Psychiatric Mental Health NursingEve Karpinski, APHN-BC, RN-BC
Question 1How stress are you now?1. Not at all.2. Mildly3. Moderately4. Severely
StressThe word stress lacks a definitive definition.Adaptation is defined as restoration of
homeostasis to the internal environmental system.
Adaptation includes responses directed at stabilizing internal biological processes and psychological preservation of self-identity and self-esteem.
Stress as a Transaction Between the Individual and the Environment
Individual’s perception of the eventPrimary appraisal – a judgment about the
situation in one of the following ways: Irrelevant Benign-positive Stress appraisal
Secondary appraisal – an assessment of skills, resources, and knowledge that the person possesses to deal with the situation
Precipitating event – a stimulus arising from the internal or external environment and perceived by the individual in a specific manner
The physiological of stress . “Fight or Flight” ResponseWhen the body encounters a stressor, it prepares itself for
“fight or flight.” Identify the adaptation responses that occur in the initial stress
response in each of the physical components listed.Physical component Adaptation ResponseAdrenal medullaEyeRespiratory systemCardiovascular systemGastrointestinal systemLiverUrinary systemSweat glandsFat cells
Releases norepinephrine and epinephrine.Pupils dilate.Secretion is increased from lacrimal glands.Bronchioles dilate.Respiration rate is increased.Increased force of cardiac contractionIncreased cardiac outputIncreased heart rateIncreased blood pressureDecreased gastric and intestinal motilityDecreased secretionsSphincters contractIncreased glycogenolysis and gluconeogenesisDecreased glycogen synthesisIncreased ureter motilityBladder muscle contractsBladder sphincter relaxesIncreased secretionLipolysis
Stress Response Adrenal medulla Eye
Respiratory system
Cardiovascular system
Gastrointestinal system
Liver
Urinary system
Sweat glands Fat cells
Releases norepinephrine and epinephrine.
Pupils dilate. Secretion is increased from lacrimal
glands. Bronchioles dilate. Respiration rate is increased. Increased force of cardiac contraction Increased cardiac output Increased heart rate Increased blood pressure Decreased gastric and intestinal motility Decreased secretions Sphincters contract Increased glycogenolysis and
gluconeogenesis Decreased glycogen synthesis Increased ureter motility Bladder muscle contracts Bladder sphincter relaxes Increased secretion Lipolysis
When the stress response is sustained for an extended period of time the pituitary gland is stimulated by the hypothalamus to release a number ofhormones. Match the ultimate physical effects listed below with the appropriate hormone that triggers the response.__________ 1. Adrenocorticotropic hormone (ACTH)__________ 2. Vasopressin (antidiuretic hormone [ADH])__________ 3. Growth hormone__________ 4. Thyrotropic hormone (TTH)__________ 5. Gonadotropins
a. Results in increased serum glucose and free fatty acids.b. Suppression of sex hormones resulting in decreased libido and impotence.c. Increased gluconeogenesis; immunosuppression; anti-inflammatory response;increased sodium and water retention.d. Increased basal metabolic rate.e. Increased blood pressure (through constriction of blood vessels) and increasedfluid retention.
Stress MasteryStress Mastery is the utilization of coping
strategies in the response to stressful situations.
Adaptive coping strategies protect the individual from harm and restore physical and psychological homeostasis.
Coping strategies are considered maladaptive when the conflict being experienced goes unresolved or intensifies.
Effects of chronic Stress Increase GluconeogenisisDecrease ImmuneDecrease inflammatory responseRetention of sodium and waterDecrease in libido, frigidity and impotenceIncrease in blood pressure
The Physiological of Relaxation
Unhealthy Coping Strategies
Healthy Coping Strategies
Awareness Relaxation Meditation Interpersonal
communication with caring other
Problem-solving Pets Music
Your own thoughtsLaughterAromatherapyMassageJournaling
Personality is defined by the DSM-IV-TR as “enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts.”
Life-cycle developmentalists believe that people continue to develop and change throughout life, thereby suggesting the possibility for renewal
and growth in adults.
TheoriesFreud’s theory of psychosexual developmentErikson’s eight development stagesHarry Stack Sullivan’s interpersonal theoryMahler’s theory of object relations
developmentPiaget’s cognitive developmentKohlberg’s theory of moral developmentNursing Peplau’s stages
Mental HealthDefined as “The successful adaptation to
stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are age-
appropriate and congruent with local and cultural
norms.” Stages are identified by age. However,
personality is influenced by temperament (inborn personality characteristics) and the environment.
It is possible for behaviors from an unsuccessfully completed stage to be modified and corrected in a later stage.
Mental IllnessDefined as “Maladaptive responses to stressors
from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are incongruent with the local and cultural norms and interfere with the individual’s social, occupational, or physical functioning.”
Horwitz describes cultural influences that affect how individuals view mental illness. These include Incomprehensibility – the inability of the general population to understand the motivation behind the behavior. Cultural relativity – the “normality” of behavior is
determined by the culture.
Psychological Adaptation to Stress
Anxiety and grief have been described as two major, primary psychological response patterns to stress.
A variety of thoughts, feelings, and behaviors are associated with each of these response patterns.
Adaptation is determined by the extent to which the thoughts, feelings, and behaviors interfere with an individual’s functioning.
Anxiety
A diffuse apprehension that is vague in nature and is associated with feelings of uncertainty and helplessness.
Extremely common in our society. Mild anxiety is adaptive and can provide
motivation for survival.
Peplau’s four levels of anxietyMild – seldom a problem
Moderate – perceptual field diminishes Severe – perceptual field is so diminished that
concentration centers on one detail only or on many extraneous details
Panic – the most intense state
Behavioral Adaptation Responses to Anxiety
At the mild level, individuals employ various coping mechanisms to deal with stress. A few of these include eating, drinking, sleeping, physical exercise, smoking, crying, laughing, and talking to persons with whom they feel comfortable.
Anxiety at the moderate to severe level that remains unresolved over an extended period of time can
contribute to a number of physiological disorders – for example, migraine headaches, IBS, and cardiac arrhythmias.
Extended periods of repressed severe anxiety can result in psychoneurotic patterns of behaving – for example, anxiety disorders and somatoform disorders.
GriefThe subjective state of emotional, physical, and
social responses to the loss of a valued entity; the loss may be real or perceived.
Elisabeth Kübler-Ross
(5 Stages of Grief) Denial Anger Bargaining Depression Acceptance
Defense MechanismsCompensationDenialDisplacementIdentificationIntellectualizatio
nIntrojectionIsolationProjection
RationalizationReaction
formationRegressionRepressionSublimationSuppressionUndoing
DSM-IV-TR Multiaxial Evaluation SystemAxis I – Clinical disorders and other conditions that may be a focus of clinical attentionAxis II – Personality disorders and mental retardationAxis III – General medical conditionsAxis IV – Psychosocial & environmental
problemsAxis V – Global assessment of functioning rated on the Global Assessment of Functioning (GAF) Scale, which measures an individual’s psychological, social, and occupational functioning
PsychobiologyThe 101st Congress of the U.S. designated
the 1990s as the “Decade of the Brain,” with the challenge for studying the biological basis of behavior.
In keeping with the neuroscientific revolution, greater emphasis is placed on the study of the organic basis for psychiatric illness.
Implications for NursingEmphasis in psychiatric nursing is on a
smooth transition from a psychosocial approach to a biopsychosocial focus
Psychiatric nurses must have a specialized knowledge about Neuroanatomy and neurophysiology Neuronal processes Neuroendocrinology Circadian rhythms Genetic influences Psychoimmunology Psychopharmacology Diagnostic technology
Neurotransmitters play an important role in human emotions and behavior and are the target for the mechanism of action in many psychotropic medications.Major categories of neurotransmitters
Cholinergics Monoamines Amino acids Neuropeptides
Pituitary gland Posterior lobe
Vasopressin Oxytocin
Anterior lobe Growth hormone Thyroid-stimulating hormone Adrenocorticotropic hormone Prolactin Gonadotropic hormones Melanocyte-stimulating hormone
Circadian rhythmsFollow a near-24-hour cycle in humans and may
influence a variety of regulatory functions, including the
sleep-wake cycle, body temperature regulation, patterns of activity such as eating and drinking, and hormone secretion.
Some mood disorders have been linked to increased secretion of melatonin during darkness hours.
Symptoms that occur in the premenstrual cycle have been linked to disruptions in biological rhythms.
Sleep-wake cycle is one of the most common biological rhythms that demonstrates circadian influence.
Sleep stages 0 – Alpha 1 – Beta2 – Theta 3 – Delta4 – DeltaREM - Beta
Neurochemical influences on sleep-wake cycle
Serotonin and L-tryptophan Norepinephrine and dopamine GABA Acetylcholine
Ethical and Legal Issues in Psychiatric/Mental
Health Nursing
DefinitionsEthics - the science that deals with the rightness
and wrongness of actionsBioethics - term applied to ethics when they
refer to concepts within the scope of medicine, nursing, and allied health
Values – ideals or concepts that give meaning to the individual’s life
Moral behavior – conduct that results from serious critical thinking about how individuals ought to treat others
Values clarification – a process of self-exploration through which individuals identify and rank their own personal values
Values – ideals or concepts that give meaning to the individual’s life
Moral behavior – conduct that results from serious critical thinking about how individuals ought to treat others
Values clarification – a process of self-exploration through which individuals identify and rank their own personal values
Ethical ConsiderationsTheoretical PerspectivesUtilitarianism – an ethical theory that promotes
actions based on the end results that produce the most good (happiness) for the most people
Kantianism – suggests that decisions and actions are bound by a sense of duty
Christian ethics - do unto others as you would have them do unto
you; alternatively, do not do unto others what you would not have them do unto you.
Natural law theories – do good and avoid evil. Evil acts are never condoned, even if they are intended to advance the noblest of ends.
Ethical egoism – decisions are based on what is best for the
individual making the decision.
Ethical Dilemmas Ethical dilemmas occur when moral appeals
can be made for taking either of two opposing courses of action.
Taking no action is considered an action taken.
Avoiding Liability Respond to the client Educate the client Comply with the standard of care Supervise care Adhere to the nursing process Document carefully Follow up and evaluate Maintain a good interpersonal
relationship with client and family
Ethical PrinciplesAutonomy – This principle emphasizes the status
of persons as autonomous moral agents whose rights to determine their destinies should always be respected.
Beneficence – This refers to one’s duty to benefit or promote the good of others.
Nonmaleficence – abstaining from negative acts toward another; includes acting carefully to avoid harm
Justice – principle based on the notion of a hypothetical social contract between free, equal, and rational persons. The concept of justice reflects a duty to treat all individuals
equally and fairly.Veracity – principle that refers to one’s duty to be truthful
always.
A Model for Making Ethical Decisions
Assessment Problem identification Plan Implementation Evaluation
Ethical Issues in Psychiatric/Mental Health Nursing
The right to refuse medication The right to the least restrictive treatment
alternative
Legal Considerations Nurse Practice Act defines the legal parameters of
professional and practical nursing. Types of Laws
Statutory law Common law
Civil Law – protects the private and property rights of individuals and businesses
Tort Contracts
Criminal law – provides protection from conduct deemed injurious to the public welfare
Confidentiality and right to privacy Doctrine of privileged communication
Informed consent Restraints and seclusion
False imprisonment Commitment issues
Voluntary admissions Involuntary commitment Emergency commitment The mentally ill person in need of treatment Involuntary outpatient commitment The gravely disabled client
Malpractice and negligence Types of lawsuits that occur in psychiatric
nursing Breach of confidentiality Defamation of character
Libel Slander
Assault and battery False imprisonment Invasion of privacy
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