PSYCHIATRIC NURSING. Objectives: By the end of the section the learner will be able to;

•Discuss the concepts of mental health and mental illness •Describe 2 theories of personality development •Explain causes of mental illness •State the factors that influence attitude towards mental illness •Explain principles of psychiatric nursing •Describe trends in psychiatric nursing

What is mental health? Mental health is defined as a state of emotional wellbeing which enables one to function comfortably within the society and to be satisfied within ones own achievements.(WHO) What is mental illness? It is defined as a disorder with psychological or behavioral manifestations or impairrement of functioning due to a social, psychological, genetic physical, chemical or biological disturbance.(Evelyn and Wasili)

A mentally ill person may have one of the following characteristics: •Being dissatisfied with ones abilities and accomplishments •Having ineffective or unsatisfying interpersonal relationships •Dissatisfaction with ones place in the world •Having ineffective coping/adaptation mechanisms and lacking personal growth.

Factors that influence attitudes towards mental health and mental illness: •Culture: It influences the way people think and behave. It determines the features of insanity. It gives guidelines on the nature of treatment and the identity of the helper

•Education: An educated person has a more positive attitude to mental illness •Health beliefs: The attitude will depend on whether the person believes on the germ theory, •Evil spirit or an imbalance of some kind.

•Religion: Reaction to mental illness depends on whether the person believes in God or not. Religion encourages the followers to be empathetic.

Principles of psychiatric nursing: •Respect for the client •Availabilty i.e being there to alleviate suffering. •Spontaneity; Avoid being too formal. Be comfortable with yourself and therapeutic goals •Sensitivity: Be persistent even when no observable improvement is made. •Accountability: Consider that mentally ill patients are vulnerable due to their distorted thinking and behaviour.You are also accountable to yourself and your colleagues •Empathy: It enables you to give the client the feeling of being understood and cared for •Self understanding: •It is recognition and acceptance of your own behavior and how it affects the relationship with other people. It helps you to understand other peoples behavior. •Permissiveness and firmness. The therapist is expected to set limits and to be firm in implementing them. Skill and observation: It is important for the nurse to be alert and observant at all times in terms of patients behavior, attitudes, and how the patient reacts to staff, relatives and fellow patients. HISTORICAL TRENDS IN PSYCHIATRIC NURSING

Demonological period: The earliest record of a person believed to have suffered mental illness relate to king Nebuchadnezzar who ate grass like an animal. •During that time the cause of mental illness was believed to be demons •Treatment was harsh and involve beating , chainning and locking the individual in dark rooms or throwing the into rivers Those who escaped the harsh treatment survived on stealing food and eating wild fruits. Wild animals ate those who roamed the forests

Political period •King Edward the 2nd of England passed a law which protected the property of the mentally sick •In 1403, the sisters of the order of St Mary started a facility to care for the mentally ill at Bedlam in England. It started with 6 people and later became a hospital. The hospitals were overcrowded leading to massive deaths during disease outbreaks In the early 18th century the first qualified nurse was appointed to look after the mentally ill. The nurses who followed were very harsh to patients

The Humanitarian period. It came after the forms in France in 1793.Dr Philippe Pinel unchained a group of patients who had been in chains for 30 years. He advocated kindness. There was marked improvement of the mentally sick. In 1796 William Tuke introduced Occupatiional therapy for the patients e.g. sewing gardening In 1808 a bill was passed to regulate the treatment of mental health patients. In 1884, formal training in mental health was started in Germany and other countries followed. The scientific Period •In the 19th century modern treatments were developed based on scientific findings •The current forms of treatment include physical treatment e.g. chemotherapy and electroconvulsive therapy. •Others are : Psychotherapy,Behaviour therapy, occupational therapy and rehabilitation DEVELOPMENT OF PSYCHIATRY AND MENTAL HEALTH SERVICES IN KENYA. The current Mathare hospital was started jn July 1910 as a lunatic asylum. Before then it served as a smallpox vaccination centre •The facility was named Mathare Mental Hospital in 1924.Currently it is known as Mathare Hospital •Europeans ,Asians and Africans were managed separately, the quality of care depended on the race. Mathare was the only mental hospital until 1962 Decentralization of Mental Health Services Act. •Others started in Nakuru in 1962,Machakos in 1963 Nyeri and Muranga in 1964, Port Reitz and Kakamega in 1965. •Currently all provincial hospitals have operational psychiatric units. •Community psychiatric services were established in Nairobi in 1983 started training psychiatrists. PSYCHIATRIC DISORDERS Affective disorders The major affective disorders are characterized by disturbances of mood.

General concepts: Major depression is seen more often in women. More common in higher social economic group. Major causes: •Depressive: Loss of significance others or objects. Decrease in levels of norepinephrine •Increase in steroids •Loss of self esteem leading to hopelessness helplessness and pessimism towards self and others. •Manic: unresolved diffuse anger and hostility, denial of depression, may develop fro early childhood as a result of high parental expectations Personality characteristics with affective disorders: 1. Depressive: lacking in confidence, introverted. Dependent, pessimistic, feelings of inadequacy 2. Manic: extroverted,confident,manipulative and obsessive Psychodynamics. 1. Manic: During infancy, needs are not met, which leads to impairment in the development of self esteem. 2. Low self esteem and hopelessness lead to need for excessive attention affection warmth and appreciation 3. There is a massive denial of depression 4. The air of happiness and confidence is a defense against dependency feelings. Depressive: 1. Loss of real or perceived of a loved person or object. 2. Turning aggressive feelings inwards and displacing them into self, accompanied by feelings of guilt 3. A ambivalent feelings towards valued or lost object 4. Repressive guilt which leads to feelings of helplessness and hopelessness. Assessment:

Manic: Onset; before the age of 30 •Mood: elevated, expansive and irritable •Speech: loud, rapid, difficult to interpret, rhyming and clanging (using words that sound like meaning rather than the actual words) •Cognitive skills: flight of ideas, grandiose delusions, easily distracted •Psychomotor activity: Hyperactive, decreased need for sleep, exhibitionistic,vulgar,profane, may make inappropriate sexual advances Can be obscene. •Course of manic episode: begins suddenly, escalates over a few days and ends more abruptly than major depressive episodes.

Depressive: Has one or more manic episodes •Mood : depressive, despairing, loss of interest or pleasure in most usual activities •Cognitive process; negative view of self, world and of the future. Poverty of ideas, crying and suicidal preoccupations. Psychomotor: may have either agitation or retardation in movement, feelings of fatigue,anorexia,constipation,insomnia and a decreased libido

Mixed: •It involves both manic and depressive episodes, either intermixed or alternating rapidly every few days •Depressive phase symptoms are prominent and can last a whole day. Major depression: •It may occur at any age. •May be differentiated as a single episode or a recurring type •Severity and type of depression may vary with the ability to test reality 1. Psychotics: feel worse in the morning and better as the day goes by 2. Neurotics: Wakes up feeling optimistic, mood worsens as the day passes Nursing intervention: Manic episode: Goal: •Provide for basic human needs of safety, rest and activity •Reduce outside stimuli and provide a nonstimulating environment •Monitor food intake: provide high calorie diet with finger foods to be eaten as the client moves about •Encourage noncompetitive solitary activities e.g walking, painting •Assist with • personal hygiene Goal: To establish a therapeutic nurse client relationship •Use firm consistent, honest approach •Assess clients abilities and involve in his own care •Promote problem solving abilities: recognize that a false sense of independence is often demonstrated by loud behavior Do not focus on or discuss grandiose ideas Goal: set limits on behavior •Instructions should be clear and concise •Initiate regularly scheduled contacts to demonstrate acceptance •Maintain some distance between self and client to allow freedom of movement to prevent feelings of being empowered •Maintain neutrality and objectivity: Realize that the client can be easily provoked by harmless remarks and may furious reactions and calm down quickily Use measures to prevent overt aggression e.g distraction, increased excitement

Goal: to promote adaptive coping with constructive use of energy •Do not hurry the client, this may lead to anxiety and hostile behavior •Provide activities and constructive tasks that channel the agitated behavior e.g. cleaning game room, gardening •Goal: To assist in medical treatment: teach client about his medication Depressive episode; Goal; To assess for suicidal potential Recognition for suicidal intent: 1. Self destruction behavior are viewed as attempts to escape unbearable life situations 2. Anxiety and hostility are overwhelmingly present. 3. Ambivalence i.e. living versus self destruction •Depresion,low self esteem and a feeling of hopelessness are critical to evaluate because suicide attempts are often made when the client feels like giving up. •Assess for indirect self destruction behavior: any activity that is detrimental to the physical wellbeing of the client in which the potential outcome is death: 1. Noncompliance with the medical treatment e.g. diabetic who refuses to take insulin 2. Alcohol and drug abuse •Criminal and socially deviant activities •Eating disorders; Anorexia nervosa, overeating, obesity

Suicide danger signs: 1. The presence of a suicide plan: the specifities relating to method, its lethality and likelihood for rescue. 2. Change in established d patterns in routines e g. giving away of personal items, making a will or saying goodbye •Anticipation of failure: loss of a job, preoccupation with physical disease, actual or anticipated loss of a significant other •Change in behavior, presence of panic, agitation or calmness. As depression lifts the client has enough energy to act on suicidal feelings •Hopelessness: feelings of impending doom, futility and entrapment •Withdrawal and rejection of help Clients at risk: •Adolescents and the elderly, males usually complete the suicide acts. •Clients experiencing recent stress of a maturational or situational crisis •Client with chronic or painful illness •Clients with previous suicide attempts or suicide behavior •Withdrawn, depressed or hallucinating clients •Clients with sexual identity conflict and those who abuse alcohol or drugs. Goal: to provide for basic human needs of safety and protection from self destruction 1. Remove all potentially harmful objects e.g. belts , sharp objects, matches lighters strings etc. 2. Maintain one to one relationship and close observation 3. Have client make a written contract stating he or she will not harm himself and provide an alternative method of coping Goal: to provide for physical needs of nutrition rest and activity •Assess for changes in weight ( increasing weight loss may indicate deepening depression •Encourage increasing bulk and roughage with sufficient fluid if client is constipated Provide for adequate amount of exercise and rest. Encourage client not to sleep during the day Assist with hygiene and personal appearance Failure or inability to trust others and self Security and identity are threatened making the client withdraw from reality

Prepsychotic personality characteristics •Aloof and indifferent •Social withdrawal •Relatives and friends note a change in personality •Disturbed communication pattern •Lack of personal grooming Maladaptive disturbances 1. Disturbed thought processes •Communicates in symbolic language in which all symbols have special meaning •Belief that thoughts and wishes can control other people( magical thinking) •Retreats to a fantasy world rejecting the real world of painful experience while responding to reality in an autistic manner 2. Disturbed affect •Difficulty expressing emotions •Asent,flat blunted or inapproprite affect Disturbance in psychomotor behavior: •Display of disorganize, purposeless activity •Behavior may be uninhibited and bizarre, abnormal posturing (catatonia) or waxy flexibility •Often appears aloof, disinterested apathetic and lacking motivation Disturbance in perception: •Hallucinations and delusions especially auditory •Abnormal body sensations and hypersensitivity to sounds sight and smell Disturbance in interpersonal relationships: Establishment of interpersonal relationships is difficulty because of inability to communicate clearly and react appropriately Difficulty relating to others: •Unable to form close relationships •Has difficulties trusting others Goal: To promote expression of feelings. •Encourage expression of angry guilty or depressed feelings by allowing client to respond at his own time •Initiate frequent contacts •Assist with decision making when depression is severe •Goal : To provide for meaningful socialization activities •Encourage participation in activities, plan a work assignment to do simple tasks •Assess hobbies, sports or activities client enjoys and encourage participation •Encourage client to participate in small group conversations or activity .Practice social skills through role playing and psychodrama •Encourage activities that promote a sense of accomplishment and enhance self esteem.

•Goal: to assist in medical treatment •Administer antidepressant medications •Assist in electroconvulsive therapy SCHIZOPHRENIA It is a maladaptive disturbance characterized by a number of common behaviors involving disorders of thought content, mood ,feelings ,perception, communication and interpersonal relationships. Onset of symptoms occurs in early childhood with a duration of symptoms of at least 6 months. General concepts: •Loss of ego boundaries 1. Organic causes; genetic ,biochemical i.e. overactive dopamine, insufficient norepinephrine immunological imbalance, structural deviation of the brain tissue, enlarged ventricles 2. Psychosocial: Poor family relationships,maladaptation to stress, lack of ege strength, a deficit in cognitive development due to prenatal nutritional Primary mental mechanisms are regression, repression, progression and denial Failure or inability to trust others Security and identity are threatened prompting the client to withdraw from reality MENTAL STATUS ASSESSMENT: Psychiatric history: Purpose: To obtain data from multiple sources e.g. clients, family, friends police, and mental health personnel in order to identify patterns of functioning that are healthy, as well as patterns that create problems in the clients everyday life. General history of client: •Obtain general demographic information: address, age religion,occupation,insurance •Birth, growth and development, illness and medical history. •Previous mental health hospitalization or treatment.

Components of psychiatric history: Chief complaints: reason for seeking treatment. Use clients own words as to why he or she is hospitalized or seeking help. Check for recent difficulties or changes in relationships, level of function, behavior, perceptions or cognitive abilities

Presenting symptoms: onset and development of symptoms and problems: Check for increased feelings of depression, anxiety,hoplessness,, suspiciousness, confusion And fear. •Assess for changes in bowel habits, insomnia,lethargy,weght loss or gain, anorexia palpitations,, pruritis,headaches. Family history: •Have any family members sought psychiatric treatment? •Was there physical, emotional or sexual abuse? •Did parents use alcohol or drugs? Personality profile: •Assess clients interests feelings, mood and usual leisure or hobby activities? •How does the client cope with stress? •Enquire about sexual patterns, sexually active? Sexual orientation or sexual difficulties •Have client describe social relationships: who are clients friends? Who is important to the client? What is a usual day like? Mental status examination: It is used to identify an individuals present mental status. General appearance, attitude and behavior. •Describe: posture, gait, activity, facial expression, mannerisms. •Disturbances include deviations of activity, distortions immobility (waxy flexibility) uncooperativeness and changes in personal hygiene Characteristic of talk and stream of thought: •Emphasis of form rather than content of clients verbal communication: loudness, flow, speed, quality, logic and level of coherence Disturbances include the following patterns: •Mutism: nonverbal response •Circumstantialities: cumbersome detail in clients communication •Perseveration: Pattern of repeating same words or movements •Flight of ideas: rapid speech, loosely connected thoughts •Blocking: Sudden silence, often associated with intrusion of delusional thoughts or hallucinations •Echolalia: Repeating the last word heard •Neologism: coining of new words •Verbigeration:reapeating words, sentences or phrases several times. •Pressured speech: an increase in quantity Of speech, usually becoming loud, rushed and emphatic

Emotional state: clients report of subjective feelings(mood or affect) and examiners observation of clients dominant emotional state. Disturbances include deviations elation depression apathy incongruence and disassociation Thought content: What is the central theme? How does the client view himself (self concept) is suicidal or homicidal ideation present? If so what is the potential danger? Disturbances include special preoccupations and experiences such as hallucinations, delusions, depersonalization, obsessions or compulsions, fantasies and daydreams Sensorium and intellect: Determines the degree of awareness and level of intellectual functioning: general ability to grasp information and calculate; abstract thinking; memory( recall of remote past experiences, retention and recall of immediate impressions); reasoning and judgment Disturbances of orientation in terms of time, place person and self; memory retention; attention; information and judgment are assessed Assessed through use of standardized tests and questions Insight and evaluation: Determines whether the client can understand and appreciate the nature of his or her condition and the need for treatment