Preliminary Exam Reviewer

Content outline provided by Ma’am Aida Bautista

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PRAISE (Criteria for Mental Health)

• Positive Attitude Toward Self: a strong of identity, esteem, confidence.
• Realistic Perception: being able to view reality; avoidance of over-pessimism or over-optimism.
• Autonomous Behavior: independence in functioning.
• Integrative Capacity: the management of adverse or difficult situations. This involves resilience (ability to adjust), hardiness (resist illness under stress), self-efficacy (ability to succeed), and resourcefulness (problem-solving) .
• Self-Actualization and Personal Growth: the ability to be motivated to achieve one’s full potential and make use of it to achieve goals.
• Environmental Mastery: the ability to meet the demands of any situations and adapt to changing circumstances.

Criteria for Mental Illness

1. Lack of Personal Growth
2. Ineffective Coping
3. Non-Satisfactory Relationships
4. Self-Dissatisfaction

Theorists and their contribution

• Sigmund Freud:
  • The founder of psychoanalysis. “The unconscious can be accessed through dreams and free association”. A personality theory and a theory of infantile sexuality was also developed. One of his greatest contributions was “talk therapy”, which stated that simply talking about their problems can help alleviate them.
  • Application: It is used as an individual therapy approach for the enhancement of personal maturity and personal growth.
  • Major Concepts:
    • Personality Components: Id, Ego, Superego
      • 1. Id: the unconscious level of awareness which is concerned with pleasure principles (biological), being primitive, uncivilized, and immoral. It demands immediate gratification of needs.
        • Present at birth
        • Overdevelopment: narcissism, lawless, antisocial, irresponsible manipulative, liar, rebellious, revengeful
      2. Ego: “self”; primarily conscious, but functions on all levels of awareness. Concerned with reality principles (psychological). It controls or delays the demands of the Id through delayed gratification.
      3. Superego: primarily subconscious, but functions on all levels of awareness. Concerned with moral principles (social), it is the ethical component of the personality split between the conscience and ego ideal:
         • Conscience: what is primarily or basically wrong.
         • Ego Ideal: what is primarily or basically right.
         • Overdevelopment: guilt-ridden, inhibited, withdrawn/isolated, shy, lack of self-confidence, depression, obsessive-compulsive, anxious, seeking to reach expectations of others.
    • Psychosexual Stages of Development:
      1. Oral Stage: 1 to 1 ½ years old; regular feeding is very important
         • Erogenous Zone: mouth; tension is relieved by sucking and fixation may be caused by insecurity in parting with the breast or bottle.
         • Satisfaction: sucking, biting, crying; results in development of trust in later years
         • Greatest Need: security
         • Greatest Fear: separation anxiety
      2. Anal Stage: 1 ½ to 3 years old
         • Erogenous Zone: anus
         • Satisfaction: control over defecation and urination; critical period for toilet training.
           • Anal-Retentive Personality: the child “lets go” of control. Results in a stingy, stubborn, compulsive need for orderliness; punctual and respectful to authority. May also include schizoid, schizotypal, and Superego personalities.
           • Anal-Expulsive Personality: the mother “lets go” of control. Results in a messy, careless, disorganized, and prone to emotional outbursts; inconsiderate to others. May include an Id personality.
         • Greatest Need: power and control; development of Ego and Superego occurs due to introduction of the reality principle.
           • Toilet Training can be started once ready; the child should be able to stand alone, walk steadily, keep themselves dry (bladder control) in at least two hour intervals, demonstrate awareness of needing to defecate and void and the use of words and gestures to show it, and are desirous to please the caregivers.
             • Bladder Control: 18 months
             • Daytime Bladder Control: 2 ½ year old
             • Nighttime Bladder Control: 3 year old
      3. Phallic Phase: 3 to 6 years old; the first period of realization of gender. Identification also occurs, where children incorporate the values of their parent of the same sex into their superego.
         • Erogenous Zone: genital; sexual curiosity, consensual validation, castration anxiety/penis envy, oedipal/electra complex.
         • Satisfaction: masturbation; provide privacy but attempt to distract when possible. Fixation results in narcissistic, vain, and proud personalities, fear or incapability in close love, and homosexuality.
      4. Latency Phase: 6 to 12 years old
         • Erogenous Zone: genital, but dormant/inactive.
         • Satisfaction: acquiring knowledge, social skills (peer development), development of competence (in school and activities), character formation, achievements. Fixation results to immature behavior and less competence.
      5. Genital Phase: 12 to 18+ years old
         • Erogenous Zone: genitals
         • Satisfaction: genitals; development of heterosexual relationships. Interest in the welfare of others develops during this stage.
    • Anxiety and Defense Mechanisms
    • Free Associations
    • Transference and Countertransference
• Erik Erikson:
  • Psychosocial Stages of Development: also known as the Eight Ages of Man, Erikson devised the various age groups and each one’s developmental tasks or goals and associated virtues.

Stage	Age	Task	Virtue
Infancy	0 to 1 1/2	Trust vs. Mistrust	Needs are met: trust develops. Hope and Faith
Toddler	to 3	Autonomy vs Shame and Doubt	Toilet training is successful: autonomy develops. Will and Determination
Preschooler	to 6	Initiative vs Guilt	Curiosity is supervised consistently: initiative and conscience develops. Management of conflict and anxiety. Purpose and Courage
School-Aged	to 12	Industry vs Inferiority	Efforts to learn are supported: industry develops. Competence, confidence, and pleasure in accomplishments
Adolescence	to 21	Identity vs Role Confusion	Sexual orientation, role performance, body image, and self-concept are well defined: identity develops. Fidelity and Loyalty
Young Adult	to 35	Intimacy vs Isolation	Relationships are satisfying: intimacy develops. Love
Adult	to 60	Generativity vs Stagnation	Sense of usefulness to others: generativity develops. Involves establishing the next generation. Care
Elderly	60+	Integrity vs Despair	Satisfying past recollection: integrity develops. Wisdom

• Emil Kraepelin INC
• Eugene Bleuler INC

Health Care Delivery Systems

1. Primary Care: first point of contact; outpatient-based care.
   • Serves to provide preventive and promotive mental health practices. This involves information dissemination, early consultation, alleviation of early symptoms, and health education.
     • Youth Seminars: substance abuse, alcoholism, sex education, stress and anger management, problem solving and conflict resolution skills, social skills, proper personal hygiene, environmental sanitation.
     • Prenatal and Perinatal Seminars: prenatal and parenting class, proper nutrition for pregnant and lactating mothers, newborn care, importance of immunization, normal growth and development, child rearing practices, proper nutrition and hygiene for children, father roles in child development, family planning
     • Community Seminars: healthy lifestyles, good hygiene habits, crisis interventions, disaster preparedness, environmental sanitation and waste management, immunization, communicable and non-communicable diseases
   • Curtailing the disease process: case finding, surveying, early detection, immediate implementation of treatment, early recognition of symptoms, identifying available resources, case management
2. Secondary Care: referral to psychologists and psychiatrists where short hospital visits and consultation-liaison services e.g. assessment, counseling, and/or prescription drugs. Normally involves hospitalization.
   • Hospitalization: admission to an institution may be voluntary or involuntary.
     • Voluntary Admission: the client or their guardian seeks and signs consent for treatment, but with the right to leave even against medical advice (AMA).
     • Involuntary Admission: the client is confined with a court order. This may be done for patients who are dangerous to their self or others, are gravely disabled, or mentally disordered.
       • Emergency Commitment: without requiring a court order, a health care provider may confine a patient for 48 to 92 hours.
       • Extended Commitment: treatment is renewed for a period of three to six months.
3. Tertiary Care: referral to psychiatric institutions if the mental illness needs specialized care or rehabilitation.
   • Rehabilitation: measures to minimize relapse and chronic disability, and restoring the client’s optimal level of functioning. It involves recovery, continuing treatment, reduced hospital admission, personal growth, independency, social, vocational, and occupational functioning, and reintegration to the community.
   • Stigma: reduce mental health stigma via PES; Protest, Education, and Social Contact Strategies (allow the community to interact with the mentally ill).

Terminology

• Institutionalization
• Deinstitutionalization
• Decentralization
• Centralization
• Standards of Care
• Self-awareness: (discussed later, see Nurse-Patient Relationships)
• Self-esteem
• Self-disclosure
• Therapeutic Use of Self: self-awareness and the use of effective communication techniques to aid in comfort, safety, and non-judgmental acceptance of clients.

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​Mental Health Institutions (#6 to #8)

• NCMH history
• San Lazaro Hospital Insane ward
• Dr. Elias Domingo
  • 1st director
  • father of Philippine psychiatry
• Philippine Mental Health Association and its headquarters
  • Bacolod - Negros Occidental
  • Baguio-Benguet
  • Cabanatuan-Nueva Ecija
  • Cagayan de Oro-Misamis Oriental
  • Cebu
  • Dagupan-Pangasinan
  • Davao
  • Dumaguete-Negros Oriental
  • Lipa-Batangas
• NCR
  • The Medical City
  • PGH
  • Manila Doctors
  • UERMMMC (University of the East Ramon Magsaysay Memorial Medical Center

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Conflicts and Frustrations

“Conflict” is a painful emotional state that results from tension, opposition, and contradiction (Douglas, Holland). It is brought by the presence of two or more opposing desires in an individual (Barney, Lehner). There are various sources in differing environments:

• Home: faulty upbringing, unhealthy relationships, overprotection
• School: teachers, faulty teaching methodology, denial of self-expression, classmates
• Occupation: improper working environment, unsatisfactory relationships, dissatisfactory working conditions

“Frustration” refers to emotional tension resulting from non-fulfillment of desires or needs. (Good, 1959). It may be caused by failure to satisfy basic needs because of internal or external obstacles (Barney, Lehner)

• External Factors: physical (natural calamities, accidents, injury), societal (norms and values that may restrict individual needs), economic and financial (unemployment, lack of money)
• Internal Factors: physical abnormality or defects, conflicting desires, morality and high ideals, level of aspirations (inability to meet one’s aspirations). This often falls into five main triggers:
  • Desire: something the character wants.
  • Need: something the character requires for survival.
  • Duty: some obligation the character feels is right or necessary.
  • Fear or worry that drives the character.
  • Expectation: the character feels they are obligated to something because of someone else.

Anxiety and Anxiety Responses

“Anxiety” is a vague, unpleasant feeling of apprehension. It may be a response to unknown and non-specific threats. It normally motivates a person to take action for resolving a problem or crisis. It may become abnormal when excessive, chronic, and results in impairment of major functioning e.g. panic without reason, phobias, and uncontrollable repetitive actions. Hildegard Peplau outlined four types of anxiety: mild, moderate, severe, and panic.

Types of Anxiety

1. Mild Anxiety: a positive state of heightened awareness and sharpened senses, allowing the person to learn new behaviors and solve problems, taking in all available stimuli (perceptual field)
   • Perception: increased
   • Behavior: alert, energetic, attentive
   • Physiologic Changes: slight discomfort, restlessness, “butterflies in my stomach”, difficulty sleeping.
   • Coping: adaptive
   • Nursing Management: none
2. Moderate Anxiety: decreased perceptual field (only able to focus on the immediate task); assistance is required to learn new behaviors or solve problems.
   • Perception: decreased, selective
   • Behavior: difficulty in concentration, easily distracted, pacing
   • Physiologic Changes: clammy hands, diaphoresis, muscle tension, GI distress, headache, xerostomia, frequent urination
   • Coping: palliative; the use of any defense mechanism available.
   • Nursing Management: refocus attention; supervise in problem solving and learning. When talking, keep it short and simple (KISS).
   • Medical Management: oral anxiolytics
3. Severe Anxiety: feelings of dread and terror. Redirection to a task by another individual is not possible. Their focus is on scattered details and physiologic symptoms of tachycardia, diaphoresis, and chest pain occur (They may go to the emergency room believing they are having a heart attack).
   • Perception: distorted perception
   • Behavioral: impaired rational, decision-making, problem solving, judging, concentration, and ability. Confusion and disorientation.
   • Physiologic Changes: increased BP, RR, CR, chest pain, severe headache, nausea and vomiting, diarrhea, tremors, dilated pupils.
   • Coping: excessive, maladaptive defense mechanisms.
   • Nursing Management: relaxation techniques, decrease environmental stimuli, stay or walk with the patient, and listen attentively.
   • Medical Management: intramuscular anxiolytics
4. Panic Anxiety: loss of rational thought; delusions, hallucinations, and complete physical immobility and mutism may occur. The person may bolt and run aimlessly, leading to injury.
   • Perception: disorganized
   • Behavioral: immobilization, hysterical or mute, irrational reasoning, overwhelmed and helpless - suicidal, potential hallucination or delusions.
   • Physiological: same as severe anxiety, shortness of breath, and hyperventilation.
   • Coping: dysfunctional use of defense mechanisms.
   • Nursing Management: provide safety, reduce environmental stimuli, continuously talk with the patient, use touch judiciously, and stay with the person during their panic attack (5 to 30 minutes).

Type	Perception	Behavioral	Coping	Nursing Management	Medical Management
Mild	Widened	Alert, Energetic, Attentive	Adaptive	None	N/A
Moderate	Narrowed	Distracted, Pacing	Palliative	Refocus, Supervision, KISS	PO Anxiolytic
Severe	Distorted	Impaired thinking, Confusion, Disorientation	Excessive, Maladaptive	Relaxation, Less Stimuli, Presence, Listening	IM Anxiolytic
Panic	Disorganized	Immobilization, Mute/Hysterical, Irrational, Overwhelmed (Suicidal), Potential Hallucination/Delusion	Dysfunctional	Safety, Less Stimuli, Presence (judicious touch)	N/A

Underlying Causes of Anxiety

1. Interpersonal Factors: fear of interpersonal rejection; traumatic or dysfunctional relationships.
2. Behavioral Factors: exposure to early negative life circumstances and learned responses to frustration.
3. Psychoanalytic Factor: conflicts between the Id and the Superego.

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Adaptation

“Adaptation” is the physical or behavioral characteristic of an organism that helps an organism to survive better in the surrounding environment. Adaptation occurs in various levels:

• Adaptive: facing and finding solutions to situations
• Less Adaptive: temporary use of defense mechanisms
• Maladaptive: excessive use of defense mechanisms
• Dysfunctional: ineffective use of defense mechanisms; results in negative ADL and social impact.

Coping Mechanisms

“Coping” is any effort done to reduce stress responses. It may be constructive; task-oriented (direct problem solving) or defense-oriented (regulate stress via defense mechanisms), or destructive, where the individual often avoid the problem.

“Defense Mechanisms” also known as “ego defense mechanisms” or “protective defenses” are patterns of behavior or thought utilized to protect oneself from threatening internal or external aspects. It allows an individual to maintain control, safety, self-esteem, lessen discomfort, cope with stress, and decrease anxiety.

Normal and Adaptive Mechanism

Persons who effectively utilize these mechanisms are perceived as virtuous. These mechanisms enhance the individual’s feeling of mastery and pleasure.

• Anticipation: planning ahead for realistic expectations.
• Compensation: making up for imagined or actual handicaps or deficiency.
• Compromise: give-and-take dynamics; often seen in relationships.
• Sublimation: channeling socially unacceptable behavior to a socially acceptable one. It is the most constructive defense mechanism.
• Humor: seeing the lighter side of the situation.

Narcissistic Defense Mechanism

The most primitive mechanism often utilized by children. These mechanisms eliminate the need to cope with reality.

• Denial: refusal to acknowledge reality.
• Projection: blaming others for unacceptable deeds or thoughts.
• Fantasy: gratification of wishes through imagination.

Immature Defense Mechanism

Often seen in adolescents and some non-psychotic individuals; it lessens distress and anxiety-provoking situations. Excessive use of these defenses are seen as socially undesirable (immature, difficulty, out-of-touch).

• Conversion: transferring emotional conflict into physical symptoms.
• Malingering: fabrication of ailments.
• Fixation: psychosocial development ceases to advance.
• Regression: returning to previous developmental stages.
• Identification: unconscious attempts to change oneself as another, admired person.
• Introjection: sub-type of identification in which a person incorporates traits or values of other individuals into themselves.
• Intellectualization: excessive reasoning to obscure feelings.
• Suppression: forgetting thoughts or feelings voluntarily.
• Isolation: blocking feelings associated with unpleasant experiences; may be physical or emotional.
• Symbolism: conscious use of an alternate idea or object to represent another idea or object.

Neurotic Defense Mechanisms

Often seen in obsessive-compulsive, hysterical individuals and adults under stress. These are advantageous in short-term coping situations, but can cause long-term problems in relationships and life if used as a primary coping method.

• Displacement: releasing anger in a less threatening way.
• Dissociation: blocking off events from the conscious mind e.g. amnesia.
• Substitution: replacing original goals or desires with something else.
• Rationalization: justification of behavior to make them acceptable.
• Reaction Formation: reacting in a way that is opposite of what is felt.
• Repression: involuntary forgetfulness of unacceptable thoughts.
• Undoing: engaging in behaviors opposite of previous unacceptable actions.

Crisis (Extra)

When events causing anxiety becomes overwhelming and usual coping patterns become suspended. These may involve man-made and natural disasters, interpersonal events, traumatic experiences, etc.

1. Maturational Crisis: occuring as a normal part of growth and development e.g. leaving home for the first time, completing school, marriage, childbirth and rearing, beginning a career, etc. The successful resolution of these crises result in positive character development.
2. Situational Crisis: sudden or unpredicted events that threaten an individual’s integrity (physical, emotional, societal, economic, etc.).
3. Adventitious Crisis: unexpected unusual events that can affect an individual or a multitude of people; a social crisis e.g. natural disasters; societal injustices like racism, kidnapping, terrorism; violent crimes.

Stages of Crisis

1. Denial: an initial reaction of shock or disbelief.
2. Increased Tension: the recognition of the crisis; initial functioning remains adequate.
3. Disorganization: preoccupation with the crisis affects the individual’s functioning.
4. Attempts to Reorganize: the utilization of old and new coping mechanisms.

Defense Mechanisms

• Compromise: give-and-take dynamics; often seen in relationships.
• Anticipation: planning ahead for realistic expectations.
• Projection: blaming others for unacceptable deeds or thoughts.
• Regression: returning to previous developmental stages.
• Repression: involuntary forgetfulness of unacceptable thoughts.
• Sublimation: channeling socially unacceptable behavior to a socially acceptable one. It is the most constructive defense mechanism.

Therapeutic Communication

The nurse’s ability to establish effective communication in nursing is imperative to providing the best care and patient outcomes possible; to develop a helping relationship. Communication may be helpful or unhelpful. It is helpful when it encourages the transfer of information, thoughts, or feelings between communicators, and unhelpful if otherwise. Helpful communication allows for better assessment, intervention, and evaluation. Therapeutic communication allows for:

• Assess the patient’s perception of the problem
• Facilitate the client’s expression of emotions
• Recognize the client’s needs
• Implement interventions
• Guide the client towards identifying a plan of action to a satisfying and socially acceptable resolution of needs.
• Facilitating personal growth and behavioral change
• Teach the client and family necessary self-care skills

Therapeutic Communication Techniques

1. Open-Ended: Allows the client to share their personal experiences.
   • Giving Broad Openings: these may stimulate hesitant patients to start talking.
     • “Is there something you’d like to talk about today?”
   • Gentle Encouraging Descriptions of Perception
     • “Tell me/Share with me/Describe for me something about your home life.”
     • “What happened?”
     • “What does the voice seem to be saying?”
2. Close-Ended: helps obtain important facts or specific details and give information or explanations. These may also help focus a wandering client.
   • Close Ended Questions/Seeking Information
     • “How long have you been hearing these voices?”
3. Presenting Reality: indicating what is real to the patient.
   • “I see no one else in the room.”
   • P: “Someone’s trying to shoot me!” N: “That was a car backfiring.”
4. Others (read more)

Non-therapeutic Communication Techniques (COWARD)

• Changing Topics, Challenging, Testing, and Defending
• Giving Opinions, Advice, Value Judgement, False Reassurance
• “Why?” Questions
• Asking Yes or No Questions
• Refusing to Listen or Pay Attention
• Disapproving or Approving

1. Changing Topics: the nurse may change topics when they are unable to respond, has a topic in mind they want to discuss, or uncomfortable. They attempt to introduce an unrelated topic into the conversation.
   • P: “I’d like to die. Can you kill me with an overdose?”
   • N: “Did you have any visitors last evening?”
2. Challenging: for the nurse to demand proof from or present counterarguments to the patient. This may result in those with altered perception to defend their perceptions more strongly than before.
   • “If you say you’re dead, then why is your heart still beating?”
3. Defending: attempting to protect someone or something from verbal attacks by the patient. This makes the patient feel like they have no right to express impressions, opinions, or feelings, which results in communication blockage.
   • P: “Is the doctor really trying to cure me?”
   • N: “I’m sure the doctor has your best interests in mind.”
4. Testing: appraisal of the client’s degree of insight; acknowledgement of the client’s lack of insight is not helpful.
   • “Do you know what kind of hospital this is?”
5. Opinions and Value Judgement: these are opinionated or moral feedback from the nurse that limit the patient’s decision-making, thinking, analysis, and independence.
   • “That’s unfair.”
6. Advising: telling the client what or how to do things, which imply that only the nurse know the best for the client.
   • “I think you should…”
   • “Why don’t you…”
7. False Reassurance: indication that there is no reason for anxiety or other forms of discomfort in an attempt to dispel the client’s feelings, stating there is no sufficient reason for concern.
   • “Everything will be alright.”
   • “You’re coming along just fine.”
8. Requesting an Explanation: the use of “Why?” questions that ask the client for reasons to their thoughts, feelings, behaviors, or events. This form of questioning is intimidating, and the client likely does not have an answer. They may become defensive trying to explain themselves. There is a marked difference between asking the patient to describe perceptions than to explain them.
9. Probing Questions: persistent questioning, which causes feelings of being “used” or being invaded. Patients have the right to withhold concerns or feelings, and probing will only encourage the client to close up.
   • “Now tell me about your recent suicide attempt. You know I have to find out.”
10. Yes-No Questions: due to its limited nature, questions that are answered only with yes or no are unable to provide an accurate look into the patient’s ideas, thoughts, or feelings.
11. Interpreting: asking to make conscious that which is unconscious, and telling the client about the meaning of their experiences. The nurse cannot decipher the patient’s feelings. Only the client can identify or confirm the presence of feelings.
    • “So what you’re really saying is…”
12. Stereotyped Comments: The use of cliché phrases from social conversation with the patient provides little to no value. Any “automatic” responses lack the nurse’s consideration or thoughtfulness.
    • “Keep your chin up.”
    • “It’s for your own good.”
13. Approving or Disapproving: Sanctioning or denouncing the client’s behaviors, thoughts, or ideas. These imply that the nurse has the right to give judgment over the client’s thoughts and actions, also creating an expectation that the client should please the nurse.
    • “I’d rather you wouldn’t…”
    • “That’s good.”
14. Agreeing or Disagreeing: These create the idea that the client is “right” or “wrong”. If accepted, the client cannot change their mind without being “wrong”. Opinions and conclusions should only be from the client. If rejected, the client may then feel defensive about their points of view or ideas.
15. Rejecting or Denying: Refusing to consider or even showing contempt for the client’s ideas or behaviors, or even refusing to admit the existence of a concern or problem. These block exploration and deny the feelings and seriousness of the client due to dismissal.
    • “Let’s not talk about this.”
    • “I don’t want to hear about it.”
    • “Don’t be silly.”
16. Devaluation of Expression: belittling the feelings of the patients, and giving literal responses to figurative comments minimize the importance of the patient’s concerns.
    • P: “I wish I was dead.” N: “Even I’ve felt that way before.”
    • P: “They’re looking in my head with a television camera.” N: “What channel is it on?”

Nurse-Patient Relationships

• Therapeutic Use of Self: self-awareness and the use of effective communication techniques to aid in comfort, safety, and non-judgmental acceptance of clients.
• SOLER: utilized for attentive and active listening:
  1. Sit Square and Straight when conversing with the patient, also allowing for careful and complete observation of the patient.
  2. Open Posturing should be used. Crossed arms and the like should not be used.
  3. Lean Forward: it conveys interest in the patient.
  4. Eye Contact should be used appropriately; also engages sincerity and honesty with the patient
  5. Relaxed Attending Attitude
• Self-awareness: understanding the self is an on-going process of becoming aware of one’s self where individuals willingly identify, process, and store information about themselves (self-evaluation). It allows an individual to differentiate their values, beliefs, personal boundaries, weaknesses, and strengths. This in turn, allows one to understand how they can affect others.
  • In the context of a nurse, having self-awareness allows them to understand variances between values and beliefs of different individuals.
  • Improves self-knowledge, self-regulation, self-improvement, and inferences about other individual’s mental states.
  • Self-awareness is not only knowing how their mood, but also how one feels about their mood.
• Proxemics: “personal space” used in communication, with varying levels of “closeness” depending on patient status.

Space	Distance	Use Case
Intimate	0 to 1.5 ft.	Body contact; assisting in ambulation, positioning, etc.
Personal	1.5 to 4 ft.	Often used in nursing care e.g. administering medication, teaching, and various forms of therapeutic use of self
Social	4 to 12 ft.	Formal communication limited to seeing and hearing, group communication
Public	12 ft.+	Communication requires a loud and clear voice

• Phases of NPR:
  1. Pre-Interaction Phase: the phase before first contact with the patient. The nurse gathers relevant information such as the client’s name, address, age, and medical/social history. With the data gathered, the nurse can consider their own strengths and limitations when working with the patient in any area that may signal difficulty.
  2. Introductory Phase: First contact with the patient. A relationships is established, trust and respect is developed, goals are set, and security is felt within the relationship.
     1. Establish Boundaries and Acceptance
     2. Establish Trust
     3. Establish Contract and Boundaries: purpose, time, place, and length of the session; persons involved; client and nurse responsibilities.
        • Nurse responsibilities: punctuality, confidentiality, assessment of anxiety levels, preparation for termination and separation.
     4. Establishing Relationships: gain trust, establish boundaries and expectations, and goals to be met.
  3. Working Phase: the nurse works with the client for the resolution of the patient’s identified problems and to meet goals. Evaluation and redefinition of goals is done as necessary.
  4. Termination Phase: the nurse summarizes the relationship and assessment of the client’s self-sufficiency. Progress of the relationship is discussed, and potential separation issues are identified and dealt with; emotional stability is assessed.
     • Do not promise that relationships with clients are going to continue.
     • Refer and transfer the client to other support systems.
• Barriers to Effective NPR
  • Transference: clients transfer their feelings to the nurse.
  • ​Countertransference: the nurse transfers their feelings to the client.
  • Encouraging Dependency: the nurse should develop the patient’s functional independency instead.
  • Sympathy vs. Empathy: the state of knowing what another person is feeling (sympathy) versus being able to feel what the other person is feeling; being able to put oneself in their perspective (empathy).
  • Advising vs. Counseling: counseling allows the patient to find their answers themselves, while advising provides a definite answer. Advise may be judgmental i.e. you need to be told what to do.

Mental Status Examination

Differentiate the ff:

• psychomotor restlessness
• psychomotor retardation
  • thoughts and motor/behavior
• motor restlessness
• motor retardation
  • motor/behavior only
• Disturbances in Affect
  • Flat, Blunt, Labile, etc.
• Disturbances in Thoughts
  • Loose Association
  • Flight of Ideas
  • Neologisms
  • Clang Association
  • Neologism
  • Ideas of Reference
  • etc.
• Disturbances in Perception
  • Delusions
  • Hallucination
  • Illusion
• Disturbance in Memory
• Disturbances in Motor Behavior
  • Catatonia, Waxy Flexibility, Stupor, etc.

Psychosocial Assessment

• MSE Continuation (ATOMICS)
• Appearance vs Behavior
• Thought Content vs Thought Process
• Orientation vs Sensorium
• Insight vs Judgment
• Cognitive Functions

Tests used in Psychiatry

• Personality Test
• Emotional Quotient Test
• Intelligence Test

Treatment Modalities

1. Electroconvulsive Therapy
   • Indications:
   • Contraindications:
   • Assume a supine position before ECT
   • Assume a lateral position after ECT to prevent aspiration.
   • Oxygen maybe given before and after ECT to ==prevent anoxia==.
2. Milieu Therapy
3. Group Therapy
4. Individual Therapy
5. Stress management

Schizophrenia

• Description of DSM-5 and its purpose
• DSM-5 Criteria
• Positive Symptoms - Delusion and Hallucination - Disorganized Speech and Behavior
• Negative Symptoms - Anhedonia, Asociality, Avolition - Suicide risk - Alogia, Affective Changes, Attention Deficit

Psychopharmacology

1. Antipsychotic Drugs
   • Indications: schizophrenia
   • Side Effects: EPSE, Non-EPSE
   • Chlorpromazine (Thorazine); typical, Phenothiazine
   • Clozapine (Clozaril); atypical
   • Haloperidol (Haldol); typical, Butyrophenone
   • Prolixin
2. Antidepressants
   • Imipramin (TCA)
   • Amitriptyline (TCA)
   • Bupropion (NDRI)
   • Phenelzine (MAOI)
3. Antimanics
   • Lithium Therapy
4. Other Drugs
   • Propranolol (beta blocker)
   • Flumazenil (benzodiazepine antagonist)
   • Cholinergics vs Anticholinergics
     • Adrenergic vs Antiadrenergics

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Extra points to remember:

• Amphetamines enhance performance.
• Amphetamine effectivity is reduced by antidiabetic agents.
• Hyperglycemia is the metabolic effect of adrenergic drugs
• When giving MAOIs, avoid giving drugs that affect the CNS because of the possibility of hypertension.
• Methylphenidate (Ritalin) drug use in children with ADHD may result in Tourette’s syndrome and suppress growth.
• Benzodiazepines should be stopped gradually to avoid withdrawal symptoms.