BASIC PRINCIPLES OF PSYCHIATRIC NURSING These principles: 1. are by necessity general in nature 2.

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 behavior 2. limit or reject inappropriate behavior without rejecting the individual 3. recognize that all behavior has meaning and is meeting the needs of the performer regardless of how distorted or meaningless it appears to others 4. accept the dependency needs of individuals WHILE SUPPORTING AND ENCOURAGING moves towards independence; build ego strengths 5. 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 or judgement 7. recognize that individuals need to use their defenses until other defenses can be substituted 8. recognize how feelings affect behavior and influence relationships 9. 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. PHASES 1. Preinteraction this phase begins before the nurses initial contact with the client a. self-exploration regarding misconceptions and prejudices of the general public and acknowledging ones own feelings and fear should occur before contact; self awareness is necessary task before one can establish mutuality with others b. additional tasks of this phase include gathering data about the client, and planning for he first interaction with the client 2. Orientation or introductory the nurse, who initially is in the role of stranger, establishes a trust 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 of concern that are upsetting to them 3. Working the nurse and the client discuss areas of concern and the client is helped to plan, implement, and evaluate a course of action 4. Termination the end of the therapeutic relationship between the nurse and the client; the time parameters should be set within the first or second session; meetings spaced farther and farther apart near the end will facilitiate termination B. THEMES OF COMMUNICATION

- recurring thoughts and ideas that give insights into what an individual is feeling and tie the communication together 1. Content conversation may appear superficial but careful attention to the underlying theme helps the nurse identify problem areas while providing insight I into the clients self concept 2. Mood emotion or affect that the client communicates to the nurse; includes personal appearance, facial expressions, and gestures that reflect the clients mood and feelings 3. 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 RELATIONSHIP 1. 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 questions b. reflection of words and feelings and paraphrasing c. acceptance of the clients behavior d. nonjudgemental, objective attitude e. focusing on the emotional needs of the client f. having a therapeutic goal for the interview 2. Recognition that an individual has potential for growth a. individuals need to learn about their own behavior in relation to others b. exchanging experiences with others provides a new learning environment and the reassurance that reactions are valid and feelings shared c. participating with groups increases knowledge of interpersonal relationships and helps individuals to identify strengths and resources d. the identification of the individuals strengths and resources helps to convey the expectation of growth 3. Recognition that an individual needs to be accepted a. acceptance is an active process designed to convey respect for another through empathetic understanding b. acceptance of others implies and requires acceptance of self c. to be non judgemental, one must become aware of ones own attitudes and feelings and their affect on perception d. acceptance requires that individuals be permitted and even encouraged to express their feelings and attitudes even though they may be divergent from the general view point i. individuals should be encouraged to express both positive and negative ii. feelings iii. 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 say ii. developing an awareness of the other persons likes and dislikes iii. attempting to understand anothers point pf view iv. using non-verbal as well as verbal expression of acceptance f. acceptance requires the development of interpersonal techniques that encourage others to express problems; the listeners:

i. reflection of feelings, attitudes, and words help the speaker to identify feelings ii. Open-ended questions permit the speaker to focus on problem iii. paraphrasing assists the speaker in clarifying statements iv. use of silence provides both the listener and the speaker with the necessary time for thinking over what is being discussed g. Acceptance requires the recognition of factors that block communication, such as: i. any overt/covert response that conveys a judgemental or superior attitude ii. direct question that convey an invasive or probing attitude iii. ridicule that conveys a hostile attitude iv. 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 ILLNESS 1. 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 continues b. anxiety develops whenever a real or imagined threat to the body image occurs 2. 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 a health problem b. denial of reality: usually related to attempts to maintain stability and integrity of the personality c. reaction formation: usually related to attempts to block the reality from consciousness and acting as if nothing is wrong d. failure to keep appointments and follow physicians or nurses directions: usually related to fear of finding additional problems or admitting there is something wrong e. overconcern with body functions and symptoms: usually related to fear of death f. 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 members b. some control to achieve feelings of self worth and self-esteem c. assistance in accepting the dependent role d. self-protection, disbelief, denial, avoidance and/or intellectualization; with developing awareness of the implications of illness the individual defends the self further by use of anger, depression, and/or joking e. assistance in resolving conflicts while maintaining security f. assistance in refocusing inner resources g. contact with the reality of the external world

TO HELP THE INDIVIDUAL MAINTAIN THE SELF-CONCEPT DURING ILLNESS, THE NURSE MUST UNDERSTAND THE NORMAL EMOTIONAL STAGES OF ILLNESS a. Denial: the individual cannot believe it is happening and seeks other opinions to collaborate 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 chance d. Depression: one grieves for loss or expected loss e. Realization: with developing realization of implications of illness, the individual reorganizes self-feelings and restructures relationships with family and society f. Resolution: the individual begins to accept the consequences of the illness and acknowledges feelings about self and further changes that must be made g. 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 MANY HEALTH PROBLEMS a. Attitudes toward ones body and self-concept greatly influence response b. 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 be happening to me; Is this really happening to me?; What did I do to deserve this?; Why am I being punished d. Grief and mourning are universal responses; the individual may focus on: what was in the past; what could have been in the future; missed opportunities; a magnified view of the loss; avoiding interpersonal contacts RELATED PHARMACOLOGY: Psychotropic medications drugs that affect a persons psychic functioning, behavior, and experience 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 the first trimester is for teratogenic effects; during the remainder of the pregnancy, the lowest possible dose is desirable; administer with caution and only after consulting with psychiatrist and 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 DEFENSE DEFINITION MECHANISM 1. Displacement Redirection of negative urges or feelings from an original object to EXAMPLE The man who is angry with his boss returns home and becomes angry

instead with his wife or children 2. Denial The woman who miscarries denies that she has lost the baby and continues to wear maternity clothes 3. Intellectualization A woman attending an Alcoholics Anonymous meeting reports that she is a nurse and has conducted many 12-atep session 4. Introjection Engulfment or incorporation of A depressed man who incorporates specific traits, behaviors, or the negative feelings and hatred of qualities into self or ego structure his estranged wife, who recently filed for divorce 5. Projection Blame of others or things for ones The client experiencing paranoia own feelings or thoughts blames others for disliking him 6. Rationalization An effort to replace or justify A woman with overextended credit acceptable reasons for feelings, cards rationalizes that she can use beliefs , thoughts, or behaviors for her savings to pay for a new dress real ones she recently purchased 7. Reaction formation Repression of painful or offensive The college student who feels angry attitudes or traits with unconscious and hostile toward her professor is opposite ones overtly friendly and agreeable in class 8. Regression Retreat to an earlier The 3-year-old child who begins developmental stage wetting his pants after the birth of a new sibling 9.Repression Unconscious, purposeful The married woman who expresses forgetting of painful or dangerous hostility toward a male coworker to thoughts (the most basic defense avoid dealing with her sexual mechanism) attraction to him 10. Sublimation Normal form of dealing with The woman who is unable to bear undesirable feelings or thoughts children begins working in a preby keeping them in an acceptable school context 11. Suppression Conscious and deliberate A rape victim attempts to forget the forgetfulness of painful or incident and fails to report it to the desirable thoughts and ideas proper authorities

a safer or neutral substitute Refusal to admit a painful reality, which is treated as if it does not exist Use of excessive reasoning rather than reacting or changing