Mental Health Of Gnm z2x4w

Biyani's Think Tank Concept based notes

Mental Health & Psychiatric Nursing-I (GNM)

Subita Fageria Lecturer Deptt. of B. Sc. (Nursing Biyani Nursing College, Jaipur

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Published by :

Think Tanks Biyani Group of Colleges Concept & Copyright :

Biyani Shikshan Samiti Sector-3, Vidhyadhar Nagar, Jaipur-302 023 (Rajasthan) Ph : 0141-2338371, 2338591-95 Fax : 0141-2338007 E-mail : [email protected] Website :www.gurukpo.com; www.biyanicolleges.org

First Edition : 2011

While every effort is taken to avoid errors or omissions in this Publication, any mistake or omission that may have crept in is not intentional. It may be taken note of that neither the publisher nor the author will be responsible for any damage or loss of any kind arising to anyone in any manner on of such errors and omissions.

Leaser Type Setted by : Biyani College Printing Department

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Preface

I

am glad to present this book, especially designed to serve the needs of

the students. The book has been written keeping in mind the general weakness in understanding the fundamental concepts of the topics. The book is selfexplanatory and adopts the “Teach Yourself” style. It is based on questionanswer pattern. The language of book is quite easy and understandable based on scientific approach. This is to help the students for clearing their doubts and for guidance and to understand the subject why easily in a settled manner. This book covers the diagnosis and management of both medical & nursing including the psychopharmacology & general therapies of psychiatric disorders. Any further improvement in the contents of the book by making corrections, omission and inclusion is keen to be achieved based on suggestions from the readers for which the author shall be obliged. I acknowledge special thanks to Mr. Rajeev Biyani, Chairman & Dr. Sanjay Biyani, Director (Acad.) Biyani Group of Colleges, who are the backbones and main concept provider and also have been constant source of motivation throughout this Endeavour. They played an active role in coordinating the various stages of this Endeavour and spearheaded the publishing work. I look forward to receiving valuable suggestions from professors of various educational institutions, other faculty and students for improvement of the quality of the book. The reader may feel free to send in their comments and suggestions to the under mentioned address. Author

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Mental Health/ Psychiatric Nursing Course Description This course is designed to help students develop the concept of mental health and mental illness, symptoms, prevention, treatment modalities and nursing management of mentally ill. General Objectives:Upon completion of this course, the students will be able to: 1. Describe the concept of mental health and mental illness and the emerging trends is psychiatric nursing. 2. Explain the causes and factors of mental illness, its prevention and control. 3. Identify the symptoms and dynamics and abnormal human behavior in comparison with normal human behavior. 4. Demonstrate a desirable attitude and skills in rendering comprehensive nursing care to the mentally ill. Course Content Unit I Introduction  Meaning of mental health and mental illness  Definition of used in psychiatry.  Review of mental mechanisms (ego mechanisms)  Review of personality and types of personality. Unit II History of Psychiatry  Contributors to psychiatry  History of psychiatric nursing  Trends in psychiatric nursing

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Unit III Mental Health Assessment  Psychiatric history taking  Interview technique and mental status examination.

Unit IV community Mental Health  Concept, importance and scope  Attitude and misconceptions towards mentally ill.  Prevention of mental illness (preventive Psychiatry) during childhood, adolescence, adulthood and old age.  Community mental and old age.  Community mental health services.  Role of nurses in community mental health services.

Unit V Psychiatric Nursing Management  Definition of psychiatric nursing  Principles of psychiatric nursing  Nursing process  Role of nurses in providing psychiatric nursing care.  Therapeutic nurse-patient relationship  Communication skills Unit VI Mental disorders and nursing interventions  Etiology – various etiological theories (genetics, biochemical, psychological, etc)  Classification of mental disorders.  Organic mental disorder-Acute brain syndrome  Chronic brain syndrome  Functional mental disorder

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 Prevalence, etiology, signs and symptoms, prognosis, medical nursing management  Schizophrenic disorders.  Mood (affective ) disorders.  Manic Depressive Psychosis  Anxiety Status.

Definition, etiology, signs, symptoms, medical and nursing management of: Phoebic disorders, obsessive compulsive disorders, depressive neurosis, conversion disorders, dissociative reaction, hypochondriasis, Psychoactive disorders, alcohol, drugs and other psychoactive substance abuse. Unit-VII Bio-Psychosocial  Psychopharmacology  Definition, classification of drugs, antipsychotic, antidepressant, antimanic, antianxiety agents.  Role of nurses in psychopharmacology  Psychosocial therapies  Definition of psychosocial therapies.  Types of therapies; individual and group therapy, behavior therapy, occupational therapy.  Role of nurse in these therapies.  Somatic therapy  History,

technique

of

electro

convulsive

therapy

(ECT)

contraindications.  Role of nurses before, during and after electroconvulsive therapy.

indications,

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Unit VIII Forensic Psychiatry/Legal Aspects  Legal responsibilities in care of mentally sick patients.  Procedure for ission and discharge from mental hospital, leave of absence.  Indian Lunatic Act 1912  Mental Health Act 1987  Narcotic Drugs and Psychotropic Act 1985

Unit IX Psychiatric Emergencies and Crisis Intervention  Over active patient  Destructive patient  Suicidal patient

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Unit I

Introduction Q.1 Ans:

What do you mean by mental health? According to WHO " Health is define as a state of complete physical, mental, social and spiritual well being not merely an absence of disease or infirmity? Mental Health means a Healthy mind in a healthy body. Mental Health is a part of general health. It requires a balance between body, mind spirit and the environment in which a person lines. Mental Health

Environment

Body, mind & spirit

According to Kerl Malinger: The adjustment of human beings to the world and to each other with a maximum of effectiveness and happiness." According to WHO: "The capacity of an individual to form harmonious relationships with other and to participate in or contribute constructively to change in social environment". Thus, Mental Health is positive state in which the person is responsible, selfdirective and displays self-awareness.

Q.2 Define Mental illness ; Ans.: It is an opposition of mental illness. Mental illness occurs when a state of physical, mental, social and spiritual well being is disturbed. It is explained in 3 ways: 1.

Absence of Health: It defines illness is an absence of health. It emphasize problem but does not solve it.

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2.

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Biology Approach : According to scadding – "Mental illness is result of biological disturbance".

3.

Pathological Approach: According to szusz – "Mental illness only is term of physical pathology". According to American Psychiatric Association defines "mental illness or mental disorder is an illness or syndrome with psychological or behavioural manifestations and/or impairment in functioning due to social, psychological, genetic, physical/chemical or biological disturbance. The disorder is not limited to relation between the person and society. The illness is characterized by symptoms and/or impairment in functioning".

Q.3

How will you differentiate the mentally healthy people from mentally ill people?

Ans.: S.No. Mental Health 1 Positive attitudes towards self acceptance and self awareness (Optimistic) 2 Able to solve problems by self with creativity 3 Positive self concept relate well to people and their environment 4 Able to cope up stress and reality perception 5 Able to make decision and sound judgment. 6 Able to establish and maintain healthy relationship 7 Accepts the authority and responsibility 8 Able to work effectively and independently 9 Differentiate and analyze the situations 10 Has good sense of humar

Mental illness Negative attitude towards self acceptance & self awareness (pessimistic) Avoid problems than solve - Poor self concept - Feels inadequate Not able to cope thus stressful situations Poor decision making & judgments power Relationship with friends & family are disturbed. Unable to assume authority & responsibility Mostly dependent work Unable to analyze Easily get irritated

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11 12

Behavioural that is generally acceptable to others Able to solve conflict very easily

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Deeper insight

Maladaptive behavior Always confused and unable to solve conflict Poor insight.

Q.4

What is mental (Defense) mechanism? How many types of mental mechanism ? Ans.: Sigmund freud the father of modern psychiatry coined the term, " Defense mechanism". He described defense mechanism are unconscious processes that d defined a person against anxiety. It is often used by all people to feel free or relieved from the emotional stir, internal conflict or anxiety. It gives ego satisfaction. Very commonly it is used : To solve mental conflict  To reduce fear or anxiety  Protect one's self esteem  Protect one's sense of security Definition of mental mechanism :1. According to Bhatia & Craig : The individual has mental capacities or devices for protecting himself against psychological danger & stress" A defense mechanism is a coping mechanism used in an effort to protect the individual from feelings of anxiety. Types of mental mechanism and their origin

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Origin in oral period (0-2 yrs)

Defense mechanism and their origin.

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 Compensation  Displacement, denial  Fixation & substitution

Origin in habit training (1-3 yrs)

     

Conversation Identification Introjections Reaction formation Transference Sublimation

Origin in later period of childhood (13-6)

   

Repression Suppression Regression Rationalization

Origin in latency period (6-12 yrs age)

Other commonly use defense mechanism

 Projection  Isolation  Fantasy

   

Incorporation Intellectualization Symbolization Undoing

 Psychotic patient use defense mechanism:- Projection, denial, fantasy, regression, symbolization and fixation.

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 Neurotic patient use following defense mechanism:- Repression, isolation, reaction formation, displacement and dissociation.

Q.5

How mental mechanism help the person to react appropriately to the situation?

Ans.

It is one of the coping mechanism used to reduce anxiety & fear.  It assist the client to identify the source of anxiety and explore the methods to reduce anxiety.  It also keeps an individual temporarily free or away from the problem.  They protect the individual against psychological threats related to ego.  Helps the people to other people's behaviour and the factors associated with their nature.  It helps the people to lead a satisfactory & productive life which prevents mental illness, promote mental health of individual in specific family & community in general. For example:A graduate nurse is expected to do comprehensive nursing care, if

she fails to do so and the tutor identifies it and scolds, she cries like a child to overcome her failure instead of putting more efforts and succeeding in it. Here, the nurse uses regression mental mechanism.

Q.6

Define personality?

Ans: According to Allport: Personality is the dynamic organization within the individual of those psychophysical systems that determine his unique adjustment to his environment.

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According to Taylor :

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Personality refers to "the Aggregate of the physical & mental

qualities of the individual as these interact & function in characteristic fashion with his environment. 

Personality is expressed through the behaviour of a person. The characteristic behaviour which is a combination of physical and mental characteristics of an individual, differentiate one individual from another with his/her unique ident.

Q.7

Mention the factors affecting development of personality?

Ans.

Factors affecting development of personality :   

Heredity Embryonic factors Fetal factor Antenatal factor

I.

Biological Factors

II.

Physiological factors

 Nervous system  Endocrine glands

III.

Social Factor

   

IV.

Emotional / Psychological Factor

V.

Biochemical Factor

VI.

Physique

–

Family Scholastic Environment Social-economic influences Society

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Q.8

Explain Freud's psychodynamic theory:

Ans.: Freud explained psychodynamic theory as : 1.

Conscious Level: It is awareness part certain thought which are pleasurable and ed

2.

Unconscious level: Some thought are completely repressed which the person doesn't like is painful for ethical standard or self image. All ID are unconscious.

3.

Preconscious level: The memories/thought are easily available with a moment reflection.

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Unit II

History of Psychiatry Q.1

Brief the historical development of psychiatry nursing?

Ans.: History of psychiatry: History is meaningful record of human achievement. The term, 'History' is derived from a Roman word "Historics" which means knowledge through" enquiry. The whole series & record of past events that occurred chronologically in relation to psychiatry were described. The following categories of periods are identified historically : 1.

The period of persecution : 1550 BC – 1400 AD

2.

The period of Segregation : 1545 AD -1800 AD

3.

The humanitarian period – 1745 – 1826 AD

4.

Beginning of scientific attitude : 1796 AD – 1878 AD

5.

The period of prevention : 1885 AD – 1960 AD

1. Past history:- In first century "CHARAK SAMHINTHA" has referred to psychiatric as " Bhut vidhya" and personality was basically divided into 3 categories : A. Satveek (Moral level) B. Rajasse (Emotional level) C. Tamsie (Said as mentally retard)  Mental disorders was known as " UNMADA" & fainting was known as " Murkh"

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 Psychotherapy process was present in form of "DAIUAIY APARYA CHIKITSHA"  About 4th century method of treatment are : -

Tortures

-

Burning

-

Jail

-

Asylum

-

1st Mental asylum established in India in "DHAR" (MP)

-

Philippe pinel (father of modern psychiatry) raise his voice against asylum.

II. Present History: 1.

First psychiatric nurse" Linda Richards" from America start training of nurses for care of psychiatric patient in 1873.

2.

In 1953, national, legue of nursing (USA) publish a study's brought out function's and qualification of a psychiatric nurse.

3.

In 1956 DPN (Diploma in psychiatric nursing) was started in NIMHANS

(National

Institute

of

Mental

Health

Neurological

Science), Banglore, 1 year course. 4.

1960, psychiatric nursing was made a compulsory course in America.

5.

1973, standard of psychiatric nursing was established.

Past Situation : 1.

In 1946, bhore committee report recommend preparation of psychiatry nurses.

2.

In 1965, INC - Psychiatric Nursing or a compulsory course in BSc. (N)

3.

In 1975, MSc. (Psychiatric Nursing) started in RAK New Delhi

4.

In 1983, DPN in Ranchi

5.

In 1986, Psychiatric Nursing In GNM

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6.

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In 1990, started in MG university Kottayam.

Present situation: 1.

22000 bed in 42 mental hospital

2.

2000-3000 bed in general hospital

3.

I bed for 32,000 population

4.

No. meaningful available for rural population

5.

1000-1500 psychiatrist in India.

6.

Every year 150 are being trained.

7.

All the same time number of psychiatric nurses only 900-950

8.

About 60 seat are available for DPN & may not be filled each year.

9.

1 Nurse for every 1,00,000 population.

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Unit III

Mental Health Assessment Q.1

What is mental health assessment?

Ans.: Mental Health Assessment is the first step of nursing process that includes analysis of data collected from the patient and his family and identification of nursing needs. The data can be collected from primary source, that is from the clients his family (subjective data) or from secondary source e.g. Clients care record, nurse notes or notes from health team .

Q.2

How many types of basic techniques included in Mental Health Assessment?

Ans.

Three types of basic techniques included in mental health assessment:

1. History taking 2. Mental status examination 3. Psychological tests Q.3 Describe the steps for taking psychiatric history? Ans.: History taking and mental status examination are important measure for diagnosis & treatment outline preparation of mental illness. Psychiatric history included the following steps: I. Identification data: Name of the patient ……………………. age……….. Sex………………… Bed no. …………………….

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Hospital Reg. No. ……………………. Education ……………………….. occupation ………………………… Marital status …………………….. religion ………………………….. Language………………………….. nationality …………………………………. Income ……………………………. Address ………………………………… Data of ission ……………………… Final diagnosis …………………………… Identification mark……………………………. II.

a) Informant ……………………….. b) reliability of informant ……………………

III.

Present chief complain According to patient …………………………. According to relatives :

IV.



Onset of present complains ……………………..



Duration of present complains……………….



Nature of present complains ………………………



Precipitating factors …………………………..

History of present illness : a. Time of onset of present episode of illness b. Chronological arrangement of the symptoms

V.

Past history of illness: a. Medical illness b. Psychiatric illness

VI.

Personal history 1. Developmental History a) Infancy history

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b) Childhood history c) Adolescence d) Adulthood e) Late maturity 2. Educational history 3. Play history 4. Occupational history 5. Sexual & menstrual history

VII. Family history :  Family structure  Family history of mental illness  Current social condition of family

VIII Premorbid personality

Q.4

Define MSE (Mental Status Examination).

Ans.: According to K. Lalitha: MSE is defined as systematic evaluation of Behaviour, emotion, cognitive functions of an individual.  MSE in a standardized format is which the clinician records the mental sign & symptoms present at the time of interview

Q.5.

What are the aspects of MSE?

Ans.

The aspects included in this examination are:-

1. General appearance & behavior: Consciousness  Physique

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 Personal hygiene  Posture  Facial expression  Gestures 2. Talk or speech : a) Speech activity :i. Unusual pattern ii. Unusual words b) Tone and volume of speech c) Speech pattern d) Coherence

3. Mood or affect :A. objective mood a) Appearance b) Intensity of happiness c) Consistency of word d) Emotional Expression B. Subjective mood 4. Thought process : 1. Thought at formation level 2. Stream of Thought 3. Thought at content level. 5. Perception : a) Illusion b) Hallucination 6. Cognitive function:

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1. Level of consciousness 2. Attention 3. Concentration 4. Memory – immediate/Recent memory/remote memory 7.

Orientation: time, place, person

8.

Intelligence: average/confused

9.

Insight: Present/Partial/Present/Absent

10.

Judgment: Personal/social

11.

Abstract ability:

12

General Information

13

Psychosocial factor 

Stressor



Coping skills



Relationship



Socio-cultural aspects



Adaptability



Spiritual areas

Q.6 Ans.

Define interview technique? Interview is an oral questionnaire where the interviewee gives the needed information verbally in a face-to-face relationship. Interviewer– The person who conduct interview Interviewer – the person that interviewed According to oxford English dictionary: - interview is a private meeting between people where questions are asked & answered According to Webster: Interview is a meeting at which information is obtaining from a person. Q.7 Mention the types of interview techniques : Ans.: Interview Techniques:1. Observing

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2. listening 3. Validating 4. Providing information 5. Restating 6. Clarifying 7. Paraphrasing 8. Pin pointing 9. Linking 10. Questioning 11. Focusing 12. Sharing summarizing 13. Reflecting 14. Confronting

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Unit-IV

Community Mental Health

Q.1 Ans.

What are common misconceptions regarding mental illness? Some of the misconceptions of community towards mental illness are: 1. Abnormal behavioural is bizarre. 2. Normal person will never be abnormal. 3. Mental illness is heredity. 4. Mental illnesses are not related to physical health. 5. Mental disorders are incurable. 6.

Mental illness is caused by supernatural power.

7. Mental illness is life long 8. Mental illness is contagious 9. Marriage can cure mental illness 10. Mentally ill person should only be treated in asylums. 11. Mentally ill patients are dangerous. 12. Mental illness sometimes to be ashamed. 13. Prevalence of mental illness is low in India 14. Professionals who works with psychiatric patients are likely to become disturb themselves. 15. Mental hospitals are place where only dangerous mental ill individual are treated with restraint as a major approach. Q.2

Define community mental health nursing

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Ans.: Community mental health nursing is the application of knowledge of psychiatric nursing in preventing, promoting and maintaining mental health of people to help in early diagnosis and to rehabilitate the client after mental illness. It is also defined as to promote, maintain and conserve the health of population aggregates in the community with emphasis on mental health. Q.3

What are the facilities (Services) available in the community to strengthen their mental Health ? Ans.: varied community facilities are available to provide mental health care for total population and self involvement for their future life. 1. Day hospital centre: Patient receives a full range of treatment, services during day time and return home at the end of day. Patients develop routine & discipline in life. 2. Half way house: These are for those who no longer need full services of a hospital but are not yet ready for a completely independent living, still he may require supervision for medication & carrying domestic activities 3. Quarter way house: Chronically ill patients are kept in quarter way homes.  These patients are enough improved to live in family but their family reject them  This home try to make these patients self dependent. It reduces gap between hospital life & community life. Ex. 13 & 14 ward at NIMHANS, Banglore. 4. Group homes: 15-20 recovered mentally ill patients (client) will be placed in this home.  They stay together & provides moral, emotional, & social to each other. 5. Foster homes

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 It is a social agency sponsored programme in which recovering patients are placed for family care.  This voluntary family is paid by social agency  This placement may be for short time or permanent. 6. Sheltered workshop  It is a work oriented rehabilitation facilities with a controlled working environment to fulfill the individual vocational goals.  Appropriate for those patient who find difficult to complete for employment. 7. Mental Health Emergency Care : Hotline : Telephone link  Walk-in-clinic – psychiatric emergency room (24 hrs.)  Home visits  Crisis intervention centre 8. Self help Groups  Group of patients having same mental illness Eg. Alcohol anonymous Group of MR patient 9. Evening/Night Hospital:  Evening hospital – provide mental health facilities on 5 evening of a week  Night hospital – for those patients who are unable to attend clinic due to job in day time.

Q.4

What are the role of nurse in community mental health services?

Ans.

Nurse can play an important role in linking the community services to the hospital. The following roles of nurse in community mental health services:-

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1. Consultative role 2. Clinician role/Practitioner role 3. Therapeutic role 4. Researcher role 5. Educator role 6. Liason role 7. Coordinator role 8. Domiciliary role 9. Manpower facilitator 10. Social skill training 11. Manger/istration role 12. Preventive role 13. Other role :  Assertiveness training to improve self confidence  Conducts groups meeting.  Carryout community outreach services.  Provide crisis intervention services. Q.5 What is preventive psychiatry? Ans.: Preventive psychiatry includes preventive measures at three levels. 1. Primary Prevention:  Means reducing incidence of mental illness by controlling the factors which cause mental illness.  It includes two component: Health promotion Specific protection 2. Secondary prevention :

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 Aims at early diagnosis and treatment of mental illness  It Includes following components : Screening of population Crisis intervention services Mental health education 3. Tertiary prevention: Aims at reduce the recurrence of mental illness & prevalence of residual defects or disability due to mental illness. It includes following components:  Intensive patient care  Rehabilitation services.  Follow up care of patient.  Interactional skill training  Recreational therapy  Individual & behaviour therapy Preventive psychiatry includes different preventive measures according to age of mental ill patient:1. Prevention during child hood 2. Prevention during adolescence 3. Prevention during Adulthood 4. Prevention during Old age

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Unit V

Psychiatric Nursing Management Q.1 Ans.

Define psychiatric nursing. Write the branches of Psychiatric Nursing. Psychiatric nursing : Mental health nursing or psychiatric nursing can be defined as a part of nursing where nurse uses herself, her knowledge of social and behaviour sciences and communication skills for the purpose of :  Promotion of mental health  Prevention of mental illness  Helping individual family and community to cope with mental disorders.

 It is a branch of medicine deal with diagnosis and treatment of mental illness. BRANCHES OF PSYCHIATRIC NURSING: 1. Community psychiatry 2. Forensic psychiatry 3. Cultural psychiatry 4. Geriatric psychiatry 5. Child psychiatry 6. Industrial psychiatry Q.2 Ans.: 1. 2. 3.

What are the principles of psychiatric nursing? Basic principles of MHN (Mental Health Nursing) are: To Provide a sense of individuality, safety & comfort to the patient. Economise her time & energy judiciously while nursing the patient. Maximum therapeutic intervention

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General principles are: 1. Accept the client exactly as he is : a) Being non-judgmental & Non punitive b) Sincerity & positive interest c) Recognizes & reflects on clients feelings, which he expresses. d) Be an active listener e) Purposeful conversation. 2. Self understanding will be used as a therapeutic tool 3. Be consistent while working with patient with behavioural problem 4. Give reassurance to the client in an acceptable and realistic manner 5. Modify client's behaviour through emotional experience. 6. Avoid unnecessary increase in patient's anxiety. 7. Maintain therapeutic nurse patient relationship (T-NPR). 8. Be maintained objectivity in understanding client's behavioural. 9. Avoid physical & verbal restrains 10. Continuous close observation. 11. Explained ward routines & procedures at the level of pt's understanding. 12. Use appropriate language. 13. Treat and respect the client as an individual & specificity in nature. Q.3 Ans.

Describe the role of Mental Health nurse in various setting? Mental Health nursing practice encomes various roles in different settings like community hospital, varied agencies, therapies, etc.

A. Role of nurse in mental hospital:1. Direct patient care 2. Education 3. Communication of interpersonal relationship

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4. Ward management 5. Role of nurse in psychotropic drugs 6. Role of nurse in psychotherapy :a. Nurse as a Psychotherapist b. Nurse as a parent substitute c. Nurse as a role model d. Nurse as a resource person e. Nurse as a er f. Nurse as a socializing agent g. Nurse as a communication h. Nurse as a counselor i. Nurse as a catalyst j. Nurse as a Occupational Therapist k. Nurse as a l. Nurse as a interpreter m. Nurse as a teacher or technician n. Role of nurse before during and after electro convulsive therapy (ECT)

B. Role of nurse in community setting : Main function of nurse in community setting are :1. Case finding 2. Assessment of individual needs 3. Consultation with other professionals 4. Involvement in individual, family and group therapy' 5. Co ordination of health services for individual and family 6. Establishment of therapeutic milieu 7. Function as client advocate

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8. Prevention of mental illness 9. Nurses' role in primary prevention, secondary prevention, tertiary prevention.

Q.4 Ans.

Define Therapeutic - Nurse Patient Relationship (T-NPR)? T-NPR :- Interaction occurs between two persons, the nurse who possesses the skills, abilities and resources to relieve the clients discomfort and assisting him to alleviate his existing problems. According to Webster new collegiate dictionary defines – "Relationship as character of being related or interrelated".

Q.5

What is the difference between therapeutic relationship and professional (social) relationship?

Ans. S.No.

Character

Therapeutic Relationship

1

Technique

Planned

2

Interaction time

Planned for specific time & place

3

Objective

Helping the patient

4

Duration

5

ability

 Depends on goal  time is limited Nurse focus on goal during relationship

6

Acceptance

7

Termination

Q.6 Ans.

Nurse accept the patient as "Here and Now" without attaching judgment & interest Planned and discuss with patient

What are essential qualities of T-NPR? Essential qualities of T-NPR:-

Professional Relationship It just happen with mutual interest May be planned & unplanned & by chance two people meet Satisfying needs of each other This varies & may last for years Both are responsible in this relationship Based on shared values and belief Relationship exist life long.

Mental Health & Psychiatric Nursing

1. Genuineness 2. Respecting the client 3. Empathy 4. Self-discipline 5. Sincerity 6. Role model 7. Good communication skills 8. Good observer 9. Show love & affection 10. Active listeners 11. Good speaker 12. Exploration of the problem (catharsis) 13. Immediacy 14. Trustful 15. Professionalism 16. Caring Q.7 Ans.

Why T-NPR is essential? T-NPR is essential: I. 1. Self realization, self acceptance and self respect. 2. Sense of personal identity and personal integration 3. An intimate interdependent and interpersonal relationship 4. Satisfying needs 5. Development goals. II. Nurse helps the patient to –  Cope with problems  Understand the problem

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 Face problem realistically  Find out alternate solution to problem  Tryout new pattern of behaviour  Communication freely  Socialize effectively  Find meaning in his/her illness. Q.8 Ans.

What are phase involved in establishing and maintaining the therapeutic relationship? T-NPR involves series of phases:T-NPR Phases

I. Pre-Interaction phase

II. Introductory or Orientation phase

III. Working phase

IV.Termination phase

Phases of T-NPR :Quality

Definition

Task :

PreInteraction phase Begins when a nurse assigned a patient before the nurse first with client.

1. Nurse explore her fear & anxiety. 2. Set objective for introductory

Introductory/ Orientation phase Begin when nurse goes to patient, introduce herself & get introduction about him.

1. Establishme nt of 2. Developmen t of an agreement or

Working phase

Termination phase (Resolution/End phase)

It starts when nurse and patient are able to overcome barrier of orientation phase. Nurse & patient actively works on meeting the goals.

Begins during orientation phase. In this nurse develop pact with patient

1. Nurse collect data and identifying nursing needs of patient. 2. Assist the patient to identify his problem. 3. Help the patient to socialize &

1. Bring a therapeutic end of T-NPR. 2. Establish reality of separation by attaining specific goals. 3. Feeling of rejection,

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III) Barriers

Q.9

phase. 3. Take help of clinical supervisory to overcome anxiety and fear.

pact 3. Talking with the patient

1. Improper self awareness and self analysis 2. Anxiety & fear towards the client 3. Unplanned goals 4. Uncertainty about her ability

1. Client display manipulative behavior 2. Social class of patient 3. Status of patient 4. Anxiety level of nurse/patient 5. Transference 6. Counter transference

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communicate. 4. Help the patient to find out alternate solution to problem, 5. Encourage the patient to use new pattern of behaviour. 6. Set goals for relation ship 7. Assist the patient to achieve his goal. 8. Encourage the pt. towards independency decision making ability.

loss of sadness & anger are expressed & explore. 4. Decrease patient dependency and increases with independency in his environment

1.

1. Develop termination 2. Develop sense of disappointment & feeling of sadness 3. Gift giving 4. Patient may like to telephone the nurse. 5. Develops negative self concept.

2.

3.

4.

Patient test the nurse in various situations. Nurse think that patient's progress is slow. Resistance to explore & to develop independency Fear of closeness with patient.

Define communication, therapeutic communication and communication skills?

Ans. Communication: Communication refers to the reciprocal exchange of information, ideas, belief, feeling and attitudes between persons or among a group of persons. It is goal directed process in which people use a system of symbols & signs to convey a message. Therapeutic Communication: The therapeutic interaction between the nurse and the client will be helpful to develop mutual understanding between two individuals. It occurs when the nurse exhibits empathy, utilize effective communication skills and responds to the client's thought, needs and concerns. Communication Skills:It is the ability or efficiency of the nurse to utilize their knowledge systematically and effectively

36

a) General ability: Ability to listen, interpret speak & express through writing. b) Special ability:  Ability to observe or interpret observation  Ability to ascertain  Ability to recognize when to speak, silent smile, interact  Ability to wait, proceed, speed  Ability to maintain T-NPR Q.10 What is communication process? Ans.: Communication Process: Communication is two way process (sender & receiver), multidisciplinary process, multistage process & goal directed process. Communication between two or more persons involves a series of steps & element this is known as communication process. In communication process, we will discuss: 1. Stages of communication process 2. Steps of communication process 3. Elements of communication process a) Stages of communication process (Multistage process) 1. Attention 2. Comprehension 3. Acceptance of the information 4. Retention & Action

B)

Steps of communication process: 1. Clear perception of the ideas, information or problems 2. Participation of other in the decision 3. Transmission of ideas or message 4. Ensuring that the receiver of the message acts & behave as derived by the sender. 5. Ascertaining the effectiveness of communication

Mental Health & Psychiatric Nursing

C)

37

Element:

Stimulus Need for information, comfort, advice etc.

Source / Sender

Ideas,

Encoding

Message filter

Can be : -

symbols

Through personal

– Suggestion

Factors

– Order

Channels

– Request

Speech, written

– Instruction

Message, gesture

Decoding

Receiver

Feed back Receiver agree with

Message

Message

evaluated

Disagree with message

through

Needs classification

personal

Provides information

Factor

38

Q. 11 Classify the communication?

Ans. Communication

On the basis of relationship

On the basis of flow

Formal

Informal

Communication

Communication

On the basis of expression

Verbal Communication

Upward communication

Downward Communication

Nonverbal Communication

Lateral/Horizontal communication

Spoken/oral

Written

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39

Unit IV

Mental Disorders and nursing interventions Q.1

What are common causes of mental illness or mental disorder?

Ans:

As there are many causes for single effect (Mental Retardation caused by gentio, birth injury etc) and single cause for several effects (Parental neglect leads to behaviour disorder, Suicide, depression etc.) Many causes are responsible for mental disorders which are classified as: Causes of mental Disorder

Predisposing

Precipitating

Perpetuating

Abnormal

Factor

Factor

Factor

Behaviour

1. Genetic factor 2. Obstetric Complication a. Antenatal b. Intra natal c. Postnatal 3. Personality

1. Physical Factor 2. Psychological 3. Social Factor

1. Isolation 1. Biological factor 2. Social withdrawal 2. psychosocial factor 3. Socio-cultural factor 4. Neuro biological factors

40

Diagrammatic presentation of causes of abnormal behaviour :-

Mono Amines Amino Acids Peptides

i. Neuro biological factors

ii. Biological Factors

Genetic factor Constitutional factor Physical handicap Physical deprivation Emotional factors

CAUSES OF ABNORMAL BEHAVIOR

iii.Social cultural factor War & violence group prejudice economic and employment problem technological & social changes

iv. Psycho-Social factor Maternal deprivation Pathogenic family Pattern Pathogenic IPR Stress

Mental Health & Psychiatric Nursing

Q.2

Write the Classification of mental disorder?

Ans.

Major classification of mental disorder are :

41

1. International classification of diseases by WHO (ICD-10) 2. Diagnostic and statistical manual of mental classification (DSM-IV-TR) 3. Research diagnostic criteria (RDC) 4. ICMI – Indian classification of mental illness. 1. International classification of diseases: 

Organic, including sympathetic, mental disorders. (F00-F09)



Mental & behavioural disorder due to psychoactive substance use (f10-f19)



Schizophrenia, schizotypal & delusional disorders (F20-F29)



Mood (affective) disorder (F30-F39)



Neurotic, stress related & somatoform disorders (F40-F49)



Behavioural syndromes associated with psychological disturbances and physical factors (F50-59)



Disorder of adult personality & behaviour (F60-F69)



Mental retardation (F70-F79)



Disorder of psychological development (F80–F89)



Behaviour & emotional disorders with onset usually occurring in childhood and adolescence (F90-F98)



Unspecified mental disorder (F99)

2. Diagnostic & Statistical manual of mental classification: (DSM-IV) 

Clinical psychiatric diagnosis



Personality disorders and mental retardation



General medical condition



Psychosocial & environment problems.



Global Assessment of functioning

42

3. Research diagnostic criteria: (R&C) According to this, at least two of following symptoms for schizophrenic are essential :I. a. Withdrawal b. Delusions of being controlled c. Delusion other than persecution lasting at least one month d. Delusion accompanying hallucination of any type for at least one week. e. Current auditory hallucination II.

Period of illness lasing for at least 2 weeks.

III.

No manic or depressive symptoms

4. Indian classification of mental illness :

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43

Mental Illness

Organic disorder

Non-organic disorders

I. Dementia

II. Delirium

(Chronic brain syndrome)

(Acute brain syndrome) I. Psychosis

A. Psychotic (Adult) Disorder 1. Schizophrenia

B. Childhood Disorder 1. Mental disorder

2. Mood or Affective disorder , . Mania . Depression 3. Psychosexual

2. Developmental

. Disorder 4. Substance abuse disorder

Disorders 3. Adolescence

a. Alcohol abuse

disorder

b. Drug abuse 5. Personality disorder 6. Psychosomatic disorder

Disorders

II. Neurosis

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Neuropsychiatric disorder

Functional disorder

Anxiety Disorder

(Hysteria)

Panic dis. Dissociative disorder

Conversion disorder

Dissociative Amnesia

Somatoforms disorder



Panic disorder

Dissociative Fugue

Body dimorphic disorder



Phobia

Somnambulism

Hypochondriasis



Post Traumatic Disorder

Depersonalization

Somatoform pain disorder



Obsessive Compulsive

Multiple personality

Conversion Disorder

Q.3 Ans.

Neurosis 

Hypochondriasis



Neurasthenia



Depersonalization

What is the different between the organic psychosis and functional psychosis?

S.No. Organic Psychosis 1 Impairment of brain tissue function due to head injury, toxic condition, encephalitis, brain tumour. Systemic infection etc. 2 Disturbance Of consciousness 3 Disturbance Of Memory, Orientation & Intelligence Present 4 Visual hallucination 5 Emotional incontinence 6 Deterioration of personal & social 7 Physical examination reveals clinical features of systemic disease.

Functional Psychosis Caused by : Biological factor Psychological factor Socio Culture factor Very rare Markedly affected Auditory hallucination Rare It is uncommon. Physical examination of patient usually reveal no abnormality which can explain mental illness

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9

Psychological test – BGT – Bender Gestalt test positive. Laboratory & Radiological diagnosis as EEG help in determining the etiological factor responsible for psychosis

Q.4

What is the difference between the psychosis and neurosis?

8

BGT Negative These reveals no specific abnormality

S.No. Psychosis 1 Definition: Very severe illness of personality - Impairment of ego function 46 reality besting is highly impaired Grave maladjustment to life 2

3 4

5

6

7

Etiology: – Biological factor – Psychosocial factor – Socio culture factor Personality disintegration–total Defense mechanism: – Denial (Run from reality) – Regression – Identification – Introjections (Self analysis)

Clinical Features : - Impaired ego function - Loss of reality testing - Loss of insight - Loss of judgment - Presence of illusion & hallucination - Memory marked affected - Impaired attention - Intelligence absent - Orientation absent - Disturbance in consciousness - Disturbance of thinking - More behavioural change - Social relationship affected - Vocational, Social, Sexual, Adjustment markedly impaired Treatment: - Hospitalization present - ECT - Psychotherapy - Psychotropic drugs

Prognosis: - Bad prognosis - Recurrence common

Neurosis Definition : – Mild to moderate illness of personality – Ego function & reality testing is not affected much. – maladjustment to life is limited Etiology : – Mainly due to psychological factor Personality disintegration–partial Defense mechanism: – Repression – Suppression – Conversion – Substitution – Reaction formation – Displacement – Undoing Clinical Features - Ego function affected much - Not much affected - Insight present - Not lost - Absent illusion & hallucination - Memory present - Attention present - Not affected intelligence - Present Orientation - Consciousness - No disturbance in thinking - Minor behavioural change - Not affected - Not markedly Impaired

Treatment : - No need hospitalization - No ECT - Psychotherapy useful - Psychotropic drug

Prognosis : - Good prognosis - Recurrence less

Mental Health & Psychiatric Nursing

Q.5 What is the difference between the delirium and dementia? Ans.:

47

48 S.No. Delirium 1 Etiology Intracranial : Tumour, Injury, Epilepsy

(ii) (iii) (iv) (v)

Metabolic : Acidosis/alkalosis Endocrinal causes Nutritional deficiency Example Vitamin B Drugs – Alcohol use, digitalis, bromide

Dementia Etiology i. De-generative brain diseases : - Alzheimer’s disease - Pick's disease - Huntington chorea - Parkinson's disease Cerebral Arteriosclerosis Drugs Brain pathology Other - Co-poisoning - Vitamin deficiency - Hypercholesterolemia - diabetes - Koraskoff disease [Delirium + thiamine deficiency] - Wernick disease

(vi)

Systemic deficiency example TB, Septicemia (vii) Others – post operative care – circulatory disturbance 2 Course – reversible 3 Onset – Acute 4 Duration – few days 5 Clinical features:(i) Clouded of consciousness (ii) Impaired memory (iii)

Orientation present

(iv) (v) (vi) (vii) (viii)

Illusion, hallucination & delusion present Emotions – labile mood Inappropriate or violent behaviour Intelligence deterioration Other – reasoning ability & judgment impaired

course – irreversible onset – chronic Duration – Months Clinical features:No clouded of consciousness Recent memory impairment is greater than remote memory Orientation absent (First involve time) Very rarely Loss of emotional control Indecent behaviour Present Intelligence Other : Neglect personal hygiene, Anxiety, depression, loss of learning, reasoning.

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Q.6 Define personality disorder? Ans.: Personality disorders is defined as any deviation in personality traits from the normal that they interfere with his well being or adjustment to society and require psychiatric attention. Personality disorders is different from mental illness. The symptoms of mental illness are mostly episodic & not continuous and starts from adolescence or even before. It is commonly found in 18-40 years age. Q.7 Ans.

Mention the different types of personality disorders? Personality disorders can be classified into four groups. Personality disorder

Withdrawn Dependent Personality disorder Personality Disorder

Inhibited personality disorder

Anti-Social Personality disorder

1. Schizotypal 2. Schizoid 3. Paranoid

1. Hypochondrial 2. Depressive 3. Obsessive Compulsive

1. Histrionic 2. Impulsive 3. Borderline 4. Narcissitic

1. Anxious 2. Dependent 3. Aggressive

Other types of personality disorder : 1. Cyclothymic Personality disorder 2. Hypomanic 3. Melancholic 4. Expolsive 5. Inadequate Personality

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Q.8

What is the sign and symptoms of psychiatric illness? OR What are types of deviation from normal behaviour?

Ans. Deviation from normal behaviour

Disturbance Of conscio-usness

Disorders of motor Activity

Confusion Clouding of consciousness Stupor Coma Delirium Dream State Somnolence

Disorder of Perception

Disorders of Through

Disorder of Affecter or Mood

Illusion Hallucination

Disorder of memory Disorder of or intelligence orientation

Hyper Amnesia Amnesia Paramnesia Dejavu Dementia Jamisvu

II. Disorder of motor activity

Increased activity (Over Activity)

Dysactivity

Repetitious Behaviour

Compulsion

Negativism

Stereotype Activity

Automatic behaviour 1 Echoprexia 2. Echolalia

Stereotype Position

Stereotype Movement

Stereotype Speech

Waxy flexibility Catalepsy

Mannerism

Verbigeration

Decreased activity

Violence

Suicide

Agitation

Tics

Mental Health & Psychiatric Nursing

III.

Disorder of perception

Illusion

Auditory

visual

Gustatory

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Hallucination

Olfactory

Tactile

Kinesthetic

Hypnogogic

Hypnosomatic

IV. Disorder of Thought

At Formation level

At progression (Association) level

At content level

1. Autistic thinking 2. Derestic Thinking

Structure

Speed of association Type of Association

of Association 1. Magical Thinking 1. Neologism

Flight of ideas

Motor aphasia

2. Poverty of

2. Word salad

Clang association

Sensory aphasia

content

3. Circumstantiality Blocking of through Nominal aphasia

of speech

4. Tangentiality

Thought retardation

Syntactical

3. Overvalued

5. Perseveration

Poverty of speech

aphasia

ideas

6. Irrelevant answer

4 Delusion

7. Lossening of association

5. Obsession

8. Derailment

6. Phobia 7. Hypochondriasis

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V. Disorder of affect

Pleasurable affect

Unpleasurable affect

Other affect

Euphoria

Depression

– Anxiety

Elation

Grief and Mourning

– Apathy

Exhaltation

– Panic

Ecstasy

– Inappropriate affect – Ambivalence – Depersonalization – Mood swing

Q.9 Define delusion. Mention the types of delusion? Ans. Delusion is defined as false, fixed unshakable belief, not in accordance with one's intelligence socio cultural and educational back ground. For example : Sitting in a classroom as a student, thinking that he is the prime minister of the county or he is supreme or god. Types of Delusion : 1. Bizarre delusion 2. Delusion of grandeur 3. Delusion of self accusation 4. Delusion of control 5. Delusion of persecution 6. Delusion of reference 7. Delusion of jealousy/infidelity 8. Encapsulated delusion 9. Nihilistic delusion 10. Delusion of worthlessness and property

Mental Health & Psychiatric Nursing

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11. Delusion of thought possession 12. Hypochondrial delusion 13. Sexual delusion 14. Religious delusion 15. Delusion of loving 16. Delusion of influence 17. Delusion of dysmorphophobia 18. Erotic delusion 19. Somatic delusion

Q.10 What do you mean by phobia? Ans. Phobia is an exaggerated pathological fear of a specific type of stimulus or situation The fear that a person feels in the presence of particular object or experience. An irritational fear of an object/situation that persist, although the person may recognize it as unreasonable Types of phobia : 1. Acrophobia –– Fear of heights 2. Agoraphobia –– Fear of Open spaces 3. Astraphobia –– Fear of Electrical Storms 4. Claustrophobia –– Fear of Closed Spaces 5. Haematophobia –– Fear of blood 6. Hydrophobia –– Fear of water 7. Monophobia –– Fear of being alone 8. Mysophobia –– Fear of dirt/germ 9. Nyctophobia –– Fear of darkness 10. Pyrophobia –– Fear of fires 11. Social phobia –– Fear of situation in which one might be criticized; fear of making a fool of one self; 12. Xenophobia – Fear of Strangers

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13. Zoophobia – Fear of animals

Q.11 Define Schizophrenia? Ans.: In 1911, Eugene Bleuler, a Swiss psychiatrist explain the schizophrenia, which is combination of two Greek words schizo means split and phrenic means mind. In other words schizophrenia means splitting of mind. Split occurred between the cognitive and emotional aspect of the personality. According to ICD 10 & DSM-IV Schizophrenia is a group of disorders manifested by fundamental disturbances in thinking, mood (affect), behavior (BAT) last for at least a month of active phase symptoms. – Disturbance in thinking is marked by alteration of concept formation which may lead to misinterpretation of reality hallucinations and delusions. – Mood changes includes ambivalent constricted and inappropriate responsiveness or blunted affect and lack of empathy with other. – Behaviour may be withdrawn regressive and bizarre.

Q.12 How schizophrenia is classified? Ans. No accurate classification is possible because symptoms of one type of schizophrenia may be observed in another type. Schizophrenia

Typical Schizophrenia

Simple

Hebephrenic Catatonic Paranoid Undifferentiated or mixed Simple Classification according to ICD-10 (F20-29) F 20 – Paranoid F 21 Hebephrenic – F 22 Catatonic – F 23 Undifferentiated –

Atypical Schizophrenia

Juvenile Late Schizoaffective Latent Residual Psychosis

Mental Health & Psychiatric Nursing

F 24 F 25 F 26 F 28 F 29

– – – – –

Post Schizophrenic depression Residual Schizophrenia Simple Schizophrenia Other Schizophrenia Unspecified Schizophrenia

Q.13 State the clinical features of schizophrenia? Ans.

Bleuler has explained : –

Primary/Fundamental symptoms

–

Secondary/Accessory symptoms

According to recent concept : –

Positive symptoms

–

Negative symptoms

Positive Symptoms : 

Aggression



Agitation



Delusion



Excitement



Grandiosity



Bizarre behaiour



Conceptual disorganization



Hallucination



Hostility



Suspiciousness

Negative symptoms :  Apathy 

Blunted affect



Diminished Emotional Responsiveness



Stereotype thinking

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56



Social withdrawal



Lack of spontanity



Avolition



Detachment Primary/Fundamental Symptoms (Bleuler 4 A's)

Associative disturbance

Autism

Affective Incongruity or Inappropriate Mood

Ambivalence

Secondary/accessory symptoms

Disorder Disorder Or of Perception activity

Disorder of thought

1 Hallucination Negativism (Auditory automatism Visual or Echolalia Gustatory) Echopraxia 2 Illusion Mannerism Mutism Stupor Waxy flexibility Catatonic Excitement

Deterio rated Appearance Manner

Delusion Self-care (Grandiosity & grooming persecution become reference) minimum Depersonalization Incoherence Neologism Clang association Perseveration

Disturbance Disturbance in in Attention behavior

Client is unable to held attention for long time

Insight

Agitation Severly bizarre affected Suicidal and homicidal tendencies Sexual over activity criminal behaviour violent Assaultive & destructive behavior

Q.14 How schizophrenic patients are managed? Ans. Treatment of schizophrenia depends upon the type of schizophrenia:1. Prevention of schizophrenia : by reducing etiological factors 2. Chemotherapy drugs  Sedative is indicated when patient is excited and restless  Hypnotics when patient is sleepless

disturbances will

Blunting of will power (anergia) Aloofness (avoiding mixing with friend & family) Inability to take decisions

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 Neuroleptics antipsychotics such as :

3.

–

Clozapine

–

Sulpride

–

Risperidone

–

Phenothiazines

–

Antiparkinsonian drugs

Electro – conclusive therapy : (ECT)  Indicated when patient with severe schizophrenia  About 10-12 ECT in 4-6 weels

4.

Intense Psychotherapy : Indicated in  Early schizophrenia  Maintenance & rehabilitation of recovered patient  Psychotherapy are given follows:i.

Individual psychotherapy

ii.

ive psychotherapy

iii.

Group psychotherapy

iv.

Behavioural psychotherapy

v.

Occupational psychotherapy

vi.

Recreational psychotherapy

vii.

Social psychotherapy

viii.

Milieu therapy

ix.

Family therapy

5.

Psycho education

6.

Rehabilitation

Q.15 Define Manic-Depressive Psychosis (MDP) Ans.: MDP is characterized by recurrent episodes of mania and depression in the same patient at different times.

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MDP is a mood disorder that is characterized by a severe disturbance of mood manifested as elation and depression. Q.16 What are the criteria to define mania and depression? Ans.: Criteria to define mania (Triad Symptoms) :1. Elevation of mood  Euphoria 

Elation



Exaltation



Ecstasy

2. Increase pressure of speech :  Flight of ideas 

Increase tone of speech



More talkative



Delusion of grandeur



Increase self esteem

3.

Increase psychomotor activity 

Over activeness



Restlessness



Person wants to keep himself busy



Unusually alert



Try to do many things at a time

Criteria to define depression (Triad symptoms):1. Sadness of mood (Depressive mood) A. Mild depression – sensitivity to criticism, – Lack of confidence B. Acute/severe depression 

Head fixed face immobile



Look fixedly downwards

Mental Health & Psychiatric Nursing



Social withdrawal



Persistent sadness



Hypochondrial ideas

C. Depressive stupor : 

Intense form of depression



Clouding of consciousness



Marked ideas of death

2. Poverty of ideas : 

Retarded thinking



Difficulty in thinking



Death of thought



Delusion of nihilism



Suicidal of ideas



Feeling of hopelessness

3. Decrease Psychomotor activity : 

Reduce energy level



Negativism



Delusion of guilt



Frustration in day to day activity

Q.17 How will you classify the mood disorder ?

59

60

Ans.: I. Classification Mood disorder

Manic-depressive psychosis (MDP)

Manic type

II.

depressive type

Involution psychotic reaction

circular type

Classification of Mood disorder

Unipolar disorder

Bipolor disorder

Only attack of depression

Bipolar I

Bipolar II

Episode of severe

Episode of depression Episode of major

Mania and

& Hypomania

depression

Bipolar III

depression

Mental Health & Psychiatric Nursing

III. According to ICD10 classification of mood disorder – (F30-F39) F 30

–

Manic episode

F 31

–

Bipolar affective disorder

F 32

–

Depressive episode

F 33

–

Recurrent depressive disorder

F 34

–

Persistent mood disorder

F 38

–

Other mood disorder

F 39

–

Unspecified mood disorder

Q.18 What are the treatment modalities available for depression? Ans.: 1. Hospitalization : indicated in Severe attack of depression Suicidal & homicidal tendencies Stupor condition of patient Psychotic & delusional depression 2. Electro convulsive therapy : Total 6-8 Ect 3 in Ist Week 2 in IInd Week 1 in IIIrd Week

3. Drugs : a) Sedatives –– if patient agitated b) Hypnotics - if insomnia present

61

62

c) Tranquillizers: – Meprobamate 200-400 mg – Chlordizepoxide 10-20 mg – Diazepam 5-10 mg T.D.S. If patient is anxious d) Neuroleptics - if patient agitated and anxious –

Chlorpromazine hydrochloride

e) Antidepressant drugs : –

Tricycle & Tetracyclic compounds Such as immipremine, hydrochloride



–

amitryptiline Hydrochloride

–

Trimipramine

–

Mianserin

MAO (Mono amino oxide) inhibitors like phenelezine. It is more powerful anti

depressant drug 

Recently more specific drugs are : –

Aminiptine

–

Fluoxetine

–

Amoxopine

–

Tradozone

Psychotherapy : 

Cognitive & behaviour therapy



Analytical psychotherapy



Occupational psychotherapy



Work therapy



Art therapy



Music therapy



Interpersonal therapy

Mental Health & Psychiatric Nursing



63

Family therapy

Q.19 Define anxiety disorders ? Ans.

Anxiety disorder are psychological disturbance where anxiety is the essential symptoms anxiety is a normal phenomena. Every normal person experience anxiety. But when it cause excessive tension out of proportion & interfere with physical & mental activities is known as pathological anxiety. Anxiety reaction is a neurotic state of chronic apprehension with recurrence of acute anxiety symptoms.

Q.20 Define obsessive compulsive neurosis (OCN) ? Ans.: It is a psychiatric neurotic disorder in which obsession & compulsion are a significant source of distress and interfere with an individual ability to function. Obsession:- Recurrent & persistent unwelcome ideas & impulses or images. They interfere with individual mind again and again in a stereotype from. Patient does not enjoy getting those ideas. Thoughts, images or impulses are not simply excessive worries about real life problems. They appear senseless to the individual. He actually feel miserable and guilty. Compulsion:- Repetitive stereotype behavioural or mental acts that person feels driven to perform in response to an obsession to relive tention even though they are recognized senseless by the individual. Eg. Hand washing, checking, counting.

Q.21 What do you mean by Hysteria? Ans.

It is a neurotic disorder characterized by :

64

 Hysterionic behaviour  Suggestibility (susceptible against any suggestion)  Transformation of an unconscious conflict into physical symptoms  Emotional outbursts  Repressed anxiety It is of two types:Hysteria

Somatoform disorder 1. Body dysmorphic disorder 2. Hypochondriasis 3. Somatoform pair disorder 4. Conversion disorder

Dissociative disorder 1. Dissociative amnesia a. Circumscribed amnesia b. Selective amnesia c. Continuous Amnesia d. Generalized 2. Dissociative fugue 3. Somnambulism 4. Depersonalization 5. Multiple personality

Q.22. What is psychosomatic disorder ? Ans: It is also called psycho physiological disorder : It is characterized by physical symptoms resulting from psychological factor (emotional stress) usually involving one system of body under voluntary control: Types – 1. GIT – Peptic ulcer, Anorexia nervosa 2. CVS : Hypertension, Ischemic heart disease 3. Endocrine system – Diabetes, thyrotoxicosis 4. Genito urinary system – Impotence, menstrual disorder 5. Respiratory system – Asthma 6. Integumentary - Psoriasis 7. Musculoskeletan System – Arthritis, backache 8. Others – headache, migraine Q.23 Define alcoholism? Ans.: Alcohol has been used for countries to obtain relief from discomfort & tention. Alcoholisms or alcohol abuse disorder is defined as chronic dependence of alcohol characterized by excessive and compulsive drinking that produces disturbances in mental or cognitive level of functioning which interferes with social and economic functioning : Alcoholism results due to

Mental Health & Psychiatric Nursing

– Excessive consumption – Alcohol related disability – Problem drinking – Alcohol dependence

Q.24 Mention the certain special alcohol withdrawal syndrome? Ans.: 1. Simple withdrawal syndrome : 

Mild tremors



Nausea & vomiting



Weakness



Irritability



Insomnia



Anxiety



Tachycardia



Hypertension



Impaired attention

2. Delirium tremens 3. Pathological darkness (Acute Alcoholic Psychosis) 4. Delirium 5. Alcoholic seizures 6. Alcoholic Hallucination 7. Dipsomania 8. Alcoholic paranoia 9. Dementia 10. Wernick's syndrome 11. korsakow's syndrome

65

66

Q.25 How the psychoactive substances are classified? Ans.: Psychoactive substances

Narcotics

– Opium & its derivatives Eg. Opium, heroin, morphine, Codeine – Synthetic Narcotics Such as methadone

Sedative Stimulants & Depressant –Ethyl alohol –sedative/ hypnotics Eg. Barbiturates Nindral Dalmane Doriden

Hallucinogens

– Amphetamines – Cocaine

Minor Tranquilizers

–Cannabis eg ganja, charas, bhang, hashish –other LSD: Lysergic Acid Diethylemide

–Maprobamate –Diazepain –Chlordiazepoxide

Q.26 Define substance abuse/drug dependent? Ans. Drug abuse/psychoactive substance abuse: It is a term applied to pathological use of persistent or sporadic drugs with impairment social & occupational functioning and a minimum duration of disturbance of at least one month. The substance abuse leads to many psychological dependence :1. Psychological dependence results in drug seeking behaviour 2. An inability to stop using the drug to physical dependence on the drug & tolerance to its effect. 3. Continuous substance use results in physical & mental deterioration. Drug Dependence: a maladaptive pattern of substance use leading to significant impairment or distress as manifested by :Tolerance withdrawal symptoms

Mental Health & Psychiatric Nursing

67

Frequent pre-occupation with seeking or taking the substance Often takes the substance in larger amount or over a longer period Often takes the substances to relieve or avoid withdrawal symptoms. Q.27 Define childhood disorder? Ans.: Childhood Disorder:Nursing personnel find various childhood & adolescent problems while working in a hospital as well as in a community setting. Disorders of psychological development & behaviour & emotional disorders with onset usually occurring in childhood & adolescence. The development phase from infancy to childhood is a significant period to prevent a number of behavioural and other problems. Childhood Disorders

Developme ntal

Disorders

Disruptive Behavioural Disorder

1. Mental retardation 2. Pervasive disordersa. autistic disorder b. childhood autism c. childhood psychosis d. pseudo defective psychosis 3. Specific development disordersa. Specific reading disorder b. Specific arithmetic disorder c. specific development disorder of speech & language d. Specific developmental disorder of motor function.

Anxiety Disorder of Childhood

1. Attention deficit hyperactive disorder (ADHD) 2. conduct disorder

Eating disorders

1. Separation anxiety disorder 2. avoidant Disorder 3. Overanxious disorder

General Identity disorder of childhood

1.Anorexia nervosa 2.bulimia nervosa 3. pica 4. rumination disorder of infancy

To disorder

Elimination disorder

1.Trans Sexuliasn 2. Gender identity disorder of childhood

1.Eneuresi s 2.Encopre sis

Autistic disorder

Speech disorder

Other disorder

Stuttering

Childhood Schizophrenia

Q.28 Mention the sleep disorders? Ans.: Sleep can be regarded as a physiological reversible reduction of conscious awareness. Sleep deprivation is pressing health problem. If a person is not sleeping continuously for few days or nights, it is harmful to his health.

Temper tantrum

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Types of sleep disorders

Primary Sleep Disorders

Secondary Sleep disorder

(only sign & symptoms of abnormality)

(Clinical problem accompanied by specific or nonspecific disturbance)

 Cateplexy  Insomnia  Hypersomnia  Narcolepsy  Nightmares  Night terrors

 Alcoholism  Anorexia nervosa  Depression  Hyperthyroidism  Hypothyroidism  Schizophrenia

Parasomnias (Walking up during sleep)

Bruxisam Nocturnal Eneuresis Sleep talking Sleep Walking

Insomnia quantitative and qualitative insufficient Sleep based On the individual Need.

 Sleep onset Insomnia  Frequent Nocturnal awakening  Early morning awakening

Q.29 Classify the psycho sexual disorders? Ans.: Psychosexual Disorder

Sexual dysfunction Not caused by organic Disorder

Sexual inadequacies

Gender identify disorder or Trans sexualism

In male

In female

Erectile Impotence Premature Ejaculation

Frigidity Vaginismus :Involuntary Contraction of vaginal introits at penetration

Disorder of sexual preference Fetishism Transvestism Exhibitionism Voyuerism Paedophillia Sadism Masochism

Sexual orientation disorder Homosexuality

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Unit VII Bio Psychosocial Therapies Q.1 What is psychotropic drugs/psychopharmacology? Ans. Psychotropic drug/psychoactive drugs is one which has mainly effect on the behaviour experience and other psychological functions and will be used to treat psychiatric condition. The psychoactive drugs will have specific purpose and action, work on client symptoms rather than diagnosis. Psychoactive durgs are classified into five groups : 1. Antipsychotic Drugs 2. Anti parkinsonian agents 3. Antimanic Drugs 4. Anti depressant drugs 5. Anti anxiety drugs, Sedative and Hypnotics Q.2 What are common antipsychotic drugs used? Ans.: It is also known as neuroleptic drugs or major tranquilizers and used in the treatment of psychosis. Classification of antipsychotic drugs:-

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Antipsychotic Drugs

Conventional Antipsychotic drugs

Phenothiazines

Atypical antipsychotics Es. Clozapin Risperidone

Thioxanthene

Chlorpromazine Perphenazine Fluphenazine Trifluperazine Prochorperazine Thioridazine Mesoridazine

Thio-thexene Fluphenthixol

New generation Antipsychotic Drugs Eg. Aripiprazole

Butyrophenones

Dibenzazepines

Dihydroindolane

Haloperidol (Haldol)

Loxapine Olanzapine

Molindone (Morban)

Q.3 What are the indications & contraindication's of antipsychotic drugs? Ans: Indications of antipsychotic drugs:1. Schizophrenia 2. Paranoid disorder 3. Mania 4. Organic psychosis :

Delirium Dementia

Contraindication:1. Children under 3 Yrs. Of age 2. Comatose patient

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3. Drug hypersensitivity 4. Severe depression 5. Other contraindications : 

History of epilepsy



Pregnancy



Parkinson disease



Peptic ulcer

Q.4 Explain extra pyramidal symptoms (EPS) ? Ans. It is the CNS side effect of antipsychotic agents. It includes : 1. Parkinsonism: Akinetic form Agitating form 2. Akathisia 3. Dystonia 4. Tardive dyskinesia 5. Neuroleptic malignant syndrome (NMS)

1. Parkinsonism : It occurs in 40 percent of patient with EPS It occurs one week after treatment It is of two types : (A) Akinetic form : a. Impairment in masticating movement b. Weakness c. Muscle pain d. Fatigue (B) Agitating form:

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a) Muscle rigidity b) Motor retardation c) Mask like face d) Shuffling gait e) Slurred speech f) Salivation g) Tremors

2. Akathisia: Most common  Most common  Occurs in 50 % patient  Occurs two weeks after treatment  It includes –

Difficulty in sitting skill or rest

–

Strong urge to move about (walking and talking)

–

Anxious and agitated

– 3. Dystonia: Occurs in 6 % of patient Occurs within few minutes of medicine It includesa. respiratory difficulties b. Rapidly developing contractions of muscle of tongue jaw, neck (producing torticolis) and extra ocular muscles, c. occulogyric crisis (torticolis & extra ocular muscles) d. Opisthotonous e. It is painful and gives a frightened experience to patient. 4. Tardive dyskinesia :

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It is most severe condition Occur in 3% patient Occurs after sudden termination or reduction of antipsychotic after long term high dose therapy Features :Involuntary rhythmic stereotype movement Protrusion of tongue Gritting of teeth Lip snaking Puffing of cheek Note: This condition is non-treatable. C. Neuroleptic maligment syndrome (NMS) : – It is fatal and rare condition. – It may develop within hour or after year of continuous drug use. – Features Hyperpyrexia Muscle rigidity Altered consciousness Tremors Unstable Blood Pressure Increases W.B.C.

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Q.5 Classify anti parkinsonian agents ? Ans.: These drugs are used for treatment of EPS (extra pyramidal syndrome) Antiparkinsonian Drugs

AntiCholinergic drugs

Agents :Benztropine Biperiden, HCL Procyclidine HCL Promethazine

Dopamine Agonists

Carbidopa Livo dopa Bromocriptine

Antihistamine

blockers

Muscle relaxant

Anti dopaminargic

Dantrolene

Reserpine

Diphenhydramine

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Q.6 Ans.

Write down about indication, Contraindications and action of anti manic drugs? Anti manic drugs are also called mood stabilizers.

Indications : 1. Mania 2. Manic Depressive Psychosis (MDP-Bipolar disorder) 3. Hypomania 4. Recurrent depression 5. Alcoholism 6. Schizo – affective disorder Contraindication :1. Side – effect of renal, CVS, liver and respiratory system 2. Thyroid disorder (Hypothyroidism) 3. Diuretic potent 4. Dehydration 5. Child below 12 yrs. Age 6. Parkinsonism 7. Obesity 8. High grade fever Mode of action: It reduces the level of nor-epinephrine and serotonin or catecholamine.

Q.7

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Classify the anti manic drugs?

Ans.: 1. Lithium carbonate (Lithane) 2. Anti convulsant/anti epileptic drugs :– Carbamazapine – Sodium Valporate 4. Gabapentine

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Q.8 Write a short note on lithium toxicity? Ans. Cade has describe the usage of lithium carbonate in treating mental illness. lithium causes less drowsiness while controlling the marked psychomotor over activity because of its toxicity. Lithium toxicity: 1. Mild toxicity (Lithium level – 1-2.5 m Eq/l) :- Diarrhea, nausea, vomiting, drowsiness, muscular weakness, tremors, ataxia, cardiac arrhythmias, allergic reactions, blurred vision, glycosurea, polyurea. 2. Severe toxicity : Cerebellar ataxia, seizures, hypotension and coma. 3. Chronic istration of lithium carbonate: Goiter, leucocytosis, and embryo toxicity. Note: Normal lithium level: 0.5, 1.5 mg/t Q.9

What are the indications, contraindications and mode of action of anti depressant drugs? Ans: It is also called mood elevators. Indications: 1. Major depressive illness 2. MDP depressive phase of bipolor disorder 3. Anxiety 4. Psychotic depression 5. Obsessive compulsive disorder 6. Migraine headaches 7. Panic disorders 8. Eating disorder (bullemia) 9. ADHD in children 10. Sleep apnoea 11. Cataplexy

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Contraindications: 1. Increase manic and psychotic episode of MDP. 2. CVS problem (arrhythmias) 3. Liver problem Mode of action: It acts by accelerate (increase level of) receptors of nor epinephrine and serotonin in the central nervous system and reduce anxiety. Q.10 How will you classify the antidepressant drugs? Ans.: Anti depressant drugs

Tricylic Antidepressant

Tetra cyclic antidepressant

MAO Inhibitors

Sympatho Mimetic Stimulant

Imipramine Tri-imipramine Clonipramine Amitriptyline Doxepine Nortriptyline

Mianserin maprotiline

Phenezine Isocarbaxazid Tranylcypromine

Dextroam Phetamine

Q.11 Ans.

Write is detail about anxiolytic drugs (anti-anxiety drugs). ? It is also called minor tranquillizers

Indications : 1. Anxiety disorder/Panic disorder 2. Insomnia 3. Obsessive compulsive disorder 4. Depression 5. Alcohol withdrawal symptoms.

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6. Convulsions 7. Induce sleep pre-operatively. Contraindications: Patent with renal, liver, respiratory impairment and hepatic failure. Mode of action: It acts by increasing GABA activity that can cause decrease activity of neurotransmitter in brain results in decrease neural activity. 1. Tolerance/physical or psychological dependence 2. Inhibited behaviour 3. Memory disturbances: Anterograde & retrograde 4. CNS depression : Drowsiness Poor co ordination Clouded sensorium Confusion Ataxia due to cerebellar action 5. Sexual dysfunction : Erectile and ejaculatory disturbance 6. Miscellanceous : Lethargy Impaired psychomotor disturbance Blurring vision Gastric Upset Urinary incontinence Nightmares Depression Aggression

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Headache Hypotension Bodyache Impotence

Nurses' role in providing ant anxiety drugs to the patient's 1. Assessment of patient prior to the use of anxiolytic drugs. 2. Appropriate nursing measures to induce sleep should be taken such calm & quiet environment 3. While istrating the drug daily dose should be given at bed time to promote a normal sleep pattern. 4. Look for side effects, record & report immediately if any occurs. 5. Give IM injection deep into muscles to prevent irritation. 6. Instruct the patient not to take any stimulants like coffee, alcohol. 7. Avoid excessive use of these drugs to prevent the onset of substance abuse. 8. Don't stop drug abruptly but it should be reduced gradually 9. For IV istration, do not mix with any other drug and give slowly. 10. Monitor vital signs during IV istration. 11. ister with food to minimize gastric irritation.

Q.12 What are the common side effects of psychotropic drugs? Ans.: There are following systemic side effects of psychotropic drugs : 1. CNS & ANS : CNS : 

Drowsiness

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

Confusion



Tremors



Convulsion



Ataxia

ANS : 

Dry mouth



Tinnitus

Note : EPS (Extra Pyramidal Syndrome) : In antipsychotic drugs

2. Cardio-vascular system (CVS) 

Tachycardia



Orthostatic Hypotension



Arrhythmia

Note : Bradycardia : In Antimanic drugs Palpitation : In anti anxiety drugs

3.

Hematopoietic System : 

Agranulocytosis



Leukopenia



Leukocytosis

4.

Endocrine System : 

Amenorrhea



Breast enlargement



Impotency



Change in Libido

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

Galactcorrhoea



Gynaecomostia



Hyperglycemia

5. Gastro Intestinal tract : 

Constipation



Diarrhea



Anorexia



Nausea



Vomiting



Weight gain



Jaundice

Note : Weight gain : In antipsychotic and antimanic drugs 6.

Hepatic side effect : Liver toxicity

7.

Ocular effect :  Blurring of Vision  Dilated Pupils  Retinopathy 7. Allergic effect : 

Dermatitis



Rash



Itching



Alopecia

8. Urinary system: 

Urinary Retention



Oliguria



Polyuria

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Q.13 Write in detail about nursing care of patient receiving psychotropic drugs? Ans.: Psychotropic drugs are used to treat the signs and symptoms of mental illness. But all behavioural problem are not treated by the drugs. The treatment is based on the thorough psychiatric evaluation of the patient. Before istering any drug, the nurse should know about the drugs that is half life period and after dose, the side effect of drug, age of the patient, to know the liver metabolites and kidney excretion etc Nurse's Role: I.

General Role : 1. No drug should be istered without prescription 2. Do not leave the patient alone until the drug is swallowed 3. Do not allow patient to carry medicine to another patient. 4. Keep safety measures. 5. Give a glass of water after medicine. 6. Do not leave the drug tray within reach of patient. 7. All medicine given must be recovered on patient chart. 8. Do not force the patient orally. 9. Check drug daily for any change for colour order. 10. Drug bottle should be properly labeled . 11. Drug cupboard are always to be kept locked when not in use. 12. Nurse should know side effect indication and contraindication of drug. 13. Nurse must know the legal aspect.

II) Specific Role : 1. Close observation 2. Decrease EPS with antiparikinsonian drugs.

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3. While istrating drug, if any doubt arises without hesitation nurse should consult with doctor. 4. Observe drowsiness, sore throat, fever 5. Record blood pressure. 6. Provider good oral hygiene to reduce dry month. 7. Weight recording and low salt in case of anti-psychotic/anti manic drugs. 8. Discourage the patient to take antacids as they cause decrease absorption. 9. Maintain intake/output chart 10. Advice to protect the skin. 11. Record in client's chart about which drug istered; if any side effects observed. 12. Nurse need to have an effective drug attitude. 13. Nurse has to be familiar with regular usage of drugs, their actions, side effects and they hold responsibility while istering to avoid errors. 14. Uses a variety of techniques with different clients in different situations. 15. While istering the drug, confirm the client by calling their name. 16. While istering lithium, complete investigation as urine analysis, BUN creatinine electrolytes, 24 hrs creatinine clearance, thyroid test etc should be checked. 17. Every 3 month, lithium level to be checked. 18. Blood level of lithium is tested 12 hrs after last dose. The therapeutic level should always be maintained 0.6-1.4 m Eq/lt. 19. While istering MAOI, caution should be taken food substances, as cheese, pickle, beer, red, wine chicken, liver, overripe fruit, banana peel, yoghurt and some medications as cold medication, nasal and sinus decongestants, narcotics, local anesthetics, epinephrine, cocaine, amphetamine should be avoided

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20. While istering anxiolytic/hypnotic, care to be taken to avoid addiction and not to disturb usual sleep pattern. For children, special care should be taken especially while istering hypnotics and lithium. 21. In antipsychotic drugs, ask the client to take sugar free fluids and eating sugar free hard candy to ease dry mouth. 22. Avoid calorie beverages and candy to avoid weight gain. 23. Usage of sunscreen lotion to overcome photosensitivity 24. Advice the patient not to increase/decrease stop drug without doctor permission. 25. Find out menstrual changes in female. 26. Advice not to get up quickly from lying down to sitting position. 27. Do not give medicine in empty stomach as patient complain nausea and vomiting. Q.14 Define psychotherapy, write down the goals, indications, contraindications, advantages and disadvantages of psychotherapy? Ans.: Definition of Psychotherapy: Psychotherapy is a treatment use for patient with emotional and mental disorder in which the basic concept of therapeutic nurse patient relationship is maintained between nurse and patient. The purpose of this is to modified/remove and reduce the factors causing disturb behaviour. Certain psychological processes are used for the treatment of emotional a problem in which professionally trained person deliberately establishes therapeutic relationship. According to psychiatric glossary: A process in which a person who wishes to relieve symptoms or resolve problem in living or seeking personal growth, inter act with a psychotherapist in a explicate/implicate manner. Goals of psychotherapy: 1. To achieve remission of symptoms 2. To modify disturbed pattern of behaviour 3. To strengthen the ego 4. To improve growth & development of the client. 5. Modify environment causing maladaptive behaviour. 6. Improve IPR skills.

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7. To produce deeper insight 8. To develop positive attitude 9. To modify deviated personality, thereby develops positive personality 10. To correct psychopathology 11. To helping the patient to over comes a feeling of handicap. Indicated of Psychotherapy 1. First choice for neurotic illness 2.

Very useful in psychosomatic illness.

3. Schizophrenia 4. Mania, depression 5. Alcoholism 6. Drug addiction 7. Sexual deviation 8. Personality & character disorder 9. Childhood disorder 10. Marital disharmony Contraindications 1. Severe psychotic illness 2. Unresponsive, unmotivated and in cooperated patient. 3. Violent/ excitement 4. Unconscious patient 5. Assaultive and destructive behaviour 6. Negativism 7. Organic Psychosis 8. Psychotic Depression 9. Group psychotherapy in hysteria and hypochondriasis. Advantages:

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1. Reduce intensity of symptoms 2. Increase working ability 3. Increase adjustment in various condition 4. Increase understanding situation, self confidence, of request 5. Start goal directed activity 6. Bring positive mood changes 7. Reduce maladaptive behaviour Disadvantages 1. Time consuming 2. Ineffectiveness caused waste of mental power 3. Inappropriate for who give best response to ECT and drugs 4. Patient become excessively depends on therapy and therapist

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Q.15

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How will you classify the psychotherapy?

Ans. Psychotherapy

According to depth of probing In the unconscious mind

Superficial or short term (ive psychotherapy)

Deep or long term (analytical psychotherapy)

Psycho-Educative (Group Discussion)

According to No. of patient treated in any one therapeutic session

Counseling I. Individual Psychotherapy – Psychoanalysis – Hypnosis – Abreaction – Reality – Insight – ive therapy  Mental Ventilation  Persuasion  Re-education  Re-Assurance  Suggestion II. Group therapy III. Behavioral psychotherapy  Systematic desensitization  Flooding  Aversion therapy,  Assertive therapy  Modelling  Shaping  Cognitive behavior therapy  Token economy IV. Inter personal psychotherapy  Marital therapy  Family therapy V. Other psychotherapy:  Therapeutic Community/Milieu therapy  Attitude therapy  Activity therapy Recreational therapy Occupational therapy Play therapy Art therapy Music therapy Dance therapy Education therapy

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Q.16 What are the role of nurse in psychotherapy? Ans: Nurses role in psychotherapy : Nurse plays various roles during psychotherapy 1. Nurse psychotherapist 2. Nurse as a parent substitute 3. Nurse as a role model 4. Nurse as a resource person 5. Nurse as a er 6. Nurse as a socializing agents 7. Nurse as a communication 8. Nurse as a counselor 9. Nurse as a catalyst 10. Nurse as a occupational therapist 11. Nurse as a 12. Nurse as a interpreter 13. Nurse as a teacher 14. Nurse as a technician Following are the responsibilities of a nurse during psychotherapy :– Nurse should be a good listener –

Should be have patience, sympathetic & tact full.

–

Should understand the patient's family & cultural background

–

Should not be upset with patient's irritational behavior

–

Should not show counter transference during psychotherapy

–

Nurse should have an interest in patient's problem

–

Manipulate environment according to type of patient.

–

Nurse should be non-judgmental o Good listener o Trustful

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o Attractive o Patience –

Nurse should maintain T-NPR

–

Accept the patient as unique individual

–

Nurse should encourage the patient for involvement in psychotherapy

–

Nurse must know proper knowledge of different types of psychiatric illness

–

In occupational therapy, nurse help the patient to teach new skills related to as a job.

–

Demonstration to the nursing students.

Q.17 What do you know about individual psychotherapy? Ans.: Individual Psychotherapy : It is a method of bringing about change in a person by exploring his or her feelings attitudes, thinking and behaviour. Therapy is conducted on a one to one basis, that is the therapist treats one patient at a time. This therapy helps to: 1. Understand themselves and their behaviour. 2. Make personal changes 3. Improve interpersonal relationship 4. Get relief from emotional pain or unhappiness. Indication: –

Stress related disorder

–

Alchohol and drug dependence

–

Sexual disorder

–

Marital disharmony

Types of individual psychotherapy: 1. Psychoanalysis 2. Hypnosis or hypnotherapy 3. Abreaction

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4. Reality therapy 5. Uncovering or insight psychotherapy 6. ive psychotherapy : o Mental ventilation o Environmental modification o Persuasion o Re-education o Re-assurance o Suggestion

Q.18 Define group therapy. Write in detail about the objective, types of groups, steps & merits and demerits of group therapy. Ans.: Definition : Group therapy is a mean of psychotherapy of psychological problem in which a group of patients is provided psychotherapy by a group of psychiatrist as well as the patient interact with each other & help in problem solving. Description: 1. Group therapy is less time consuming 2. Group consist of 8-10 patient. 3. Session of psychotherapy are held once in a week & generally continue for 12-18 months. 4. Duration of session longer than individual therapy. It is one or two hour. 5. It uses many type of psychotherapy technique. 6. The patient in group generally have some problem eg. alcoholic patient. Objective: 1. The member of group gain personal insight 2. The group member Improve their IPR

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3. The patient can change their destructive behaviour & can modify their behavior. 4. The patient can share their intimate feelings, ideas, experiences. 5. It provide an environment of mutual respect that further improve respect & self understanding. Types of Groups 1. Therapeutic groups: It is groups of patient. This group works together under the guidance of a therapist to improve the mental health usually the patient self help group. 2. Adjunctive group: It is not the group of patient’s it helps the other selective group of patient by providing stimulation as music therapy, art therapy & dance therapy. 3. Traditional group: The of traditional group are patient from hospital in patient department. The method of psychotherapy are lecture film show. The therapist first says few words & then allows the patient to interact with each other. 4. Non- traditional group: It is also called psychodrama. In this the group member act out various drama based upon situation. This role play helps him in expression of feeling, idea. 5. Encounter Group /"T" Group (Training Group): In this group, the focus is on the expression & feeling of people that remain unexpressed. It is not necessary for a group of member by ill patient. The inter action between member of encounter groups is more intense or rapid. 6. Homogenous group: The of homogenous are similar on basis of sex, age, race, socio economical level in society etc.

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7. Heterogeneous group: The group member does not have similarity on basis of sex, age, socio-economic in society. It is just opposite to homogenous group. 8. Open or close group: In open group member are free to or leave the group at any time. Closed group have certain number, certain duration. Patient can not or leave the group any time. 9. Group according To mental illness: The group classified according to their nature of illness. Psychotic group Neurotic group 10. Psychodrama group : The group acts event from the life of one member.

Steps of group therapy: 1. Pre-interaction phase: 

Determination of physical set up



Determination of place & time



Determination of types of group



Determination of session no. & no of group member.

2. Initial/orientation phase : 

Introduction of group member To each other



Introduction of member To therapist



Instruction of group member



Selection of group member



Selection of group leader



Preparation of environment for problem solving

3. Working phase : 

Problem solving with mutual understanding & co operation

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

Resolving of internal conflict



Role distribution to group member



Development of "we feeling"

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4. Termination phase : 

Evaluation of group experiences



Evaluation of result

Merits of group therapy: 1. This method is cost effective. Many patients can be treated by this therapy at a time. 2. Group member learn new method of problem solving through this therapy 3. It provides opportunity to know about the problem of other patients. It reduces their feeling of hospitality loneliness. 4. Group therapy provides a safe environment for communication. 5. Group therapy provide an opportunity for patient to play a functional role. Patient work as a co-therapist with therapist. Demerits: 1. It is not appropriate for those patient who keep hesitation & unable to communicate properly. 2. In group therapy patient loses his privacy because patient’s personal emotional problem are discusses in open.

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Q.19 Explain behaviour therapy. Ans.  Definition : Behaviour therapy is a type of psychotherapy that is based upon learning theory & it focuses at changing or modifying the maladaptive behaviour. 

Behaviour therapy is a type of psychotherapy in which conversational interchange is the primary vehicle used to treat people with problems.



Behaviour therapy is more action – oriented, directed towards changing specific types of maladaptive Behaviour.

Concept of behaviour therapy: 1. Most abnormal behaviour are acquired & maintain as normal behaviour. 2. Abnormal behaviour can be modified through social learning principles. 3. People are best known by their behaviour in life situations. 4. The treatment method should be precisely specified according to behaviour & should be objectively evaluated. Indications: It is the treatment of choice in: 

Anxiety



Phobia



Obsessive compulsive disorder



Hysteria



Nocturnal enuresis

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

Sexual disorder



Thumb sucking/nail biting/tics



Migraine



Anorexia nervosa



Bulimia nervosa



Obesity



Psycho – somatic disorder

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Contra Indications: Psychotic disorder that have acute pervasive symptoms and in which reinforcement is not applicable Steps: it has 3 steps 1. Training of relaxation technique before the main therapy. 2. Hierarchy formation - Patient is asked to construct a hierarchy of anxiety causing stimulus. 3. Systemic desensitization:It is done in two ways: (a) SD-1 the stimulus is confronted in imagination (b) SD-2 The stimulus is confronted in reality

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Q.20 Write a short note on occupational therapy. Ans. Introduction: Occupational therapy is a rehabilitation therapy. In occupational therapy, focus is laid upon the use of activities of as treatment medium. Its short term goal is improvement of quality of life & long term goal is rehabilitation. Definition:  Any activity which engages a person's resources of time, energy & is composed of skills and value. –"REED & SENDER SON".  Any goal directed activity meaningful to the individual providing to him about his worth & value as an individual & about his inter relatedness to other–"JOHNSON". Objectives: The major goals of patient in rehabilitation: 1. To assess need of patient 2. To identify the skills of the patient 3. To remove or modify mal adaptive behaviour 4. To improve mood & reduce, anxiety 5. To role performance 6. To stimulate self confidence 7. To give opportunity for self expression 8. To reverse psychopathology 9. To increase socialization & communication 10. To improve old skills & acquire new ones.

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Basic Requirement: 1. Knowledge levels of patient 2. Background of patient 3. Psychological problem/diagnosis. 4. Capacity or skills of patient. 5. Therapeutic nurse patient Relationship. 6. Interest of patient. 7. Continuous evaluation of progress. Type of activity in occupation therapy :  Craft work  Needle and tailoring work  Basket making  Carpentry  Gardening  Painting  Mat weaving  Cooking Various setting in occupation therapy : 1. Psychiatric hospital 2. Nursing home 3. Psycho-social rehabilitation centre 4. Physical rehabilitation centre 5. Sheltered workshop 6. Community group homes. 7. Community mental health centre 8. Day care centers 9. Half way homes

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10. De-addition centers

Process of occupation therapy: Initial evaluation of pt. Development of short term & long term objective Development of therapy plan Implementation of plan Continuous monitoring of progress Call for reviews meeting with patient & staff Resetting of new goals Discharge planning of patient.

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Q.21 Write a short note on aversion therapy ? Ans. Version Therapy: Indication: Alcohol dependence Homosexuality Child disorder Principle: Principle of this therapy is the pairing of the pleasant stimulus (eg - alcohol) with an unpleasant response. This pairing convert the pleasant into unpleasant stimulus after the therapy is over.  20-40 session are given.  Duration of session is about 1 hour 

Booster sessions are given after completion of treatment.

E.g. : Pairing of alcohol [pleasant] with drug appmorphine disulfirum (unpleasant) Thumb sucking (pleasant) with low voltage. Electric current (unpleasant) Q.22 Discuss about the family therapy? Ans: Family Therapy Definition : It is a type of psychotherapy which involve both parents together with child, Grand parents & other member of extended family. Objective : The main objective of family therapy is to improve – family functioning & to help the identified patient The other goals are :  To improve communication among family member.  To reduce conflict between parent or member  To reduce distress in the suffering member of the family  To determine role of each member & establish agreement about roles.  To provide sufficient autonomy for each member Indication: It is mainly used for young people in family, who have :  Communication problem 

Substance abuse

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

Conduct disorder



Role identify difficulty



Depression



Anorexia nervosa



Relapse in schizophrenia

Approaches in family therapy : 1. Psychodynamic 2. Structural Approach 3. Systemic approach 4. Electric approach

1. Psychodynamic: This approach is based on this concept that the entire family problem arise from past experiences of each member & unconscious conflicts. The therapist helps to gain insight that how their own problems, unconscious conflict effect the inter relations. 2. Systemic Approach: It concentrates on the present problems rather than past experiences. This therapy has 5-10 session with interval of month long. The therapist arrange family interview to assess the family disagreement, ways of communication. 3. Structural approach: The term family structure refers to the hierarchy in the family & to a set of unspoken rules regarding task & responsibility. Eg. Usually in every family both parents have more authority & responsibility. In this therapy, the therapist identifies the rules which be family tension & try to bring about changes.

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4. Elective family therapy: It is a short term method planned to bring about restricted changes in the family. It also concentrates on the present situation of family & the way of communication. Q.23 Write a short note on activity therapy? Ans. Activity therapy: Many patients in psychiatric hospital spend their energy in destructive activities. For example: manic, violent patient: An activity therapy is an effort to re-direct their energy into useful or meaningful activity. The example of activity therapies are: 1. Occupational therapy 2. Recreational therapy 3. Play therapy 4. Biblio therapy 5. Dance– therapy 6.

Art therapy

7. Education therapy

Aims of activity therapy: 1

to facilitate emotional expression.

2

To improve interaction & communication.

3

To provide outlet for aggressive feelings.

4

To release tension and pent up emotions.

5

To increase attention span and concentration power.

6

To improve cognitive skills. E.g. Learning, listening.

7

To increase self confidence and feeling of self worth.

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1. Recreational Therapy: It is a type of divisional therapy that encourage social interaction as well as it increase physical confidence & feeling of self worth. It provide activities that are enjoyable & self satisfying. 2. Play therapy: Play therapy is emerged out of efforts to apply psycho dynamic therapy to children because children are not able to talk about their problems. They also lack the capabilities for insight & self scrutiny. Through play, children often express their feeling, fear, and emotions providing a clear picture of their problems. Thus it has diagnostic functions also. 3. Education therapy: Education therapy is helpful when the problems arise out of inadequate knowledge & misconceptions. In this therapy provide enough knowledge about the disease, its causes, and its prognosis and treatment modalities. This therapy is centered upon both patient and her family. This knowledge may help in eliminating the psychological problems 4. Bibilo Therapy: Biblio therapy means treatment through reading In this therapy patient is encourages to use library facilities Sometimes reading about other emotionally disturbed patients and experiment of other may have therapeutic effect. It is also a diversion therapy as well as it promote and sustain mental health. 5. Music/Dance/Art Therapy: Music/dance and any form of art promote emotional expression. It also promotes physical integration. The art & like poetry, drama act as catharsis (emotional release). Q.24 Define ECT. What are the types of ECT techniques/methods, indication contraindications, complications of ECT? Ans. Electro Convulsive Therapy: It is a painless form of electric therapy primarily used for patients with depression and schizophrenic disorders. Definition: ECT is a physical/somatic therapy in which with the help of two electrodes, current is ed through the temporal region in between the two hemisphere of the brain, to produce a grand mal type of seizures.

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Cerleti and bini are the first neuropsychiatric who used ECT in 1937. Method/Techniques of ECT : ECT can be given by direct or indirect method. I. Direct ECT ECT has been used directly on the patient. The patient is istered atropine subcutaneously (SC) 0.6 mg to 1.0 mg, half an hour before the treatment or IV immediately before the treatment minor tranquilizers like calmpose is also used. A gland mal seizure is induced in the patient by ing an electric current through the temporal lobe Atropine prolongs the period of disorientation after the seizures. It also reduces vomiting. Immediately after The ECT treatment appropriate resuscitative and other emergency management equipment and supplies are kept ready A skilled person & nurse to resuscitate the patient should be available. ECT given by this technique causes a lot of anxiety to the patient. II.

Indirect/Modified ECT : ECT is modified with the use of anesthesia, muscle relaxant & oxygenation. Anesthesia is necessary to allay anxiety & achieve the maximum effect, avoid compilation, modify the force of convulsion.

Placement of Electrode : The location of electrode depends on the unilateral or bilateral ECT. Bilaterally, ECT involves the placement of electrodes in the bitemporal region. To minimize post convulsive confusion & amnesia, unilateral ECT has been devised in which electrodes are placed so as to avoid the dominant temporal area.

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Amount of current : The nature and range of a stimulus intensity setting varies from device to device. 70 to 1.50 volts for .1 to 1 sec. will produce a convulsive effect. The actual amount, range from 200-600 milliamphers

No. & frequency of ECT treatment: 5-10 treatment for bipolar disorders, manic type, schizoaffective disorder or catatonic schizophrenia. 20 to 25 treatment may required for chronically ill schizophrenic patient. ECT can be given 3 times a week.

Preparation of patient for ECT 1.

Patient is called for ECT accompanied by his relatives.

2.

Starvation of the patient for at least 5 hours is necessary. Longer starvation is desirable

3.

Informed consent of the patient & the relatives for the treatment is obtained. The patient & the relatives are explained the risks & complications of treatment before obtaining the consent. Complete physical examination is absolutely necessary.

X-ray of the chest haemogram urine analysis and ECG should be given whenever indicated. 4. Removal of denture if any is desirable 5. Mouth gag is put resting on the 3rd molar to prevent the tongue bite, cheek bite and lip bite. 6. Physical restraints may be necessary to prevent powerful jerky movement of the body. 7. The patient lies down comfortable on a bed in a supine position. Observation following the ECT

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The patient must be observed for at least half an hour after the treatment is given. The production of gland mal seizure is necessary. In direct ECT, the tonic phase i.e. muscle contraction last for 10 sec. approximately. The clonic phase i.e. movement or convulsions last for 2530 sec. approximately. Then patent goes into relaxation phase. Pulse & respiration recorded every 15 min. The patient should be prevented from fall & injury. If the patient become excited & rowdy IM inj. 8-10 ml of paraldehyde or 50-100 mg. if chlorpromazine or diazepam 5-10 ml have to be given to control the patient.

Indication of ECT : The indication of ECT depends upon the availability and non-availability of psychotropic drugs. The common condition for ECT are : 1. Major depressive episode is primary indication – 80 90 patient. 2. Involutional melancholia – 80-90 % 3. Depression Suicidal & stuporous patient Endogenous depression of moderate to severe degree. Delusional & psychotic depression Unipolar - bipolor depression Post partum depression Depression of old age as long as there is no atherosclerosis & brain changes. 4. Manic phase (mania) 1. Severe attack 2. Delirium Mania

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3. Mania not responding to drug 4. Destructive & assaultive behaviour 5. Catatonia 6. Schizophrenia Catatonic & paranoid type Other type of schizophrenia not responding to other treatment 7. Schizophrenia form symptom in case of epilepsy, alcoholism & drug addiction 8. For symptomatic treatment of confusion in cases of organic psychosis like GPI, atherosclerotic psychosis, senile & pre-senile dementia. 9. Other responsive groups to ECT treatment. Premorbid personality Stupor (catatonic) Previous depressive episode Paranoid delusion Anorexia Early morning insomnia Weight loss Lack of concentration Ideas of guilt & worthlessness Note: ECT in not effectives in Reactive depression (Neurotic) Psychoneurosis, hysteria, hypochondrias, anxiety states. Schizophrenia only hebephrenic and simple Drug dependence

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Contraindication No absolute contraindication 1. Patient with increased I 2. Including tumors. 3. Hematomas 4. Subarachnoid hemorrhage 5. Presence of an acute MI, hypertension 6. Patient with cardiac disease, aneurysm , thrombophlebitis, bleeding disorders embolism 7. First trimester of pregnancy 8. Disease of bone like osteomalacia, fracture 9. Systemic disease involving heart, kidney, lung & other wise versa Complication or side effect : Complication may be reduced with modified ECT. Complications are few and rarely serious. Immediately after ECT body ache, headache, painful masticatory movement to drowsiness 1. Abrasions on the lip of tongue bite 2. Dislocations of ts like shoulder & temporomendibular. 3. Fracture of bones like spine of vertebra 4. Confusion & excitement 5. Dyspnea & Apnea 6. Cardiac irregularities including arrest Delayed Compilations i.e. after the patient had a few ECT. 1. Amnesia for recent events. 2. Confusional psychosis

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Impairment of memory may vary from mild tendency to forget name to sevre confusion. Neurological & cardiac complications are very rare. Q. Ans.

Describe the role of nurse before, during & after ECT. Role of nurse in ECT: ECT can be istered in hospital/clinic/nursing Home. It converts AC main supply into stimulus by using step down transformer. In hospital setting, nurse sees the set up of ECT.

Waiting/ Resting room : patient take rest before ECT Room should be calm with dim light & light colour of wall. Put some flower for pleasant feeling Some magazines managing to divert mind & decrease anxiety Preanaesthetic keep ready. ECT Room : (a) Article for patient comfort: Room must be near to the waiting room Bed side screen for privacy. Well padded low level bed with railings. (B) Article for patient preparation Small pillow to put under patient waist to prevent injury. Mouth gag [to prevent tongue bite & clear airway), curved tongue depressor, Endotracheal tube sterile catheter O2 cylinder & ambu bag. (C) Article for the procedure: Trolly with ECT machine in working condition Jelly for putting electrode Emergency drug

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Resuscitation tray Mouth wipes. B.P. apparatus, sterile syringe, spirit swab 3. Recovery Room Observation of vital sign Mouth wipe & toilet facilities 4. Role of nurse before ECT Thorough physical examination Informed consent NBM (Nothing by mouth) before treatment Remove metallic articles from body. Remove lipstick, nail polish Loosen the tight cloth Empty bowel & bladder Maintain personal hygiene Give premedication, atropine, calmpose Nurse should display a warm ive attitude. Take the patient to the waiting room 5. Role of nurse during ECT Transfer the patient on a well padded bed placed in supine position. Place tongue depressor in between teeth Give short acting anesthetic to the patient the shoulder or arm Restraint the thigh with the help of sheet Hyperextension of head with to the chin give few breath of O2 (Oxygen)

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Apply jelly on temporal region. Make observation of grandmal seizures. 6. Role of nurse after ECT Placed the patient on a side lying position on a railed cot. Observe & record vital sign. Transfer the patient to recovery room, only if he can answer a simple question. Observe patient condition in every 15 minute, once stabilized, then after 30 min. Allow the patient to take sleep for 30 minutes to 1 hour. Reassurance to patient. Reorient the patient to time, place & person. Note any injury or complain of pain. Encourage patient for bath & change cloth. Allow patient to take breakfast. Help the patient in ADL's (activity of daily livings). Make observation on any change.

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Unit-VIII

Forensic psychiatry/legal aspects Q.1 Ans.

How a mentally ill patient get itted in a mental hospital and how he get discharged? ission and discharge of the clients in a psychiatric unit/mental hospital is based on section 31,34 of Indian lunacy Act (ILA) 1912 later it was modified on 1st October, 1931. ission and discharge can be made in one of following: 1. ission procedure on voluntary basis : (a) For major client and desires to have ission into the mental hospital based on his suffering:He will approach medical superintendent of hospital, along with two visiting medical officers (who are appointed by state govt.) will observe the case, at their own discretion, they can it the case into the hospital, provided the client has to submit the filled up performa stating that he is interested to be itted. (b) For minor cases: the nearest guardian has to apply request for ission, medical officer within 24 hours of receipt such application can it the case cast into the hospital.

Discharge Procedure : (a) For major client: If he feels his condition is better, he can ask for discharge by writing a written notice of 24 hours. (b) For minor client: If minor attains "major" and "cured", he has to write an application. The medical superintendent will observe and decide whether he can be discharged or not, within a month.

2. Reception order on petition under special circumstances:

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ission is made, if the family or the relatives of the patient have to submit the request or petition for ission of the client into mental hospital. The petitioner must be a major and personally observed the client within 14 days of making the petition. Petition Has to be written on a special form, denoting all the particulars of an individual which has to be ed by two medical certificate (one form greeted govt. medical officer and other from ed medical practitioner) Both medical officers have to

be

independently examine the "alleged lunatic" at different times and within 7 days of applying for reception order and have to certify that the lunatic needs ission and detained under care and treatment. The medical practitioner has to be very careful in giving a certificate in order to avoid legal complications for a wrong certification.

Discharge Procedure: In this clause, the clients can be itted for a period not exceeding 90 days. If relative feels that medical officer is misusing the lunatic, he can obtain permission from magistrate for discharge. The magistrate will the condition of the client through personal inquiry and if he satisfies, thinks that the client condition was improved, he recommends for discharge. The petitioner has to apply to the superintendent of the mental hospital for discharge. If the person is not dangerous and is fit to live safely, he can be discharged.

3. ission under temporary treatment order: It was mentioned is MHA sections 20, 21 of 1981. When there is risk to their own life or of others, magistrate will issue reception order. If medical officer

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in-charge feets that it is necessary to bring the legal authorities into the scene, he can apply to the magistrate or relatives can approach magistrate to issue an reception order for treatment. This order is valid for 6 months. In these cases only one medical certificate is required.

Discharge: After recovery, if medical officer feels he can be fit to live safely in the society, he will discharges.

4. ission and discharge procedure through magistrate: On receipts of petition by the relatives or the person who observed lunatic 14 days prior to petition or if lunatic is causing harm either to himself or the other. In these cases magistrate will inquiry in private and personally examines the alleged lunatic. If he is satisfied he will issue reception order, if he is not satisfies, he fixes a date for the consideration of the petition, in mean time he carries out further inquires until then, he will order for the safe custody of lunatic. If magistrate is not willing to issue an reception order and refuse the petition, he will give the probable reasons in writing and a copy will make the reception order often the medical in charge shows willingness to it the client and the petitioner would bear the maintenance cost. Discharge procedure : If he feels that client is having sound mind and capable of managing himself and his affairs. The magistrate will obtain consent of medical officer in charge regarding the soundness of the client to live safely in the society. 5. ission in emergencies (immediate restraint of the insane) : If insane is dangerous to himself or the other or likely to injure the property, he can be lawfully kept, consent of low full guardian may be obtained.

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If the mentally ill patient is very dangerous, and the medical officer in charge think that patient needs hospitalization, he can it the patient but within 72 hours. The patient need to be examined by the magistrate to produce a reception order.

Discharge procedure If the client condition improves, he can be able to take care and found to be sound, he will be discharged.

6. Reception order other than petition/ ission through police: Police officer can arrest any person, whom he believes to be a wandering, or a dangerous lunatic, the arrested person has to be produced before a magistrate. Magistrate will do personal inquiry and he asks the medical officer to examine a case. If he feels the necessity, he will it the case into hospital. After the reception order has been ed, the magistrate has to arrange for suitable place for detaining the lunatic, till he is transferred to a mental hospital. Discharge Procedure: For discharging the client, when family member or relatives agree in writing that they will take proper care and the client is found to be medically fit. 7. Reception order After Judicial inquisition: If a person is found lunatic after judicial inquisition, the high court or the district court has the authority to issue reception order to it the case into the mental hospital. Discharge procedure : If client is found to be medically fit and family agree that they will take care of client, he may be discharged. 8. Reception of criminal lunatic : A criminal lunatic has to be itted into a mental hospital on the order of the presiding officer or court. The criminal lunatic are to 3 types :

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1. Those who suffering with unsound mind and incapable of making their defense. 2. Those who committed the crime, but were acquitted on the ground of unsound mind at time of committing suicide. 3. Those who ed the disease after imprisonment. Discharge procedure: The visitors of the hospital has to report every 6 month once about the client's mental status and authority which has ordered detention. As soon as the client is fit to lead normative life they have to inform about the same to authority concerned. The person will be handed over to the prison officer for the further legal action. Q.2

What is Indian lunatic Act (ILA 1912) ?

Ans.: It is derived from English lunacy Act, 1890, contain eight chapters. ILA extends whole of India except Jammu and Kashmir in act no-4. Chapter I – Terminologies It contain some , preliminary conditions and its definition. Some of the used are: Asylum. Cost maintenance Lunatics Criminal Lunatics Reception order etc.

Chapter II ission and transfer procedure It describes voluntary ission, reception, order, through petition, ission of dangerous lunatic or criminal lunatics, transfer of lunatics from one state to other state with permission. Chapter III-Board of visitors

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State govt. will appoint board of visitors (at least 3 member’s one medical officer not necessary to have psychiatrist. Other two may by PSW or politicians)

It also deals about the treatment of client and his discharge. Chapter IV – The care of lunatic by family or relatives Court appeal by the lunatic or relatives for properties disbursement for a term not exceeding 5 yrs.

Chapter V Lunatic properties, court amendments for assessing, disbursement of properties Fine of Rs.500/- will be collected by manager of lunatic appointed by court, if he is not maintaining properly.

Chapter VI Establishment of Asylums Board of visitors has to conduct monthly visits and periodically they have to observe standard diet, medical checkup, parameters etc. and report it to govt.

Chapter VII Expenses of lunatics Asylums and state government will bear the expanses of lunatics.

Chapter VIII Rules State govt. will formulate rules related to : Prescribed forms for proceedings, place of detention and regulate the care and treatment of a person detained.

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Q.3 Write a short on Indian mental Health Act, 1987 (IMHA, 1987) ? Ans.: IMHA, 1987 is an amendment of Indian lunatic Act, 1912 Mental Health Act was introduced in Rajya Sabha in 1981, mental health bill no. XLI act 14 came into practice as a MHA from 22nd may 1987. Later government of India issued order that came in force with effect from April, 1 1993 in all state and union territories of India. It includes ten chapters. This act is applicable throughout India.

Objectives: 1. To formulate rules and regulation for the procedure related to ission and discharge of the client in psychiatric hospital units 2. To regulate establishment & maintenance charges of psychiatric hospitals 3. To provide facilities for establishing the guardianship of mentally ill, who are incapable of managing their own affairs. 4. Discarding custodial care, safeguarding mental patient from community and incorporating better provision relating to treatment & care. 5. Judicial safeguard for patient right to prevent any dignity or cruelty to mentally ill. 6. Introduces humanitarian consideration 7. To establish and coordinate the central and state authorities for mental health services. 8. To regulate the power of government for establishing, licensing and controlling psychiatric hospitals. Mental health act is divided in the ten chapters consisting 98 sections. Chapter-I Terminologies (preliminary) It deals with definitions related to mental health practice. Mentally ill person : A person who is in need of treatment of reasons of any mental disorder other than mental retardation. The lunatic changed into mentally ill person.

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Mentally ill prisoner: Criminal lunatics changed into mentally ill prisoner. Cost of maintenance: A mentally ill person itted in psychiatric hospital shall mean the cost of such items as per state government by general and special order specify in this behalf. Licensing authority: State govt. will appoint and authorized an inspective officers, who will have an authority to inspect any psychiatric hospital within the state and gives license under section 8. Licensee: The holder of a license: Licensed psychiatric hospital: Psychiatric hospital will be inspected and if it is appropriate to have the psychiatric unit facilities will be given permission to it and treat the psychiatric cases. Minor and major: Minor : client below age of 18 yrs. Major : Client above 18 yrs. Age. Reception order: Order made provision for the ission and detention of mentally ill persons in a psychiatric unit. Chapter II: Mental health authority It deals with establishment of central and state authorities for development regulation, direction and co – ordination of mental health services. Chapter III It provides guidelines for establishment and maintenance of psychiatric hospital. There is a provision of licensing authority who will process application for licenses. Valid license has to be reviewed every 5 yrs. Chapter IV It describes the procedures for ission and detention of the clients in psychiatric units Chapter V It deals with inspection, discharge, leave of absence and removal of mentally ill person. Chapter VI

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Judicial inquisition regarding alleged mentally ill persons possessing property, custody of his persons and management of his property court may appoint guardian to look after self and property. Chapter VII It deals with liability to meet the cost of maintenance of mentally ill person detained in psychiatric hospital or nursing homes. Chapter VIII It aimed at protection of human right of mentally ill person. No, mentally ill person during treatment will be subject during treatment to any indignity. Mentally ill persons under treatment cannot be used for research purpose, Unless it benefit him. Consent has to be obtained either from client or from relatives for discharge. No communication or no letter has to be sent to mentally ill cannot be read or interpreted or detained or destroyed. Chapter IX It deals with penalties and procedures for establishment of maintenance of psychiatric hospital or psychiatric nursing home. Chapter X It deals with provision for miscellaneous action. It deals with clarification pertaining to certain procedure to be followed by the medical officer incharge of the psychiatric hospital. The Medical Officer prepares the report of hospital operations every 6 months once and will send it to the authorities. Incharge Medical Officer is responsible for the supply of requisites (like food, sanitation etc) in the psychiatric hospitals, Q.4 what are the legel responsibilities of a nurse in care of mentally sick patient? Ans.: Legals responsibilities/legal aspect : A psychiatric nurse have many responsibilities while caring a psychiatric patient. She is responsible for providing quality nursing care to reduce malpractice litigation. Quality nursing care can only be legally proved by its accurate, complete documentation. So a psychiatric nurse has some legal responsibilities are as following :

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1. Collection of informed consent/substituted/consent:

mentally ill patient also

have right to informed consent before any nursing intervention for e.g.: before ECT. Concept can defense a nurse against litigation. Informed consent means the patients should: Have a clear and full understanding of the nature of illness to be treated. Should agree freely to receive the treatment Should know about the procedure available and their probable side effect. The competent to take decisions. When consent is refused: The consent may be refused by both competent and incompetent patient. Consent is refused by competent patient due to misunderstanding or fear about the illness and treatment. For this nurse should explain once made some patient continue to refuse the treatment. When consent is refused by incomplete patient there is provision for a form of proxy consent such as the application of a guardian. Situation when consent is not required: When death is likely to occur without intervention and there is doubt the competency of patient Substituted consent: In minor cases and involuntary ission and when patient is unable to understand their surroundings, the consent is obtained from another person or from court appointed guardian on behalf of patient. 2.

To maintain confidentiality : confidentiality is particularly important in psychiatric field become information in psychiatry is often collected about private matters.

Confidentiality in an issue that establish trust in nurse patient relationship. The principles related to confidentiality are : 1. The personal information must be safeguarded, records must to kept securely and unintentional disclosure should be avoided 2.

When there is need of disclosure, an informed consent should be taken for disclosure.

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3. The information can be shared with the parents who have a legal duty to act in their children's best interest 4. Patient's permission should be obtained before information in sought from other persons. 5. Patient should know from the start that information can be shared among the of health care team. 6. Rules of confidentiality can be breached in following condition: In patient's interest In the public interest For legal representatives 7. The patient should be told in advance about the special condition in which all the information may be revealed such as group therapy and family therapy. Census report Inter department report Special report on unusual condition of patient. Reports on mistakes. Reports on complaints Evaluation on report etc.

3. Protection of patient's right : It is the responsibility of nurse of protects the right of patients because the psychiatric patient are unable to protect their rights by themselves. The advocacy role of nurse is more important here than providing nursing care. Nurse have following responsibilities regarding protection of pt's right: 1. Nurse should discuss about right of patient within treatment team 2. Nurse should ensure that ward procedure and policy does not violet patient's right.

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3. Nurse

should

review

periodically the

mechanism

that

provides

right

ability. 4. Nurse should review periodically the rights & issues of violation 5. Nurse should know the right of psychiatric patient in specific condition for eg. Involuntary patient have limited right to refuse medication:

5. To keep knowledge about right of patient : A psychiatric nurse should have complete knowledge about the right of psychiatric patient. Right of psychiatric patients are : 1. The right to wear their own cloths 2. The right to see visitors everyday 3. Right to refuse ECT 4. Right to manage and dispose of property 5. Right to keep and use their own personal possessions, including toilet articles 6. Right to keep money for canteen expenses 7. Right to have ready access to letter writing material 8. Right to mail & receive unopened envelope. 9. Right to hold civil service status 10. Right to treatment in least restrictive setting. 6. Maintain standard of nursing care : American nurses association has formulated many standards to follow and to update her knowledge. This helps her to keep pace with the growing scientific world. Standard I – Theory (Appropriate & scientifically sound) Standard II : - Data collection

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a. Psychotherapeutic Intervention b. Health Education c. Self care activities d. Somatic therapies e. Therapeutic environment f. Psychotherapy Standard VI : Evaluation of her nursing action. Standard VII: Peer Review Standard VIII: Continuing Education/Action Standard IX : Interdisciplinary collaboration Standard X : Utilization of community health system Standard XI : Research

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Unit IX

Psychiatric emergencies and crises intervention Q.1 Ans:

Define psychiatric emergencies, write the classification of psychiatric emergencies. Emergency: It is situation in which immediate action is essential for the survival of system. Psychiatric Emergency : It is explained as a disturbance is behaviour, affect and thought (BAT) to that extent, that it needs immediate therapeutic intervention. It is defined as a sudden onset of an unusual disorder and socially inappropriate behaviour caused by an emotional situation. -"Bimla Kaooor, 2002"

Classification of Psychiatric Emergency

Psychiatric Emergency

Over activity/

Underactive

Over excitement

Patient

1. Violent 2. Anxious 3. Drunkenness 4. Drug withdrawal

Suicide

1. Depression 2. Catatonic stupor

Note : AIDS : Acquired immune deficiency syndrome Q.2

How will you manage the psychiatric emergency?

Others

1. AIDS associated 2. Adolescent crisis 3. Post partum psychosis

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Nurse have to assume overall in-charge for interventions and seeks guidance from the psychiatrist whenever necessary. Handle the case tactfully Provide calm & watchful environment Emergency cases has to be shifted as early as possible where he will be safeguarded against injury either to himself or to the others. Protect other patient. Encourage verbal expression of feeling. Provision of care in meeting the client's need accordingly. Use communication techniques Always remain with patient. Build trusting relationship with patient. Talk in simple language and slow volume. Do not threaten theater the patient but set limit on his behaviour Remain aware of pt's right, feeling & dignity Constant observation on patient activity Crises intervention Education to family and friends of patient.

Q.3 Ans.

Define suicide, what are the risk factors of suicide? Classify the suicide and how the patient with suicidal ideation be managed? Suicide: It is commonest psychiatric emergency It is act of killing on self. Patient's threats, gestures are always taken seriously.

Definition of suicide: "Aggression towards the self following the internalization of frustration or disappointment related to loved one". According to Clayton "Ultimate act of self destruction"

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Myths about suicide:Suicidal threat is just a bid for attention and should not taken seriously It is not harmful for a person to talk about suicide. Only psychotic person commit suicide. Nice home, good job, intact family prevent suicide. Risk factors of suicide: 1. Psychotic disorder : Schizophrenia Depression Alcoholism 2. Social Causes : Failure in exam Love failure Marital disput Social isolation Parental separation Family problem with substance abuse Lack of parental & maternal care More scholastic difficulty Unemployment of parents 3. Medical disorder : AIDS (Acquired Immune deficiency Syndrome) Cancer Estimation of lethality & degree of suicide

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High lethality

Low lethality

Use of gun

Wrist cutting

Hanging burning

Hypochondriasis

Jumping from a high building, Train

Inhaling domestic gas Mild depression

Classification of suicide : In 1951 E-mail Durkheim classified social categories of suicide: 1. Egoistic suicide: one who may lose social integration with their social group. 2. Altruistic suicide: Results from a response to a cultural expectation e.g. sathee sahagamanam which has followed in ancient India. 3. Anomic suicide: Occurs in response to the changes occurs in individual life. For e.g.: divorce, loss of job. 4. Sam sonic suicide of revenge: Experiencing as being unfriendly for e.g.: if the husbands is unfaithful to his wife. She may attempt to commit suicide to take revenge from him.

Management of suicidal patient: "When the firstly patient come in emergency main attention to stabilize physical conditions" then: 1. Inform psychiatrist 2. A taking psychiatric history 3. MSE 4. Past medical history of patient

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5. Continuous survey 6. Provide calm & safe environment to the patient. 7. ECT for major depression 8. Antidepressant for OPD patient. 9. Keep strict observation to prevent repeat attempt. Nursing management : 1. Make a treatment plan 2. Conduct suicide assessment, lethality plan 3. Engage the client in purposeful activities by diverting the mind. 4. Careful observation of client is needed in vulnerable time. 5. Provide symptomatic psychotherapeutic treatment. 6. ister the drug, if any prescribed. 7. Report to the team if any clues related to suicide are identified. 8. Encourage the client to develop optimistic ideas or sense of hope and self control. 9. Motivate the client to express his repressed feelings 10. Involve the family in provisions of care and guide them to provide situational . 11. All psychiatric drugs should be kept under lock 12. Patient should not left alone. 13. Constant observation on patient activity. 14. Give the patient opportunities to express feeling. 15. Remove object which might be used as a means of suicide. 16. Teach better problem solving techniques, alternative expression, sense of achievement in personal life, decision making ability and importance of positive self esteem.

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17. Encourage the client to explore his hobbies one by one, restart it constructively. 18. Staff has to be aware of problems raised by the client. 19. If client leave ward without intimation take immediate action. 20. Discharge plan has to be made in advance, inform follow up visits. Q.4

Define crisis, what are the types of crisis situation? Which types of techniques used in crisis intervention and describe nurses role in crisis intervention?

Ans. Crisis: In Chinese language crises word has two meaning: 1. Danger 2. Opportunity When people face problems which they are unable to solve by well tried defense mechanism, a brief psychotherapeutic intervention focus on the immediate crisis can be great assistance. Definition: 1. According to oxford English dictionary: crisis is " A time when a problem, great danger difficulty or uncertainty is at its worst points and needs immediate attention. 2. Crisis in an initial disturbance that results from a stressful event or perceived threat 3. "A sudden event that occurs in one's life, which disturbs the individual homeostasis and usual copying mechanism, will not resolve the problem. Classification/types of crises situation: Crises are classified in various types: 1. Development crisis/maturational crisis/Internal crisis: Erik H Erikson divided the whole life into eight development stages. When a person enters into next phase from one phase he goes through many emotional and psychological changes. This transition phase make work as a crisis for that person. For e.g.: Puberty, adolescence, adult, old, age menopause, pregnancy, retirement etc. Maturational, crisis involves how an individual will perceive themselves, their role and their status.

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2. Situation crisis/External crisis/Accidental crisis: If biopsychosocial equilibrium upsets because of external event or due to environment influence. It is sudden, unexpected onset for example : Death loved one Loss of employment An accident Marital disput Sexual assault Change in living place Severe suicidal ideation Loss of status an acute illness Loss of valued object Technological changes 3. Accidental crisis adventitious/community crisis: It is most common type, also called unexpected crisis, results in multiple loses may be because of environment changes. For Ex. Any Accident Severe illness Loss of both parents Natural disasters Tidal waves Nuclear war etc. 4. Crisis resulting from traumatic stress: It results when unexpected stress over which individual has little or no control. For e.g.: Rape Robbery Terrorism 5. 6.

Socio cultural crisis : For e.g. Discrimination between race & robbery Psychiatric emergencies :

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For e.g.:  Suicide  Addicts Techniques used in crises intervention: Aguilera modal of crises intervention:

Human being Stressor –––Balanced condition––– stresses

Imbalance state Felt need was not fulfilled To restore equilibrium

Presence of Balancing Factors

Absence of one of more balancing factor

Right perception of event

Wrong perception of event

Adequate situational

Inadequate situational

Resolution of problem

No resolution

Normal condition

Crisis

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Crisis Intervention: Crisis intervention is form of psychotherapy which includes ventilation, abreaction,. Resolving the conflict. It starts with identifying the problem & ends with helping the patient to understand the methods to solve them. Crisis intervention is type of brief psychological method of treatment in emotional crisis. Techniques: 1. Reassurance 2. Sedative/Hypnotics 3. Suggestion 4. Mental ventilation 5. Environmental modification 6. Behaviour modification 7. Abreaction 8. Providing 9. Clarification 10. Manipulation 11. Raising self-esteem 12. Exploration of situation 13. of defenses Role of nurse in crisis intervention: Nurse has the following role in the crisis intervention:  Establish trusting relationship with patient.  Actively listen the problem of patient and his family it is challenging but very important skill.  Encourage an honest disclosure, ensure confidentiality.  Do not attempt to avoid emotional reaction such as anger or crying.  A change in environment may serve to alleviate stress and may produce a sense of comfort.

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 the patient in use of defense mechanism that s an adaptive adjustment.  Never criticize the patient's method of coping at a time of crises.  Be aware of crisis groups or group in their local communities for reference purpose.  Use warmth, acceptance, empathy, reassurance to provide general of patient.  Use various techniques of crisis intervention.  Identify feeling of anger, guilt, and hopelessness and not to reinforce these feelings  Guide the patient through complete problem solving process. It may bring positive life changes.