Psychiatric Nursing

By: Million Tsegaw

(CLN,HO,MSC in ICCMH)
Wollo university, medical college of health
science,
department of psychiatry
Dessie, Ethiopia.
Oct.,2018.
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 Course information
 Course title: Psychiatric Nursing
 Credit hour: …….
 Course code: Nurs 4151
 Mode of delivery: Parallel
 Course instructor: Million T.
 Email address:[email protected]

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 Course Description
 This course is intended to help nursing students in
understanding human behavior and in
differentiating between normal and abnormal
behavior.
 It also will help students to develop skills in;
 therapeutic communication,
 establishing nurse- patient relationship,
 managing, supporting, and rehabilitating patients
with mental illness in the hospital and in the
community.

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 Course objective
After completing this course students will be
able to;
 Successfully identify/recognize mental health and
mental health problems.
 Properly apply nursing process for patients with
psychiatric disorders and develop skills of
therapeutic communications.

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 Supportive objectives
Up on completing this course, students will be
able to:
 Recognize mental health and mental illness in the
individual, in the health institution and in the
community.
 Identify factors contributing to mental health and
mental illness.
 Understand the classification of mental illness based
on DSM–5.
 Identify psychiatric disorders and provide treatments
in the health institutions and in the community.
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  Use of nursing process, to provide appropriate care
for mentally ill patients in the health institutions and
in the community.
 Demonstrate skills in therapeutic communications.
 Refer cases that require further investigation and
treatment.
 Teach the community about preventive, curative and
promotive aspects of mental health problems and
maintenance of mental health.

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 Teaching methods
 Interactive lecturing.
 Group discussion, seminar.
 Case study/Role-play.
 Group assignment.
 Supervised-practicum.
Teaching Aids
 Printed materials /Soft copies
 LCD projectors , computer
 Black &/whiteboards

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 Course Policy
 Attendance is mandatory(100%).
 Any absence without justifiable reasons will result
in the repetition of the course.
 Students must do given assignments on time. Late
assignment submission will not be accepted.
 Students must do their own work. Cheating or
Plagiarism will result in disqualification of the
result.

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 Mode of evaluation(Assessment)
 Attendance…………..……….…10%
 Group assignment…….…............15%
 Mid-term examination…………...30%
 Final written examination………...45%
Total------------------------------------100%

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 References
1. Basic concepts of psychiatric mental
health nursing .
2. Psychiatric nursing in the hospital and in the
community.
3. Oxford text book of psychiatry.
4. A short text book of psychiatry.
5. Kaplan and sandock. 2015. Synopsis of psychiatry.

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 Topics to be covered;
1) Introduction to psychiatry.
2) Introduction to psychiatric assessment.
3) Psychopathology.
4) Cognitive Disorder.
5) Schizophrenia Spectrum & Other Psychotic
Disorder.
6) Mood Disorder.
7) Anxiety Disorder.
8) Substance Related Disorder.

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 Con’d…
9) Obsessive-Compulsive and Related Disorder.
10) Trauma- and Stressor-Related Disorders.
11) Psychosomatic Medicine.
12) Epilepsy and psychiatric Co-morbidity.
13) Psychiatric Emergency.
14) Sexual dysfunction.
15) Personality disorder.
16) Psychopharmacology.
17) Mental health education.

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 Chapter 1: Introduction to psychiatry
Learning objectives
At the end of this session, students will be able
to:
Explain the historical development psychiatric
nursing.
List the principles and qualities of psychiatric
nursing.
Describe the classification and etiology of
mental disorders.
Recognize the epidemiology of mental disorders
in the world.
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 Psychiatric Nursing historical development
 Mental illness began in the primitive age as
human existence began.

 There is evidence that it existed at the time and

attempts were made to treat it.

 It was thought to be caused by evil sprits entering

and take over the body.

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 Con’d…
 People attempted to drive these evil sprits from the
body through the use of incantations and magic.

 Some primitive tribes rejected their mentally ill and

drove them from the community.

 In the ancient civilization, Greeks, Romans and

Arabs viewed mental deviations as natural
phenomena and treat the mentally ill humanely.

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 Con’d…
 Care consists of sedation with opium, music, good
physical hygiene, nutrition and activity.

 The Greek philosopher Plato (429-348 BC) and the

Greek physician Hypocrites (460-377 BC),known
as the father of medicine), were concerned about
the treatment of mentally ill patients.

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  Mental illness was considered irreversible.
 The mentally ill were beaten for disobedience and
confined to cages or closets.

 Generally, mentally ill patients were viewed as

incompetent, defective and potentially dangerous.
 They had no rights and were left in social isolation to
communicate primarily with other mentally ill patients.
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 Con’d…
 Their care-takers were untrained and often punitive.
 As a result, the mentally ill patient tended to become
more ill and less able to function.
 Bethlehem Royal Hospital, the first mental hospital
in England, was opened during the 17th Century.

 The first hospital in America to admit mentally ill

patients was the Pennsylvania Hospital.

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 Con’d…
 The first American textbook on psychiatry was written,
during this period by Benjamin Rush (1745-1813) a
physician who used a humanistic approach in the
treatment of mental illness.
 He is considered as to be the father of American
psychiatry.
 The first psychiatric training school was established
in 1882 at McLean Hospital in Belmont,
Massachusetts(United States).
 Participation in psychiatric nursing course becomes a
requirement for a nursing license in the USA(1955).

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 Con’d…
 In Ethiopia the first mental hospital (Amanuel Mental
Specialized Hospital) was established after the end of the
Ethio-Italian war to protect the royal family from
mentally ill patients.

 The patients were collected and taken to jails to the corner

of the town that is now known as Amanuel Mental
Specialized Hospital.

 Slowly and gradually a more humanitarian type of care

was introduced by one psychiatrist(Dr.Fikire Workineh).

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 Con’d…
 The first psychiatric nursing school was established
in Amanuel Mental Specialized Hospital in 1991 and
twelve nurses graduated for the first time.

 Until this time there was no formal psychiatric

nursing training in Ethiopia.

 Then after ,the service started to be decentralized to

other corners of the country, such as Jimma,
Nekemte, Harar, Dire Dawa, Yirgalem, Bahirdar and
Mekele,Wollo,…etc
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  Basic Principles of Psychiatric Nursing
 View the client as a holistic being.

 Focus on the client’s strengths and assets, not

on his weakness and liabilities.

 Accept the client as a human being who has

value and worth.

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 Con’d…
 View the client’s behaviour as designed to meet a
need or to communicate a message.

 Have potential for establishing relationship with

clients.

 View the client’s behaviour as the best possible

adaptation.

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 Essential Qualities of Psychiatric Nurse
 Therapeutic use of self (use yourself as a tool to help
patient).
 Genuineness and warmth.
 Empathy.
 Recognizing and understanding the state of mind,
beliefs, desires and emotions of another person
without interjecting your own.
“Putting yourself in another’s shoes”

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 Con’d…
 Acceptance
 Maturity and self-awareness(process of
understanding one’s own values, beliefs, thoughts,
feelings, attitudes, motivations, strengths and
limitations and how one’s thoughts and behaviors
affect others).

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 Definition of terms
Psychology
 Study of behavior and processes of the mind as it
relates to the individual’s social and physical
environment.
Psychologist
 Professional who specializes in the study of the
structure and function of the brain and related
mental processes.

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 Con’d…
Psychiatry
 Branch of medicine that deals with the causes,
treatments, and prevention of mental, emotional,
and behavioral disorders.

Psychiatrist
 Professionals who specializes in diagnosing,
preventing, and treating mental disorders.

Psychiatric nursing
 A branch of nursing profession concerned with
prevention and cure of mental disorder.
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 Health(WHO's definition)
 A state of complete physical, mental and social well-
being, and not merely the absence of diseases or
infirmity.

 Mental health:- “the successful performance of

mental functions, in terms of thought, mood, and

behavior that results in productive activities, fulfilling

relationships with others, and the ability to adapt to

change and to cope with adversity”.

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 In other way MH means

 A state of well-being in which an individual can;

 realize his or her own abilities,

 interact positively with others,

 cope with the stressors of life and study,

 work productively and fruitfully, and

 contribute to his or her family and community.

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 Specifically Psychiatry is a medical discipline that
deals with mental and behavioral disorders.

 ‘psyche" refers to mind/soul; and ‘-osis’ refers to

abnormal condition or derangement) means ‘an
abnormal condition of the mind’.

 Normality and mental health are central issues in

psychiatry, but there are no clear-cut definitions of
these terms.
 Normality = definition of health(WHO).

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 What is mental disorder?
 Mental Disorder(MD)
 Clinically significant behavioral pattern or
psychological syndrome;
 associated with distress, painful experience or
disability.

 Causes suffering which result in;

Loss of freedom, Isolation, Pain &/or Death
(i.e impairment in one or more areas of functioning).

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 Con’d…
 Must not be an expectable & culturally sanctioned
response to particular event.
 E.g. death of a loved one.
 Neither deviant behavior nor conflict that are
primarily b/n the individual & society are mental
disorders unless it is a symptom of a dysfunction in
the individual.
 For most people MD is considered;
When a person displays a severe mental
disturbance such as agitation, violence or going
naked.
Some MD are associated with severe disorders like
33 psychotic disorders. 11/27/2023
 Persons can be classified as having:
A. No mental illness
B. Mental illness
Psychosis
 Organic
 Acute, chronic, substance related, Gmc
 Functional
 Affective, Non affective
No psychosis
 Neurosis, Others

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 Classification mental disorders
 ICD 10– WHO  Schizophrenia Spectrum
 DSM V TR– American and Other Psychotic
psychiatric association Disorders
 Over 150 different types  Mood Disorders
 There are 22 major classes  Anxiety Disorders
of mental illness in DSM V.  Obsessive-Compulsive and
o Some of these are; Related Disorders
 Neurodevelopmental  Trauma- or Stressor-
Disorders. Related Disorder
 Feeding and Eating  Dissociative Disorders
Disorders  Somatic Symptom and
 Sexual Dysfunctions. Related Disorders, etc.
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 Purpose of classifications
1. Provide a language with which all mental health
professionals can communicate.

2. To study the natural history of a disorder &

develop an effective treatment.

3. To develop understanding on the causes,

diagnosis & treatment of various mental
disorders.

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  Neurosis
 Chronic or recurrent non psychotic disorder.

 Distressing symptoms to the patient & recognized

as unacceptable.

 Reality testing is intact.

 Behavior does not actively violate gross social

norms
E.g. phobias, anxiety disorders.

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  Psychosis
 Loss of reality testing & impairment in mental
functioning manifested by delusion, hallucination,
grossly disorganized/catatonic behavior.

 Severe impairment of social & personal functioning.

E.g. schizophrenia

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 Con’d…
The four major criteria for psychosis;
 Bizarre behavior
 Abnormal experience
 Loss of contact with reality
 Lack of insight

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 What are the etiologies of mental
disorders?

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 Causes mental illnesses
 No one really knows.
A) Traditional Models/perspectives;
Supernatural

Witchcraft (belief in magical spells produce

unnatural effects).

Evil spirits

Ancestral Spirits etc

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 B) Modern explanations/perspectives;
Stressful life events(Loss, death).

Difficult family background (abuse, neglect).

Brain Pathologies(AIDS, Head injury, Stroke)

Hereditary (Genetic) factors.

Medical illness(RF, thyrotoxicosis, HIV/AIDs).

Drugs /Medications.

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 Impact of Mental Disorders
Mental and behavioral disorders have a large impact
on:
Individuals

Families and

Communities.

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 1) To the Patient/individual
 Symptoms are distressing.
 Inability to participate in work and leisure
activities.
 Worry about not being able to shoulder their
responsibilities towards family and friends.

 Being fearful of becoming a burden for others.

 Stigma and discrimination

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 2) To the Family;
 Providing physical and emotional support to the
mentally ill member.
 Bearing the negative impact of stigma and
discrimination.
 The stress of coping with disturbed behaviour.
 Disruption of household routine activities.
 Restriction of social activities .
 Expenses for the treatment of mental illness
 Prevent other members of the family from achieving
their full potential.

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 3) To the Community;
 Cost for providing care

 Loss of productivity

 Some legal problems

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 CLINICAL APPROACH TO MENTALLY ILL
PATIENT
 Communication

 Is a mutual interaction or reciprocal action that can

occur between/among people.

 Is also a learned process influenced by attitudes, socio-

cultural or ethnic background, past experience,

knowledge of the subject matter and the ability to
relate to others.
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 Therapeutic communication

 Is special form of communication that has a health

and related purposes by developing a continuous
flow of interaction between therapists and patient
with input from both.

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 Patient - physician Relationship
 Quality of patient-therapist relationship is crucial to
the practice of medicine and psychiatry.
 Effective relationship;
 Requires solid appreciation of the complexities of
human behavior, and
 Techniques of talking and listening to people(skills
of active listening).
 characterized by good rapport.

50
  Rapport- is spontaneous, conscious feeling of
harmonious responsiveness.
 promotes the development of a constructive
therapeutic alliance.
 Implies an understanding and trust between the
therapist and the patient.
 Is a relationship of mutual understanding or trust &
agreement b/n people.

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 Establishing rapport
 Development of rapport encompasses strategies:
 Putting patients & interviewers at ease;

 Finding patients' pain & expressing compassion;

 Evaluating patients' insight & becoming an ally ;

 Showing expertise, establishing authority as physicians

& therapists;

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  Balancing the roles of empathic listener, expert, &
authority.

 Non verbal communication;

 Is sometimes considered a more accurate description

of true feelings.
 One has less control over it.

 It includes;
position or posture, gesture ,touch ,physical
appearance, facial expression ,vocal cues.
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  Points to be considered for effective
therapeutic communication:

 Know yourself  Control your non verbal

reactions
 Be honest with your
 Use words carefully
feelings
 Recognize differences
 Be sure in your ability
 Recognize and evaluate
to relate with others
your own action &
 Be sensitive to needs
responses
of others.
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  Classification of causes;
 A single disorder may result from several causes;
Predisposing factors are those that render the person
susceptible or vulnerable and are present over a
long period of time.
Precipitating factors are events that precede clinical
onset.
Perpetuating factors are factors that prolong the
course of a disorder after it has been provoked.
Protecting factors.

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 PREDISPOSING FACTORS
1) Genetics:-
E.g. schizophrenia, BPD, dementia
2) Age:-
E.g. Adolescence, middle life, old age
3) Gender:-
E.g. Alcohol (M>F)
Physical, psychological and social factor early in life
and premorbid personality are also important .

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 PRECIPITATING FACTORS
1) Environment;
 Family interactions (engagement, marriage,
discord, separation, death, becoming a parent).

 Other interpersonal relationship (difficulties

with friends or neighbors).

 Living circumstances (immigration).

 Financial affairs (inadequate finances).

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 con’d…
 Legal affairs (Being arrested).
 Occupation – stress related to job (e.g. conflict with a
superior).
2) Physical illness;
 Personal (pain, discomfort)

 Financial (cost of treatment)

 Emotional (feeling of depression)

 Body image (breast amputation)

58  Endocrinal (hyperthyroidism) 11/27/2023

 Perpetuating factors
 Substance use/abuse.

 Non-adherence with treatment

 Ongoing psychosocial stressors

 Lack of social support (supportive network)

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  Epidemiology of mental disorders in the
world
 About 25% of the world’s population will develop
mental illness at some age in their lives.
 Worldwide 450 million people suffer from mental
or brain disorders.
 Most of these live in developing countries.

 Mental disorders represent 4 of the 10 leading

causes of disability worldwide.

 Around 20% of all patients seen at PHC have one

or more mental disorders
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 Con’d…
 Over 150 million people suffer from depression.

 50 million from epilepsy.

 37 million people from Alzheimer's Disease.

 24 million people from schizophrenia.

 800,000 people die from suicide each year and

over ½ of these are young people.

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 Mental Health Problems in Ethiopia
Mental Health Problems Prevalence(%)
Common mental disorders 12-17%
Schizophrenia 0.6-0.7%
Mood disorders 3.8-5%
Childhood disorders 12-24%
Substance dependence 4.0%
Problem drinking 2.7-3.7%
Khat abuse 22-64%
Suicide attempt 0.9-3.2%
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Completed suicide 7.7/100,000/year
11/27/2023
 Interviewing Techniques with Special
Patient Populations
1.Psychotic Patients
 Are patients having poor or absent reality testing
abilities.
 Evaluation of these patient needs to be
- more focused and
-structured than other patients.
 Open-ended questions and long periods of silence
are apt to /tending to/ be disorganizing.
 In such Patients short questions are easier to follow
than long ones.
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2. Patients with thought Disorders
 Disorders of thought can seriously impair
effective communications.

 When derailment is evident,

→the examiner typically proceeds with questions
calling for short responses.

 For a patient experiencing thought blocking,

→ needs to repeat questions.
3. patients with hallucinations
 For patients with hallucinations,
→full phenomenology of the hallucination should
be explored.
 patient is asked to describe the sensory
misperception as fully as possible.
 For auditory hallucinations, include
-content, volume, clarity, and circumstances
 For visual hallucinations, include
-content, intensity, the situations in which they
occur, and the patient's response.
 4. patients with delusions
 Delusional patients often come to hospital evaluation
having had their beliefs dismissed or belittled by
friends and family.
 Ask questions about delusions without revealing belief
or disbelief.
 patients can speak more freely when asked to talk about
the accompanying emotions rather than the belief itself.

 A gentle probe may determine how

tenaciously/persistently the beliefs are helded.
- Do you ever wonder whether those things might not be
true?
 5. Suspicious Patients
 Are those with a paranoid personality, have a chronic,
deeply ingrained/fixed suspicion.

 Patients misinterpret neutral events as evidence of a

conspiracy/plot, plan, scheme/ against them.

 Extremely mistrustful and may question everything the

doctor says or does.

 The physician should try to maintain a respectful but

somewhat formal and distant approach with these
patients.
6. Depressed & Potentially Suicidal Patients
 Severely depressed patients may have difficulty
-concentrating, thinking clearly, and speaking
spontaneously.
 Evaluating a depressed patient may need to be more
forceful and directive than usual; the examiner may
need to repeat questions more than once.

 All patients must be asked about suicidal thoughts.

 Assessment of suicide potential addresses;
 intent, plans, means,
 perceived consequences, as well as
 history of attempts &
 family history of suicide.

 Asking about suicide does not increase the risk!

7. Somatizing Patients
 Patients describe their emotional distress in terms of physical
symptoms.

 Somatic distress without physical findings can lead to diagnostic

uncertainty, which in turn, makes treatment less certain.

 Many somatizing patients live with the fear that their symptoms
are not being taken seriously.

 In such patients have expand discussion including all aspects

of the patient's well-being, emotional and physical health.
 It is often helpful for the physician to propose a
purely pragmatic/realistic approach.
 one focuses on willingness to use whatever works to
relieve the patient's suffering without causing harm.

 This may be using nonstandard approaches, such as

meditation, yoga, or acupuncture, in addition to
psychotherapy.
 Important for the treating physician working with a
somatizing patient form a collaborative relationship
with the primary medical doctor.
 The psychiatrist's task is not to close the door on
medical investigation ,but
 invite patients to consider an even larger range of
factors,
→including emotional and psychological issues, all
of which can affect their health.
 8. Agitated & Potentially Violent Patients
 During interviewing of these patients, conduct an
assessment; contain behavior and limit the
potential for harm.
 Most unpremeditated violence is preceded by a
prodrome of accelerating psychomotor agitation.

 Researchers and clinicians in emergency psychiatry

suggest that the prodrome lasts from 30 to 60
minutes before erupting into physical violence.
  Several steps can be taken to minimize the agitation
and potential risk.

 The interview should be conducted in a quiet, non-

stimulating environment.

 Sufficient space should be available for the comfort

of the patient and the psychiatrist,
- with no physical barrier to leaving the examination
room for either of them.

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 9. Seductive Patients
 Seductiveness can be manifested in a patient's dress,
behavior, and speech.

 The psychiatrist should also make clear that it is the

violation of those boundaries that is being rejected
and not the patient.
10. Narcissistic Patients
 These patients act as though they are superior to
everyone around them, including the doctor.

 They have a tremendous/very great need to appear

perfect and are contemptuous of others whom they
perceive to be imperfect.

 They can be rude, abrupt, arrogant, and

demanding/impulsive.
 11. Isolated Patients
 Isolated & solitary patients do not appear to need
or to want much contact with other people.

 Patients are withdrawn, absorbed in a world of

fantasy, and are unable to talk about their feelings.

 Physician should treat these patients with as much

respect for their privacy as possible and should
not expect them to respond to the doctor's concern
with openness.
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12.Obssessed patients
 Patients have a strong need to be in control of
everything in their lives.
 may struggle with their doctor whenever they feel
that decisions are being imposed.

 Their physicians should try to include them in their

own care and treatment as much as possible.

 Involve them on what is going on and what is being

planned, allowing the patient to make choices on his
or her own behalf.