dissociative identity disorder and depersonalization disorder)

Panic Anxiety

y The individual is not capable of processing what is happening in the environment and may losecontact with reality.

y Presences of delusions or hallucinations and impairment of interpersonal functioning andrelationship to the external world

y Examples areo Schizophrenico Schizoaffectiveo Delusional disorders

8. Describe Kubler-Rosss 5 stages of grieving

Stage 1 DenialShock and disbelief.

Response No, it cant be true!

Stage 2 AngerEnvy and resentment

Response Why me? Or Its not fair!

Stage 3 BargainingNot visible or evident

Response If God will help me through this, I promise I will go to church every Sunday andvolunteer my time to help others.

Stage 4 Depression

Loss of intense and feeling of depression prevailRepresents advancement toward resolution

Stage 5 Acceptance

Feeling of peace

9. Define Kubler-Ross 3 maladaptive grief responses.Prolonged response

y Is characterized by an intense preoccupation with memories of the lost by an intense preoccupationwith memories of the lost entity for many years after the loss has occurred

y Behaviors associated with the stages of denial or anger are manifested and disorganization of

functioning and intense emotional pain related to the lost entity are evidenced.

Delayed or Inhibited response

y The individual becomes fixed in the denial stage of the grieving process.

y Emotional pain associated with the loss is not experienced but anxiety disorders (phobias,hypochondriasis) or sleeping and eating disorders ( insomnia, anorexia) may be evident.

y The individual may remain in denial for many years until the grief response is triggered by areminder of the loss or even by another, unrelated loss.

Distorted response

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y Is fixed in the anger stage of grieving.

y All the normal behaviors associated with grieving such as helplessness, hopelessness, sadness, angand guilt are exaggerated out of proportion to the situation.

y The individual turns the anger inward on the self, is consumed with overwhelming despair and isunable to function in normal activities of daily living.

y Pathological depression

10.Construct and illustrate the DSM diagnostic system including the definition of each axis.

Axis I Clinical disorders and other conditions that bay be a focus of clinical attention

y Mental disorders

y Except personality disorders and mental retardation

Axis II Personality disorders and mental retardation

y Disorders usually begin in childhood or adolescence and persist in a stable form into adult life

Axis III General medical conditions

y

Any current general medical condition that is potentially relevant to the understanding ormanagement of the individuals mental disorder.

Axis IV Psychosocial and environmental problems

y Problems that may affect the diagnosis, treatment and prognosis of mental disorders named onaxes I and II.

y Problems related to primary support group, social environment, education, occupation, housing,economics, access to health care services, interaction with the legal system or crime and othertypes of psychosocial and environmental problems.

Axis V Global assessment of functioning

y Overall functioning on the Global Assessment of functioning scale

y

Scale represents in global terms a single measure of the individuals psychological, social andoccupational functioning.

Example:

Axis I Dysthymic disorder

Axis II Dependent personality disorder

Axis III Hypothyroidism

Axis IV Unemployed

Axis V GAF = 65 (current)

11.Explain the goal of a therapeutic community/milieu therapy.

Therapeutic community/milieu therapy is for the client to learn adaptive coping, interaction andrelationship skills that can be generalized to other aspects of his or her life.

12.Discuss the basic assumptions for a therapeutic community

y The health in each individual is to be realized and encouraged to grow.

y Every interaction is an opportunity for therapeutic intervention.

y The client owns his or her own environment

y Each client owns his or her behavior

y Peer pressure is a useful and a powerful tool

y Inappropriate behaviors are dealt with as they occur

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y Restrictions and punishment are to be avoided

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LEARNING ACTIVITY - MODULE 1

EGO DEFENSE MECHANISMS

Defense Mechanisms

Compensation

Chuck is awkward in sports activities and puts his energies into being an honor student.

Denial

Helen is unable to face the reality that she has a terminal illness.

DisplacementBob took out his on-the-job frustrations on his wife and children.

Identification

Cara takes on all the values and styles of her karate instructor.

IntrojectionLynn says no to cocaine, having adopted her parents' values rejecting the use of drugs.

Intellectualization

Before making an important decision, Marie reflected on her alternative choices.

IsolationWithout showing emotion, Jeff describes the accident and death of his daughter.

Projection

Luther feels a strong sexual attraction to his track coach and tells his friend, Hes coming on to me.

RationalizationBea feels awkward socially and avoids dating by saying she prefers to sit and watch television alone.

Reaction formation

Although Dick was overly polite, always smiling and joking, his humor was sarcastic and hostile.

RegressionAlthough usually independent, Sally becomes very clinging and helpless when physically ill.

Repression

Two years after graduation, John meets a high school rival and cannot recall her name.

SublimationMaggie experienced a date-rape one year ago and finds that swimming at the local spa helps her to relax.

Suppression

Frank made a concerted, conscious effort to put his disappointments out of mind.

UndoingAfter losing his temper at his girlfriend, Daryl brought her flowers.

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MODULE 2

PSYCHOPHARMACOLOGY

OBJECTIVES: Review neuroanatomy and physiology (Chapter 4)

1. Compare and contrast the responsibilities of administering medications on the mental health unit toadministering medications on a medical-surgical unit.

y The main difference between the med-surg floor and the mental health unit in administeringmedications is that an informed consent needs to be on file for all psychotropic medications.

2. Discuss the problems that may be encountered in the administration of medications to the mental health

patient.

y The patient might refuse the medication.

y No consent form on file

3. Identify the rules to be followed in the safe administration of medications to the mental health patient.

y Use the six rights to administer medication1. Right patient2. Right dose3. Right time4. Right route5. Right medication6. Documentation7. Consent forms

4. Describe indications, action, contraindication, precautions, side effects and nursing implications for the

following classifications of drugs:

a. Antianxiety agents

Generic Name Trade Name Generic Name Trade Name

Hydroxyzine Atarax Vistaril

Alprazolam Xanax Chlordiazepoxide Librium

Chonazepam Klonopin Clorazepate Tranzene

Diazepam Valium Lorazepam Ativan

Oxazepam Serax Meprobamate

Buspirone BuSpar

IndicationsUsed to treat anxiety disorders, anxiety symptoms, acute alcohol withdrawal, skeletal muscle

spasms, convulsive disorders, status epilepticus and preoperative sedation.

Action

y Depress subcortical levels of CNS, particularly the limbic system and reticular formation.

y May potentiate the effects of the powerful inhibitory neurotransmitter GABA in the brain,thereby producing a calmative effect

y BuSpar is believed to produce the desired effects through interactions with serotonin,dopamine and other neurotransmitter receptors.

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Contraindication

y Individuals with known hypersensitivity to any of the drugs with the classification(benzodiazepines)

y Not taken in combination with other CNS depressants

y Do not take when pregnant or lactating, narrow-angle glaucoma, shock and coma

Precautions

y Elderly, debilitated, hepatic or renal dysfunction clients reduced dosage may be required

y Depressed clients CNS exacerbate symptoms

y Clients with a history of drug abuse, addiction, depressed or suicidal need caution.

Side effects

Drowsiness Confusion Lethargy

Tolerance Physical dependence Psychological dependence

Dry mouth Nausea and vomiting Blood dyscrasiasDelayed onset (BuSpur)

Nursing implications

y Instruct the client not to drive or operate dangerous machinery while taking the medications

y Instruct the client on long-term therapy not to quit taking the drug abruptly. Abruptwithdrawal can be life-threatening. Symptoms include depression, insomnia, increased

anxiety, abdominal and muscle cramps, tremors, vomiting, sweating, convulsions anddelirium.

y Instruct the client not to drink alcohol or take other medications that depress the CNS whiletaking this medication

y Assess the clients mood dailyy Take necessary precautions for potential suicide.

y Monitor lying and standing blood pressure and pulse at every nursing shift.

y Instruct the client to arise slowly from a lying or sitting position.

y Have the client take frequent sips of water, suck on ice chips or hard candy or chew sugarlessgum.

y Have the client take the drug with food or milk

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b. Antidepressants


Amitriptyline Elavil, Endep Amoxampine Asendin

Clomipramine Anafranil Desipramine Norpramin

Doxepin Sinequan Imipramine Tofranil

Nortriptyline Aventyl, Pamelor Protriptyline Vivactil

Trimipramine Surmontil Citalopram Celexa

Escitalopram Lexapro Fluoxetine Prozac, Serafem

Fluvoxamine Luvox Paroxetine Paxil

Sertraline Zoloft Isocarboxazid Marplan

Phenelzine Nardil Tranylcypromine Parnate

Selegiline T/D Emsam Bupropion Zyban, Wellbutrin

Maprotiline Ludiomil Mirtazapine Remeron

Trazodone Nefazodone

Venlafaxine Effexor Duloxetine Cymbalta

Desvenlafaxine Pristiq Olanzapine & fluoxetine SymbyaxChlordiazepocide & fluoxetine Limbitrol DS Perphenazine & amitriptyline Etrafon

Indications

y Used in treatment for dysthymic disorder; major depression with melancholia or psychoticsymptoms; depression associated with organic disease, alcoholism, schizophrenia or mentalretardation; depressive phase of bipolar disorder; depression accompanied by anxiety.

y Elevate mood and alleviate other symptoms associated with moderate-to-severe depression

y Treat anxiety disorders, bulimia nervosa and premenstrual dysphoric disorder.

Action

y Increase the concentration of norepinephrine, serotonin and/or dopamine in the body

y Accomplished in the brain by blocking the reuptake of these neurotransmitters by the neurons(tricyclics, selective serotonin reuptake inhibitors and others)

Contraindication

y Contraindicated in individuals with hypersensitivity

y Tricyclics are contraindicated in the acute recovery phase following myocardial infarction

y Individuals with angle-closure glaucoma

Precautions

y Elderly, debilitated, cardiac insufficiency, hepatic or renal dysfunction clients reduced dosagemay be required

y Psychotic clients

y Benign prostatic hypertrophy

y History of seizures

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Side effects

Dry mouth Sedation Nausea

Discontinuation syndrome Blurred vision Constipation

Urinary retention Orthostatic hypotension Tachycardia

Arrhythmias Photosensitivity Weight gain

Insomnia Agitation Headache

Weight loss Sexual dysfunction Serotonin syndrome

Hypertensive crisis Priapism Hepatic failure


y Offer the client sugarless candy, ice, frequent sips of water.

y Strict oral hygiene is very important

y Request an order from the physician for the drug to be given at bedtime

y Request that the physician decrease the dosage or perhaps order a less sedating drug

y Instruct the client not to drive or use dangerous equipment while experiencing sedation

y

Medication may be taken with food to minimize GI distressy Abrupt withdrawal following long-term therapy may result in dizziness, lethargy, headache and

nausea.

y All antidepressant medication should be tapered gradually to prevent withdrawal symptoms

y Offer reassurance that this symptom should subside after a few weeks

y Clear small times from routine pathway to prevent falls

y Order foods high in fiber, increased fluid intake if not contraindicated and encourage the clientto increase physical exercise

y Monitor intake and output

y Instruct the client to report hesitancy or inability to urinate

y Instruct the client to rise slowly from a lying or sitting position

y Monitor blood pressure (lying and standing) frequently and document and report significantchanges

y Institute seizure precautions

y Ensure that client wears sun-block lotion, protective clothing and sunglasses while outdoors.

y Monitor intake of tyramine

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c. Mood stabilizing agents

Antimanic

Lithium carbonate -Eskalith, Lithane, LithobidIndications

y Prevention and treatment of manic episodes of bipolar disorder

Unlabeleduses:y Neutropenia

y Cluster headaches prophylaxis

y Alcohol dependence

y Bulimia

y Postpartum affective pyschosis

y Corticosteroid-induced psychosisAction

y May enhance reuptake of norepinephrine and serotonin, decreasing the levels in the body,resulting in decreased hyperactivity

y

1 3 weeks for symptoms to subsideContraindication

y Hypersensitivity

y Cardiac or renal disease dehydration

y Sodium depletion

y Pregnancy and lactationPrecautions

y Thyroid disorders

y Diabetes

y Urinary retention


y ElderlySide effects

y Drowsiness, dizziness, headache

y Dry mouth, thirst

y GI upset, nausea/vomiting

y Fine hand tremors

y Hypotension, arrhythmias, pulse irregularities

y Polyuria, dehydration

y Weight gainNursing implications

y

Ensure that client does not participate in activities that require alertness or operatedangerous machinery

y Provide sugarless candy, ice, frequent sips of water

y Ensure that strict oral hygiene is maintained

y Administer medications with meals to minimize GI upset

y Report to physician, who may decrease dosage. Some physicians may prescribe a small doseof beta blocker propranolol to counteract this effect.

y Monitor vital signs two or three times a day.

y Monitor daily intake and output and weight

y Monitor skin turgor daily

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y Provide instructions for reduced calorie diet

y Emphasize importance of maintain adequate intake of sodium

Anticonvulsants


Topriamate Topamax Carbamazepine Tegretol

Clonazepam Klonopin Valproic acid Depakene, depakote

Lamotrigine Lamictal Gabapentin Neurontin, Gabarone

Indications

o Epilepsy

o Trigeminal neuralgiao Panic disordero Manic episodeso Migraine - prophylaxiso Adjunct therapy in schizophreniao Postherpetic neuralgiaUnlabeleduses:

o Bipolar disordero Resistant schizophreniao Management of alcohol withdrawal

o Restless legs syndromeo Postherpetic neuralgiao Uncontrolled leg movements during sleepo Neuralgiaso Migraine prophylaxiso Neuropathic pain

o Tremors associated with multiple sclerosiso Cluster headacheso Bulimiao Binge eating disordero Weight loss in obesity

Action

y Treatment of Bipolar disorderContraindication

y Hypersensitivity

y With MAOIs lactation

y Glaucoma

y Liver disease

y

Lactationy Children < 3 years old

Precautions

y Elderly

y Liver/renal/cardiac disease

y Pregnancy

y Lactation

y Renal and hepatic insufficiency

y Children

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y Renal and hepatic impairmentSide effects

y Nausea/vomiting

y Drowsiness, dizziness

y Blood dyscrasias

y Prolonged bleeding time with valproic acid

y Risk of severe rash with lamotrigine

y Decreased efficacy with oral contraceptive with topiramateNursing implications

y May give with food or milk to minimize GI upset.

y Ensure that client does not operate dangerous machinery or participate in activities thatrequire alertness

y Ensure that client understands the importance of regular blood tests while receivinganticonvulsant therapy

y Ensure that platelet counts and bleeding t ime are determined before initiation of therapywith valproic acid.

y Monitor for spontaneous bleeding or bruisingy Ensure that client is informed that he or she must report evidence of skin rash to physician

immediately

y Ensure that client is aware of decreased efficacy of oral contraceptives with concomitant use

Calcium Channel Blockers

Generic Name Trade Name

Verapamil Calan, Isoptin

Indications

y Angina

y Arrhythmias

y HypertensionUnlabeleduses:

y Bipolar mania

y Migraine headaches - prophylaxisAction

y Treatment of bipolar disorderContraindication

y Hypersensitivity

y Severe left ventricular dysfunction

y Heart block

y

Hypotensiony Cardiogenic shock

y Congestive heart failurePrecautions

y Liver or renal disease

y Cardiomyopathy

y Intracranial pressure

y Elderly patients

y Pregnancy and lactation

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Side effects


y Hypotension, bradycardia

y Nausea

y ConstipationNursing implications

y Ensure that client does not operate dangerous machinery or participate in activites thatrequire alertness

y Take vital signs just before initiation of therapy and before daily administration of themedication. Physician will provide acceptable parameters for administration. Report

changes immediately

y May give with food to minimize GI upset

y Encourage increased fluid (if not contraindicated) and fiber in the diet

Antipsychotics


Olanzapine Zyprexa Aripiprazole AbilifyChlorpromazine Thorazine Quetiapine Seroquel

Risperidone Resiperdal Ziprasidone Geondon

Indications

y Schizophrenia

y Acute manic episodes

y Management of bipolar disorder

y Agitation associated with schizophrenia or mania

y For the treatment of depressive episodes associated with bipolar disorder

y Bipolar mania

y Emesis/hiccoughs

y Acute intermittent porphyriay Preoperative apprehension

y Acute agitation in schizophreniaUnlabeleduses:

y Obsessive-compulsive disorder

y Migraine headaches

y Severe behavioral problems in children

y Behavioral problems associated with autismAction

y Efficacy in schizophrenia is achieved through a combination of dopamine and serotonin

type 2 antagonsimy Treatment of mania

Contraindication

y Hypersensitivity

y Children

y LactationPrecautions

y Hepatic or cardiovascular disease


y Comatose or other CNS-depression

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y Prostatic hypertrophy

y Narrow-angle glaucoma

y Diabetes or risk factors for diabetes

y Pregnancy

y Elderly

y Debilitated patientsSide effects


y Dry mouth, constipation

y Increased appetite, weight gain

y ECG changes

y Extrapyramidal symptoms

y Hyperglycemia and diabetesNursing implications


y Provide sugarless candy or gum, ice and frequent sips of water.y Provide foods high in fiber

y Encourage physical activity and fluid if not contraindicated

y Provide calorie-controlled diet

y Provide opportunity for physical exercise

y Provide diet and exercise instruction

y Monitor vital signs

y Observe for symptoms of dizziness, palpitations, syncope or weakness

y Monitor for symptoms. Administer prn medications at first sign

y Monitor blood glucose regularly.

y Observe for the appearance of symptoms of polydipsia, polyuria, polyphagia and weaknessat any time during therapy

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d. Antipsychotics


Chlorpromazine Thorazine Fluphenazine Prolixin

Perphenazine Trilafon Prochlorperazine Compazine

Thioridazine Trifluoperazine Stelazine

Haloperidol Haldol Pimozide Orap

Thiothixene Navane Risperidone Risperdal

Paliperidone Invega Loxapine Loxitane

Clozapine Clozaril Olanzapine Zyprexa

Quentiapine Seroquel Molindone Moban

Ziprasidone Geodon Aripiprazole Abilitfy

Indications

y Schizophrenia

y Acute manic episodes

y Management of bipolar disordery Agitation associated with schizophrenia or mania

y For the treatment of depressive episodes associated with bipolar disorder

y Bipolar mania

y Emesis/hiccoughs

y Acute intermittent porphyria

y Preoperative apprehension

y Acute agitation in schizophreniaUnlabeleduses:

y Obsessive-compulsive disorder

y Migraine headaches

y Severe behavioral problems in children

y Behavioral problems associated with autismAction

y Efficacy in schizophrenia is achieved through a combination of dopamine and serotonintype 2 antagonsim

y Treatment of maniaContraindication

y Hypersensitivity

y Children

y Lactation

Precautionsy Hepatic or cardiovascular disease


y Comatose or other CNS-depression


y Narrow-angle glaucoma

y Diabetes or risk factors for diabetes

y Pregnancy

y Elderly

y Debilitated patients

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Side effects

Dry mouth Blurred vision Constipation

Urinary retention Nausea / GI upset Skin rashSedation Orthostatic hypotension Photosensitivity

Decreased libido Retrograde ejaculation Gynecomastia (men)

Amenorrhea (women) Weight gain ECG changesDiabetes Agranulocytosis HypersalvationPseudoparkinsonism Akinesia Akathisia

Dystonia Oculogyric crisis Tardive dyskinesiaHyperglycemia Reduction of seizure threshold

Neuroleptic malignant syndrome (NMS)



y Provide sugarless candy or gum, ice and frequent sips of water.

y Provide foods high in fibery Encourage physical activity and fluid if not contraindicated

y Provide calorie-controlled diet

y Provide opportunity for physical exercise

y Provide diet and exercise instruction

y Monitor vital signs

y Observe for symptoms of dizziness, palpitations, syncope or weakness

y Monitor for symptoms. Administer prn medications at first sign

y Monitor blood glucose regularly.

y Observe for the appearance of symptoms of polydipsia, polyuria, polyphagia and weakness

at any time during therapy

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e. Antiparkinsonian agents


Benztropine Cogentin Biperiden Akineton

Procyclidine Kemadrin Trihexphenidyl Bendadryl

Amantadine Symmertrel

Indications

y Used to treat parkinsonism of various causes

y Drug-induced extrapyamidal reactionsAction

y Restores the natural balance of acetylcholine and dopamine in the CNS.

y The imbalance deficiency in dopamine that results in excessive cholinergic activity.Contraindication

y Hypersensitivity.

y Angle-closure glaucoma

y

Pyloricy Duodenal

y Bladder neck obstructions


y Myasthenia gravisPrecautions

y Hepatic, renal or cardiac insufficiency

y Elderly and debilitated clients

y Tendency toward urinary retention

y Those exposed to high environmental temperaturesSide effects

Dry mouth Blurred vision Constipation

Paralytic ileus Urinary retention Tachycardia

Elevated temperatures Decreased sweating Nausea/GI upset

Sedation Dizziness Orthostatic hypotension

Exacerbation of psychoses


y

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MODULE 3

COMMUNICATION AND EFFECTIVE NURSE-PATIENT INTERACTIONS

OBJECTIVES

1. Describe the relevance of a therapeutic nurse-client relationship.

y Nurse-client relationships are goal oriented and the problem-solving model is used to try to bringabout some type of change in the clients life.

y The goal is directed at learning and growth promotion, in an effort to bring about some type of changein the clients life.

2. Discuss the importance of self-awareness in the nurse-client relationship.

y Self-awareness requires that an individual recognize and accept what he/she values and learn to acceptthe uniqueness and differences in others.

3. Describe the phases of relationship development and the tasks associated with each phase.

y Preinteractiono Preparation for the first encounter with the client

Obtaining available information about the client form his/her chart, significant others or otherhealth team members.

Examining ones feelings, fears and anxieties about working with a particular client.

y Orientation (introductory)o Nurse and client become acquainted.

Creating an environment for the establishment of trust and rapport. Establishing a contract for intervention that details the expectations and responsibilities of both

nurse and client. Gathering assessment information to build a strong client data base Identifying the clients 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.

y Workingo The therapeutic work of the relationship is accomplished during this phase.

Maintaining the trust and rapport that was established during the orientation phase. Promoting the clients insight and perception of reality. Problem solving using the model 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.

y Terminationo Ending of the therapeutic relationship has ended or goal has been met.

Bringing a therapeutic conclusion to the relationship 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. Feelings about termination of the relationship are recognized and explored.

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4. Identify and discuss preexisting conditions that will impact the outcome of the communication process.

y Values, attitudes and beliefso Learned ways of thinking

Children generally adopt the value systems and internalize the attitudes and beliefs of theirparents.

Children may retain this way of thinking into adulthood or develop a different set of attitudes

and values as they mature.o Examples:

Prejudice is expressed verbally through negative stereotyping An individual who values youth may dress and behave in a manner that is characteristic of one

who is much younger. Persons who value freedom and the way of life in the US may fly the US flag in front of their

homes each day.

y Culture or religiono Cultural mores, norms, ideas and customs provide the basis for our way of thinking.o Cultural values are learned and differ from society to society.o Examples:

In some European countries (Italy, Spain and France), me may greet each other with hugs andkisses. Where are this would communicate a different message in the US or Great Britain.

o Religion Wearing a clerical collar publicly by Priests and ministers communicate their mission in life. Wearing symbolic gestures such as crosses or star of David, communicate their religious

affiliation

y Social statuso Nonverbal indicators of social status or power are associated with gestures that communicate their

higher-power position.

o Examples: Less eye contact, more relaxed posture, use louder voice pitch, place hands on hips more

frequently, are power dressers, have greater height and maintain more distance whencommunicating with individuals considered to be of lower social status.

y Gendero Most cultures have gender signals that are recognized as wither masculine or feminine and provide

a basis for distinguishing between members of each gender.

o Examples: Differences in posture

y Men usually stand with thighs 10 to 15 degrees apart, pelvis rolled back and arms slightlyaway from the body

y Men when sitting usually lean back in the chair with legs apart or may rest the ankle of oneleg over the knee of the other.

y Women often are seen with legs close together, pelvis tipped forward and arms close to thebody.

y Women tend to sit more upright in the chair with legs together, perhaps crossed at theankles or one leg crossed over the other at thigh level.

Differences in Historical roles

y Masculinity roles are fathers, husband, breadwinner, doctor, lawyer or engineer

y Feminine roles are mothers, wife, homemaker, nurse, teacher or secretary.

y Age or developmental levelo Age influences communication and it is never more evident than during adolescenceo Example:

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Separate from parental confines and establish their own identity. Use of different terms such as dude, groovy, clueless, awesome, cool or wasted

o Developmental influences on communication may relate to physiological alterations.

o Example: American Sign Language for the deaf or hearing impaired person. Assists in communicating with the hearing person

y Type of environmento The place where communication occurs influences the outcome of the interaction.o Territoriality

Is the innate tendency to own space Interpersonal communication can be more successful if the interaction takes place in a neutral

area.

o Density Refers to the number of people within a given environment space

o Distance Four types of distances relating to communication Intimate distance

y 0 to 18 inchesy Closet distance that individuals will allow between themselves and others.

y Examples:o Kissingo Hugging

Personal distance

y Approximately 18 to 40 inches

y Reserved for interactions that are personal in nature

y Example:o Close conversations with friends or colleagues

Social distance

y Between 4 feet and 12 feet

y Interactions include conversations with strangers or acquaintances

y Examples:oAt a cocktail party

oPublic meeting Public distance

y Greater than 12 feet

y The distance is considered public space and communicants are free to move about in itduring the interaction.

y Examples:

oSpeaking in a public placeoYelling to someone down the street

5. Identify examples of effective verbal communication techniques

Technique Example

Accepting Yes, I understand what you said.

Giving recognition Hello, Mr. J. I notice that you made a ceramic ash tray in

OT.I see you made your bed.

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Tell me more about that particular situation.

Tell me how you are feeling about what happened.

Seeking clarification and validation Im not sure that I understand.Would you please explain?

Tell me if my understanding agrees with yours.Do I understand correctly that you said ?

Presenting reality I understand that the voices seem real to you but I do nothear any voices.

There is no one else in the room but you and me.

Voicing doubt I find that hard to believe.That seems rather doubtful to me.

I understand that you believe this to be true but I see thissituation differently than you.

I have a hard time believing that is true.

Verbalizing the implied Pt: Its a waste of time to be here. I cant talk to you oranyone.

Ns: Are you feeling that no one understands?

Pt: (Mute)

Ns: You must be feeling very lonely now.

Attempting to translate works into feelings Pt: Im way out in the ocean.

Ns: You must be feeling very lonely now.

Formulating a plan of action What could you do to let your anger out harmlessly?

Next time this comes up, what might you do to handle itmore appropriately?

Starting today you and I are going to think about somealternative ways for you to deal with those problems

things that you can do to decrease your anxiety withoutresorting to drugs.

6. Identify examples of effective non-verbal communication techniques.

y 70 to 90% of all effective communication is non-verbal

y Next to human speech, facial is the primary source of communication

Technique ExamplePhysical appearance and dress Young men who have hair down past their shoulders may convey amessage of rebellion against the establishment.

Body movement and posture Low-self esteem

Slumped posture, head and eyes pointed downwardSuperior status over person being addressed

Stand straight and tall with head high and hands on hipsWarm perception

A smile, direct eye contact hands remain still and a shift ofposture toward the other person

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increasing clients feelings of self-worth

Giving broad openings Allows the client to take the initiative in introducing thetopic

Emphasizes the importance of the clients role in theinteraction

Offering general leads Offers the client encouragement to continue

Placing the event in time or sequence Clarifies the relationship of events in time so that the nurseand client can view them in perspective

Making observations Verbalizing what is observed or perceivedThis encourages the client to recognize specific behaviors

and compare perceptions with the nurse

Encouraging description of perceptions Asking the client to verbalize what is being perceived; often

used with clients experiencing hallucinations

Encouraging comparison Asking the client to compare similarities and differences in

ideas, experiences or interpersonal relationships.This helps the client recognize life experiences that tend to

recur as well as those aspects of life that arechangeable.

Restating The main idea of what the client has said is repeated; letsthe client know whether or not an expressed statement

has been understood and gives him or her the chance tocontinue or to clarify if necessary

Reflecting Questions and feelings are referred back to the client so thatthey may be recognized and accepted and so that the

client may recognize that his/her point of view hasvalue a good technique to use when the client asks the

nurse for advice.

Focusing Taking notice of a single idea or even a single word; works

especially well with a client who is moving rapidlyfrom one thought to another.

This technique is not therapeutic however, with the client

who is very anxious.Focusing should not be pursued until the anxiety level has

subsided.

Exploring Delving further into a subject, idea, experience orrelationship; especially helpful with clients who tend to

remain on a superficial level of communication.However, if the client chooses not to disclose further

information, the nurse should refrain from pushing orprobing in an area that obviously creates discomfort.

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Seeking clarification and validation Striving to explain that which is vague or incomprehensible

and searching for mutual understanding.Clarifying the meaning of what has been said facilitates and

increases understanding for both client and nurse.

Presenting reality When the client has a misperception of the environment, the

nurse defines reality or indicates his/her perception ofthe situation for the client.

Voicing doubt Expressing uncertainty as to the reality of the clientsperceptions; often used with clients experiencing

delusional thinking

Verbalizing the implied Putting into words what the client has only implied or saidindirectly; it can also be used with the client who is

mute or is otherwise experiencing impaired verbalcommunication.

This clarifies that which is implicit rather than explicit

Attempting to translate works into feelings When feelings are expressed indirectly, the nurse tries to

desymbolize what has been said and to find clues tothe underlying true feelings.

Formulating a plan of action When a client has a plan in mind for dealing with what isconsidered to be a stressful situation, it may serve to

prevent anger or anxiety from escalating to anunmanageable level.

8. Describe non-therapeutic verbal communication techniques.

Technique Explanation/Rationale/Example

Giving reassurance Explanation:

Indicates to the client that there is no cause for anxiety,thereby devaluing the clients feelings.

Rationale:May discourage the client from further expression of

feelings if he/she believes they will only be downplayedor ridiculed

Example:I wouldnt worry about that if I were you

Everything will be all right.Now that you know what can happen when you drink

and drive, Im sure you wont let it happen again.Im sure everything will be okay.

Better to say:We will work on that together.

Rejecting Explanation:Refusing to consider or showing contempt for the clients

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ideas or behavior.

Rationale:May cause the client to discontinue interaction with the

nurse for fear of further rejection.Example:

Lets not discuss

I dont want to hear about I dont want to talk about that now. Look at that

sunshine. Its beautiful outside. You and I are

going to take a walk!

Better to say:Lets look at that a little closer.

Giving approval or disapproval Explanation:

Sanctioning or denouncing the clients ideas or behavior;implies that the nurse has the right to pass judgment on

whether the clients ideas or behaviors are good or

bad and that the client is expected to please the nurse.Rationale:The nurses acceptance of the client is then seen as

conditional depending on the clients behavior.Example:

Thats good. Im glad that you Thats bad. Id rather you wouldnt .

Thats was a terrible thing you did. You could havekilled that child!

Better to say:Lets talk about how your behavior invoked anger in

the other clients at dinner.

Agreeing/disagreeing Explanation:

Indicating accord with or opposition to the clients ideas oropinions.

Agreement prevents the client from later modifying his/herpoint of view without admitting error.

Disagreement implies inaccuracy, providing the need fordefensiveness on the part of the client.

Rationale:Implies that the nurse has the right to pass judgment on

whether the clients idea or opinions are right orwrong.

Example:Thats right. I agree.

Thats wrong. I disagree.I dont believe that.

Thats not true.

Better to say:Lets discuss what you fell is unfair about the new

community rules.

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Giving advice Explanation:

Telling the client what to do or how to behaveRationale:

Implies that the nurse knows what is best and that the clientis incapable of self-direction.

It nurtures the client in the dependent role by discouraging

independent thinking.Example:

I think you should

Why dont you The next time they laugh at you, you should just get up

and leave the room!Yes, you must tell your husband about your affair with

your boss.

Better to say:What do you think you should do?

Probing Explanation:Persistent questioning of the client; pushing for answers to

issues the client does not wish to discuss.

Rationale:This causes the client to feel used and valued only for what

is shared with the nurse and places the client on thedefensive

Example:Tell me how your mother abused you when you were a

child.Tell me how you feel toward your mother now that she

is dead.Now tell me about

Im sure they didnt mean to hurt your feelings.

Better to say:The nurse should be aware of the clients response and

discontinue the interaction at the first sign of

discomfort.

Defending Explanation:

Attempting to protect someone or something from verbalattack.

Rationale:To defend what the client has criticized is to imply that

he/she has no right to express ideas, opinions orfeelings.

Defending does not change the clients feelings and maycause the client to think the nurse is taking sides against

the client.Example:

No one here would lie to you.You have a very capable physician. Im sure he only

has your best interests in mind.

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Example:

Pt: I have nothing to live for. I wish I were dead.Nu: Everybody gets down in the dumps at times. I feel

that way myself sometimes.Youll just have to pull yourself together. Everyone

has problems and everybody doesnt use drugs to

deal with them. They just do the best that theycan.

Better to say:You must be very upset. Tell me what you are feeling

right now.

Making stereotyped comments Explanation:Clinches and trite expressions are meaningless in a nurse-

client relationship.Rationale:

When the nurse makes empty conversation, it encourages a

like response from the client.Example:

Im fine and how are you?

Hang in there. Its for your own good.Keep your chin up.

Keep your chin up and hang in there. Your time willcome.

Better to say:The therapy must be difficult for you at times. How do

you feel about your progress at this point?

Using denial Explanation:When the nurse denies that a problem exists he/she blocks

discussion with the client and avoids helping the client

identifies and explore areas of difficulty.Example:

Pt: Im nothing.Nu: Of course youre something. Everyone is

somebody.

Better to say:Youre feeling like no one cares about you right now.

Interpreting Explanation:With this technique the therapist seeks to make conscious

that which is unconscious, to tell the client the meaning

of his experience.Example:

What you really mean is Unconsciously youre saying

Better to say:The nurse must leave interpretation to the clients

behavior to the psychiatrist. The nurse has not beenprepared to perform this technique and in

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attempting to do so, may endanger other nursing

roles with the client.

Introducing an unrelated topic Explanation:

Changing the subject causes the nurse to take over thedirection of the discussion.

Rationale:This may occur in order to get to something that the nurse

wants to discuss with the client or to get away from atopic that he/she would prefer not to discuss.

Example:Pt: I dont have anything to live for.

Nu: Did you have visitors this weekend?Now I guess youll have to buy a new car. Can you

afford that?

Better to say:The nurse must remain open and free to hear the client,

to take in all that is being conveyed, both verballyand nonverbally.

9. Describe active listening.

y Is to be attentive to what the client is saying both verbally and nonverbally

y Creates a climate in which the client can communicate

y The nurse communicates acceptance and respect for the client and trust is enhanced

y Climate is established within the relationship that promotes openness and honest expressionS Sit squarely facing the clientO Observe an open posture = arms and legs remain uncrossed

L Lean forward toward the client

E Establish eye contactR Relax

10.Describe therapeutic feedback.

y Is the method of communication for helping the client consider a modification of behavior

y Gives information to clients about how they are being perceived by otherso Feedback is descriptive rather than evaluative and focuses on the behavior rather than on the cliento Feedback should be specific rather than generalo Feedback should be directed toward behavior that the client has the capacity to modify

o Feedback should impart information rather than offer advice

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y A sense of loss that precipitates the grief process may be in evidence, particularly in groups thathave been successful in their stated purpose

4. Identify various leadership styles in groups.

Characteristics Autocratic Democratic Laissez-Faire

Focus Leader Members UndeterminedTask strategy Members are persuaded Members engage in group

problem solving

No defend strategy exists

Memberparticipation Limited Unlimited Inconsistent

Individualcreativity Stifled Encouraged Not addressed

Memberenthusiasm &morale

Low High Low

Group cohesiveness Low High Low

Productivity High High (may not beas high asautocratic)

Low

Individualmotivation &

commitment

Low (tendto work only whenleaderis present to urgethem to do so)

High (satisfactionderivedfrom personal input &participation)

Low (feelings offrustrationfrom lack ofdirection orguidance)

5. Identify various roles that members assume within a group.Task Roles

y CoordinatorClarifies ideas and suggestions that have been made within the groupBrings relationships together to pursue common goals

y EvaluatorExamines group plans and performance, measuring against group standards and goals

y Elaborator

Explains and expands upon group plans and ideasy Energizer

Encourages and motivates group to perform at its maximum potential

y InitiatorOutlines the task at hand for the group and proposes methods for solution

y OrienteerMaintains direction within the group

Maintenance Roles

y CompromiserRelieves conflict within the group by assisting members to reach a compromise agreeable to all

y EncouragerOffers recognition and acceptance of others ideas and contributions

y FollowerListens attentively to group interaction; is passive participant

y GatekeeperEncourages acceptance of and participation by all members of the group

y HarmonizerMinimizes tension within the group by intervening when disagreements produce conflict

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R1 = Talk to friends on telephone

Fourteen year old Sally has been spending many hours after school watching TV. She has

virtually stopped practicing her piano lessons. Sallys parents ask for advice about how to

encourage Sally to practice more.

Discriminative stimulus = Practice piano: to do or not to do

R2 = Practice piano for 1 hourR1 = watch TV

y Extinction

The gradual decrease in frequency or disappearance of a response when the positive reinforcement

is withheld

Example:

The tantrum behaviors continue as long as the parent gives attention to them but decreases and

often disappear when the parent simply leaves the child alone in the room.

y Contingency Contracting

A contact is drawn up specifying a specific behavior change and the reinforcers to be given for

performing the desired behaviors

y Token Economy

A type contingency contracting in which the reinforcers for desired behaviors are presented in the

form of tokens

The token themselves provide immediate positive feedback and clients should be allowed to make

the decision of whether to spend the token as it is presented or to accumulate tokens that may

be exchanged later for a more desirable reward.

Example:

A client may be able to buy a snack or cigarettes for 2 tokens, a trip to the coffee shop or

library for 5 tokens or even a trip outside the hospitaly Time Out

An aversive stimulus or punishment during which the client is removed from the environment

where the unacceptable behavior is being exhibited

Example:

The client is usually isolated so that reinforcement from the attention of others is absent

y Reciprocal inhibition

A technique that decreases or eliminates a behavior by introducing a more adaptive behavior but

one that is incompatible with the unacceptable behavior

Example:

The introduction of relaxation exercises to an individual who is phobic.

Relaxation is practiced in the presence of anxiety so that in time the individual is able to

manage the anxiety in the presence of the phobic stimulus by engaging in relaxation

exercises.

y Overt sensitization

A type of aversion therapy that produces unpleasant consequences for undesirable behavior

Example:

Disulfiram (Antabuse) is a drug that is given to individuals who wish to stop drinking alcohol.

If an individual consumes alcohol while on Antabuse therapy, symptoms of severe nausea

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and vomiting, dyspnea, palpitations and headache will occur.

Instead of the euphoric feeling normally experienced from the alcohol (positive reinforcement

for drinking) the individual receives a severe punishment that is intended to extinguish the

unacceptable behavior (drinking alcohol).

y Covert sensitization

Relies on an individuals imagination to produce unpleasant consequences for undesirablebehaviors

The primary advantage of covert sensitization is that the individual does not have to perform the

undesired behaviors but simply imagines them.

y Systematic desensitization

A technique for overcoming phobias in which there is a hierarchy of anxiety-producing events

through which the individual progresses

Example:

Fear of elevators

1. Discuss riding an elevator with the therapist

2. Look at a picture of an elevator

3. Walk into the lobby of a building and see the elevators

4. Push the button for the elevator

5. Walk into an elevator with a trusted person; disembark before the doors close

6. Walk into an elevator with a trusted person; allow doors to close; then open the doors

and walk out

7. Ride one floor with a trusted person then walk back down the stairs

8. Ride one floor with a trusted person and ride the elevator back down

9. Ride the elevator alone

Fear of dogs

1. Look at a picture of a dog

2. Look at a stuffed toy dog

3. Pet the stuffed toy dog

4. Look at a real dog

5. Walk past a real dog

6. Pet a real dog

y Flooding implosive therapy

Desensitizes individuals to phobic stimuli by flooding them with a continuous presentation

(through mental imagery) of the phobic stimulus until it no longer elicits anxiety

8. Discuss cognitive therapy

y Cognitive therapy is a type of psychotherapy based on the concept of pathological mental processing.

y The focus of treatment is on the modification of distorted cognitions and maladaptive behaviors.

y Is founded on the premise that how people think significantly influences their feelings and behavior.

y Short-term, highly structures and goal-oriented therapy that consists of three major components didactic or educational, aspects or cognitive techniques and behavioral interventions

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9. Discuss cognitive therapy techniques usedRecognizing Automatic Thoughts and Schemas

y Socratic Questioning guided discoveryThe client is asked to describe feelings associated with specific situations.

Questions are stated in a way that may stimulate in the client recognition of possible dysfunctionalthinking and produce dissonance about the validity of the thoughts.

y ImageryThrough guided imagery, the client is asked to relieve the stressful situation by imagining the setting

in which it occurred. Where did it occur?Who was there?What happened just prior to the

stressful situation?What feelings did the client experience in association with the situation?

y Role PlayThis technique that should be used only when the relationship between client and therapist is

exceptionally strong and there is little likelihood of maladaptive transference occurring.The therapist assumes the role of an individual within a situation that produces a maladaptive response

in the client. The situation played out in an effort to elicit recognition of automatic thinking on thepart of the client.

y

Thought RecordingOne of the most frequently used methods

Thought recording is assigned as homework for the client outside of therapy.

In thought recording, the client is asked to keep a written record of situations that occur and the

automatic thoughts that are elicited by the situation.

Modifying Automatic Thoughts and Schemas

y Generating alternativesTherapist guides the client in generating alternatives

y Examining the EvidenceThe client and therapist set forth the automatic thought as the hypothesis and they study the evidence

both for and against the hypothesisy Decatastrophizing

The therapist assists the client to examine the validity of a negative automatic thought.

y ReattributionIt is believed that depressed clients attribute life events in a negatively distorted manner; that is they

have a tendency to blame themselves for adverse life events and to believe that these negative

situations will last indefinitely.

y Daily Record of Dysfunctional Thoughts (DRDT)Rating system

y Cognitive Rehearsal

This technique uses mental imagery to uncover potential automatic thoughts in advance of theiroccurrence in a stressful situation.

A discussion is held to identify ways to modify these dysfunctional cognitions.

The client is then give homework assignments to try these newly learned methods in real situations.

10.Implement the principals of behavioral and cognitive therapy using the steps of the nursing process.

11.Define and differentiate between anger and aggression.Anger

Anger is an emotional state that varies in intensity from mild irritation to intense fury and rage.It is accompanied by physiological and biological changes such as increases in heart rate, blood

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pressure and levels of the hormones epinephrine and norepinephrine.

AggressionAggression is a behavior intended to threaten or injure the victims security or self-esteem. It means

to go against, to assault or to attack. It is a response that aims at inflicting pain or injury onobjects or persons. Whether the damage is caused by words, fists or weapons, the behavior is

virtually always designed to punish. It is frequently accompanied by bitterness, meanness and

ridicule.An aggressive person is often vengeful.

The difference between anger and aggressive is that anger is an emotion while aggression is an action used

to deal with anger.

12.Apply the nursing process to clients expressing anger or aggression.

13.Describe the nursing intervention of seclusion as an individual treatment modality.Intervention of seclusion

y Restraintso Follow protocol for restraints/seclusion established by the institution.o JCAHO requires that an order by initiated by a licensed independent practitioner within 1 hour

of the initiation of the restraint or seclusion.

o In-person evaluations must be completed within 4 hours for 18 years and old within 2 hours for 17 years and younger

o Restraints should be used as a last resort

14.State the indications for the use of seclusion.Aggression control techniques such as seclusion are used to promote safety and reduce risk of harm to

client and others

15.Identify and describe nursing responsibilities related to the patient in seclusion.Observation and documentation

y Observe the client in restraints every 15 minutes or according to institutional policy

y Ensure that circulation to extremities is not compromised Check temperature, Color, Pulses

y Assist client with needs related to nutrition, hydration and elimination

y Position client so that comfort is facilitated and aspiration can be prevented

y Document all observationsOngoing assessment

y As agitation decreases, assess clients readiness for restraint removal or reduction

y With assistance from other staff members, remove one restraint at a time

y This minimizes the risk of injury to client and staff

16.Define crisis and describe the four phases in the development of a crisis.Crisis

A crisis is defined as a sudden event in ones life that disturbs homeostasis, during which usualcoping mechanisms cannot resolve the problem.

Phase 1The individual is exposed to a precipitating stressor

y Anxiety increases

y Previous problem-solving techniques are employed

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Example:

Ginger, age 19 and an only child, left 3 months ago to attend college of her choice 500 miles

away from her parents. It is Gingers first time away from home. She has difficultymaking decisions and will not undertake anything new without first consulting her mother.

She consults the nurse practitioner in the student health center.

y Crises reflecting psychopathologyEmotional crises in which preexisting psychopathology has been instrumental in precipitating

the crisis or in which psychopathology significantly impairs or complicates adaptive

resolution.

Examples of psychopathology that may precipitate crises include borderline personality, severe

neuroses, characterological disorders or schizophrenia.

y Psychiatric emergenciesCrisis situations in which general functioning has been severely impaired and the individual

rendered incompetent or unable to assume personal responsibility.Examples include acutely suicidal individuals, drug overdoses, reactions to hallucinogenic

drugs, acute psychoses, uncontrollable anger and alcohol intoxication.

18.State the goal of crisis intervention and discuss in sequence the steps of crisis intervention.The minimum therapeutic goal of crisis intervention is psychological resolution of the individuals

immediate crises and restoration to at least the level of functioning that existed before the crisis

periods.The maximum goal is improvement in functioning above the precrisis level.

Phase 1 - Assessment

y The crisis helper gathers information regarding the precipitating stressor and the resulting crisisthat prompted the individual to seek professional help.

Phase 2 Planning of Therapeutic Intervention

y The nurse selects the appropriate nursing actions for the identified nursing diagnoses.

y The type of crisis as well as the individuals strengths and available resources for support are

taken into consideration.y Goals are established for crisis resolution and a return to or increase in the precrisis level of

functioning.

Phase 3 - Intervention

y The actions that were identified in phase 2 are implemented.Phase 4 Evaluation of Crisis Resolution and Anticipatory Planning

y To evaluate the outcome of crisis intervention, a reassessment is made to determine if the statedobjective was achieved.

y During the evaluation period, the nurse and client summarize what has occurred during theintervention.

y They review what the individual has learned and anticipate how he/she will respond in thefuture.

y A determination is made regarding follow-up therapy; if needed, the nurse provides referralinformation.

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LEARNING ACTIVITY - MODULE 4

GROUPTHERAPY

Orientation Phase

y Members are cautious about developing relationships with each other

y Leader assures that all members know and agree to rulesy Goal is to establish explicit norms to govern group functioning

y Leader orients members to group process, to self, and to each other

y Participants feel anxious and there are frequently long pauses of silence

y Leader provides structure to the group and protects members from revealing themselves prematurely

y Members are strangers and distrustful of the leader and each other

Working Phase

y Members share feelings of rejection, loss and abandonment

y

Leader helps members think and work through problemsy Members are highly cohesive and respond positively to suggestions made by group members

y Goal is to help members examine and alter behavioral patterns

y Leader encourages members to express feelings of loss

y Members communicate readily, sharing and experiencing close feelings with each other

Termination

y Goal is to apply what has been learned in the group to other situations

y A ritual celebration may be used to help members transition into a new role

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