Basic Principles of Psychiatric Nursing

7/30/2019 Basic Principles of Psychiatric Nursing

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BASIC PRINCIPLES OF PSYCHIATRIC NURSING

These principles:1. are by necessity general in nature2. form the guidelines for the emotional care of all clients and the prevention of emotional

disequilibrium

When caring for clients, the nurse should attempt to:1. accept and respect people as individuals regardless of their behavior2. limit or reject inappropriate behavior without rejecting the individual3. recognize that all behavior has meaning and is meeting the needs of the performer

regardless of how distorted or meaningless it appears to others4. accept the dependency needs of individuals WHILE SUPPORTING AND ENCOURAGING

moves towards independence; build ego strengths5. help individuals set appropriate limits for themselves or set limits for then when they are

unable to do so

6. encourage individuals to express their feelings in an atmosphere free of reprisal orjudgement7. recognize that individuals need to use their defenses until other defenses can be

substituted8. recognize how feelings affect behavior and influence relationships9. recognize that individuals frequently respond to the behavioral expectations of others:

family, peers, authority (staff)10. recognize that all individuals have a potential for movement toward higher levels of

emotional health

Therapeutic Nurse-Client Relationships:

A. PHASES1. Preinteraction this phase begins before the nurses initial contact with the clienta. self-exploration regarding misconceptions and prejudices of the general public and

acknowledging ones own feelings and fear should occur before contact; selfawareness is necessary task before one can establish mutuality with others

b. additional tasks of this phase include gathering data about the client, andplanning for he first interaction with the client

2. Orientation or introductory the nurse, who initially is in the role of stranger, establishes atrust relationship that the client tests by discussing only what he or she wishes to discuss;clients are never pushed to discuss areas of concern that are pushed to discuss areas ofconcern that are upsetting to them

3. Working the nurse and the client discuss areas of concern and the client is helped toplan, implement, and evaluate a course of action

4. Termination the end of the therapeutic relationship between the nurse and the client; thetime parameters should be set within the first or second session; meetings spaced fartherand farther apart near the end will facilitiate termination

B. THEMES OF COMMUNICATION


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- recurring thoughts and ideas that give insights into what an individual is feeling and tie thecommunication together

1. Content conversation may appear superficial but careful attention to the underlyingtheme helps the nurse identify problem areas while providing insight I into the clients selfconcept

2. Mood emotion or affect that the client communicates to the nurse; includes personalappearance, facial expressions, and gestures that reflect the clients mood and feelings3. Interaction how the client reacts or interacts with the nurse; includes how the client

relates and what role he or she assumes when communicating with the nurse and others

C. FUNDAMENTAL REQUIREMENTS OF A THERAPEUTIC RELATIONSHIP1. Ability to communicate therapeutically requires a basic understanding and use of

interviewing techniques in developing a trusting relationship through:a. open-ended rather than probing questionsb. reflection of words and feelings and paraphrasingc. acceptance of the clients behavior

d. nonjudgemental, objective attitudee. focusing on the emotional needs of the clientf. having a therapeutic goal for the interview

2. Recognition that an individual has potential for growtha. individuals need to learn about their own behavior in relation to othersb. exchanging experiences with others provides a new learning environment and the

reassurance that reactions are valid and feelings sharedc. participating with groups increases knowledge of interpersonal relationships and

helps individuals to identify strengths and resourcesd. the identification of the individuals strengths and resources helps to convey the

expectation of growth3. Recognition that an individual needs to be accepted

a. acceptance is an active process designed to convey respect for another throughempathetic understanding

b. acceptance of others implies and requires acceptance of selfc. to be non judgemental, one must become aware of ones own attitudes and

feelings and their affect on perceptiond. acceptance requires that individuals be permitted and even encouraged to

express their feelings and attitudes even though they may be divergent from thegeneral view point

i. individuals should be encouraged to express both positive and negativeii. feelingsiii. this encouragement must occur on both verbal and nonverbal level

e. acceptance means showing interest in another person; interest requires:i. face to face contact and really listening to what the person has to sayii. developing an awareness of the other persons likes and dislikesiii. attempting to understand anothers point pf viewiv. using non-verbal as well as verbal expression of acceptance

f. acceptance requires the development of interpersonal techniques that encourageothers to express problems; the listeners:


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i. reflection of feelings, attitudes, and words help the speaker to identifyfeelings

ii. Open-ended questions permit the speaker to focus on problemiii. paraphrasing assists the speaker in clarifying statementsiv. use of silence provides both the listener and the speaker with the

necessary time for thinking over what is being discussedg. Acceptance requires the recognition of factors that block communication, such as:i. any overt/covert response that conveys a judgemental or superior attitudeii. direct question that convey an invasive or probing attitudeiii. ridicule that conveys a hostile attitudeiv. talking about ones own problems and not listening, which conveys a

selfserving attitude and loss of interest in the speaker

D. RECOGNITION OF BEHAVIORAL CHANGES THAT RESULT FROM PHYSICAL ILLNESS1. Anxiety, fear, and depression occur whenever there is a health problem

a. body image and feelings of being in control of ones body have their basis in early

development; struggle to maintain independence continuesb. anxiety develops whenever a real or imagined threat to the body image occurs2. Signs of anxiety, fear, and depression associated with illness are variable and include:

a. indifference to symptoms: usually related to failure to accept the occurrence of ahealth problem

b. denial of reality: usually related to attempts to maintain stability and integrity of thepersonality

c. reaction formation: usually related to attempts to block the reality fromconsciousness and acting as if nothing is wrong

d. failure to keep appointments and follow physicians or nurses directions: usuallyrelated to fear of finding additional problems or admitting there is somethingwrong

e. overconcern with body functions and symptoms: usually related to fear of deathf. asking many questions and offering many complaints: usually related to attempts

to keep a staff member by the bedside because of fears associated with illness;fear of abandonment

g. constantly ventilating feelings

EMOTIONAL NEEDS OF THE ILL PERSON INCLUDE:a. security of continuous relationships with friends and family membersb. some control to achieve feelings of self worth and self-esteemc. assistance in accepting the dependent roled. self-protection, disbelief, denial, avoidance and/or intellectualization; with developing

awareness of the implications of illness the individual defends the self further by use ofanger, depression, and/or joking

e. assistance in resolving conflicts while maintaining securityf. assistance in refocusing inner resourcesg. contact with the reality of the external world


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TO HELP THE INDIVIDUAL MAINTAIN THE SELF-CONCEPT DURING ILLNESS, THE NURSEMUST UNDERSTAND THE NORMAL EMOTIONAL STAGES OF ILLNESS

a. Denial: the individual cannot believe it is happening and seeks other opinions tocollaborate their feelings

b. Anger: something has happened that one cannot control

c. Bargaining: promising to be a better person or behave differently if given another chanced. Depression: one grieves for loss or expected losse. Realization: with developing realization of implications of illness, the individual reorganizes

self-feelings and restructures relationships with family and societyf. Resolution: the individual begins to accept the consequences of the illness and

acknowledges feelings about self and further changes that must be madeg. Acceptance and adaptation to the illness: this stage can only be reached when the

individual has resolved the conflicts that developed during the earlier stages

COMMON REACTIONS OCCUR TO THE CHANGE IN BODY IMAGE ASSOCIATED WITH MANYHEALTH PROBLEMS

a. Attitudes toward ones body and self-concept greatly influence responseb. Fear is a universal response; individual may focus on fear of: death, pain, incapacitation,disfigurement, altered self concept, rejection of loved ones

c. Questioning is a universal response; the individual may focus on: This cannot behappening to me; Is this really happening to me?; What did I do to deserve this?; Whyam I being punished

d. Grief and mourning are universal responses; the individual may focus on: what was in thepast; what could have been in the future; missed opportunities; a magnified view of theloss; avoiding interpersonal contacts

RELATED PHARMACOLOGY:

Psychotropic medications drugs that affect a persons psychic functioning, behavior, andexperience

Include: antianxiety or anxiolytic agents; neuroleptic (antipsychotic) agents; antidepressants;antimanic and mood-stabilizing agents; sedative and hypnotic agents

The safety of psychotropic drugs during pregnancy is not established; concern specially in thefirst trimester is for teratogenic effects; during the remainder of the pregnancy, the lowestpossible dose is desirable; administer with caution and only after consulting with psychiatristand pharmacist

DEFENSE MECHANISMS:This term refers to a predominantly unconscious self-protective process that seeks to shield the

ego from intense feelings or affect and impulses. Additionally, these intrapsychic processes modify,nullified, or convey painful affects or tendencies so they can be tolerated consciously.

Major Defense Mechanisms

DEFENSEMECHANISM

DEFINITION EXAMPLE

1. Displacement Redirection of negative urges orfeelings from an original object to

The man who is angry with his bossreturns home and becomes angry


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a safer or neutral substitute instead with his wife or children

2. Denial Refusal to admit a painful reality,which is treated as if it does notexist

The woman who miscarries deniesthat she has lost the baby andcontinues to wear maternity clothes

3. Intellectualization Use of excessive reasoning rather

than reacting or changing

A woman attending an Alcoholics

Anonymous meeting reports that sheis a nurse and has conducted many12-atep session

4. Introjection Engulfment or incorporation ofspecific traits, behaviors, orqualities into self or ego structure

A depressed man who incorporatesthe negative feelings and hatred ofhis estranged wife, who recently filedfor divorce

5. Projection Blame of others or things for onesown feelings or thoughts

The client experiencing paranoiablames others for disliking him

6. Rationalization An effort to replace or justifyacceptable reasons for feelings,

beliefs , thoughts, or behaviors forreal ones

A woman with overextended creditcards rationalizes that she can use

her savings to pay for a new dressshe recently purchased

7. Reaction formation Repression of painful or offensiveattitudes or traits with unconsciousopposite ones

The college student who feels angryand hostile toward her professor isovertly friendly and agreeable in class

8. Regression Retreat to an earlierdevelopmental stage

The 3-year-old child who beginswetting his pants after the birth of anew sibling

9.Repression Unconscious, purposefulforgetting of painful or dangerousthoughts (the most basic defense

mechanism)

The married woman who expresseshostility toward a male coworker toavoid dealing with her sexual

attraction to him10. Sublimation Normal form of dealing with

undesirable feelings or thoughtsby keeping them in an acceptablecontext

The woman who is unable to bearchildren begins working in a pre-school

11. Suppression Conscious and deliberateforgetfulness of painful ordesirable thoughts and ideas

A rape victim attempts to forget theincident and fails to report it to theproper authorities

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Basic Principles of Psychiatric Nursing