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Normal Psychiatric Nursing

22 min read

References:

  • Comprehensive Nursing Licensure Review Book: Local and International Test Prep, Volumes 1 and 2, ISBN 978-971-51-3383-8, by Josie Quiambao-Udan (Vol. 1, Part 6)
  • Lecturer (Sir Jimenez)

Compilation

This is a compilation page. It’s meant to cover a lot of topics in a short period of time. By nature, it’s not as comprehensive as reading through these topics on their own pages one by one. It’s focused on the important topics that usually appear in the board exam, but is still essentially complete.

Psychiatric Models

  1. Psychoanalytical Model: Sigmund Freud’s (the father of psychoanalysis) psychoanalytic theory, a cornerstone of the field of psychology, seeks to provide insight into the intricacies of human behavior and mental processes. At its core, this theory revolves around the tripartite structure of the human psyche, comprising the id, ego, and superego. These components engage in dynamic interactions that significantly influence an individual’s personality and behavior.
    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. The id represents the most primitive and instinctual aspect of the psyche.
      • Present at birth
      • Overdevelopment: narcissism, lawless, antisocial, irresponsible manipulative, liar, rebellious, revengeful. This results in disorders such as antisocial personality disorder, mania, and narcissistic personality disorder.
    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. It is the rational and conscious part of the psyche, emerging in response to the demands of the external world. It satisfies the id’s desires in a socially acceptable manner while considering the potential consequences. It is the arbiter between the Id and the Superego.
      • Impairment of the ego can result in a loss of reality, which is characteristic of schizophrenia.
    3. Superego: primarily subconscious, but functions on all levels of awareness. Concerned with moral principles (social), the superego functions as the moral and ethical compass of the psyche. It embodies internalized rules and values, often influenced by societal and parental expectations. It enforces moral and ethical standards and can induce feelings of guilt or shame when actions violate these standards. 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. This can result in disorders such as obsessive-compulsive disorder/personality disorder, and anorexia nervosa.
    • These components frequently engage in conflicts, resulting in psychological tensions and impacting an individual’s thoughts, feelings, and behaviors:
      1. Conflict between the Id and Ego: the ego must navigate a fine balance between fulfilling the immediate desires of the id and recognizing the constraints of the external world.
      2. Conflict between the Id and Superego: the id’s pursuit of pleasure may collide with the moral values dictated by the superego, leading to inner turmoil.
      3. Conflict between the Ego and Superego: the ego’s responsibility includes reconciling the demands of the superego with the realities of the external world, which can create internal strife when societal expectations diverge from personal desires.
      4. Id Dominance results in conditions such as mania, antisocial personality disorder, and narcissistic personality disorder.
      5. Superego Dominance results in conditions such as obsessive-compulsive disorder and anorexia nervosa.
      6. Damaged Ego may result in the loss of basis in reality, producing disorder such as schizophrenia.
    • Free Association: a tool used in psychoanalysis, aiming to deepen self-understanding by looking at whatever thoughts, words, or images come freely to mind. The therapist may ask the patient to share anything that is in on their mind such as memories, words, images, or daydreams. This may also be done with the therapist mentioning a single word, and asking what the first thought that comes to mind is for the patient.
    • Dream Interpretation: originally used in psychoanalysis and spreading to other psychotherapies, the contents of dreams are interpreted to reveal underlying motivations or symbolic meanings and representations. Freud believed that dreams represent disguised fulfillment of repressed wishes, and that studying them provided the easiest road to understanding the unconscious activities of the mind.
    • Hypnosis: guided relaxation, intense concentration, and focused attention to achieve a trance, considered as an aid to psychotherapy because of a “hypnotic state” that allows people to explore painful thoughts, feelings, and memories they might have repressed. This is done to reduce emotional distress, treatment of phobias, anxiety disorders, pain management, weight loss, smoking cessation, and other conditions.
  2. Levels of Awareness: the personality is made up of various levels of awareness:
    • Consciousness: feelings, thoughts, and beliefs that the individual is aware of, concerned with the “here and now”. It functions when the individual is awake.
    • Preconscious: not aware at present, but may be recalled at will.
    • Unconscious: aspects of the person that they are not aware
  3. Psychosexual Stages:
    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, 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.
  4. Psychosocial Development:
StageAgeTaskVirtue
Infancy0 to 1 1/2Trust vs. MistrustNeeds are met: trust develops. Hope and Faith
Toddlerto 3Autonomy vs Shame and DoubtToilet training is successful: autonomy develops. Will and Determination
Preschoolerto 6Initiative vs GuiltCuriosity is supervised consistently: initiative and conscience develops. Management of conflict and anxiety. Purpose and Courage
School-Agedto 12Industry vs InferiorityEfforts to learn are supported: industry develops. Competence, confidence, and pleasure in accomplishments
Adolescenceto 21Identity vs Role ConfusionSexual orientation, role performance, body image, and self-concept are well defined: identity develops. Fidelity and Loyalty
Young Adultto 35Intimacy vs IsolationRelationships are satisfying: intimacy develops. Love
Adultto 60Generativity vs StagnationSense of usefulness to others: generativity develops. Involves establishing the next generation. Care
Elderly60+Integrity vs DespairSatisfying past recollection: integrity develops. Wisdom
  1. Operant Conditioning: Behavior is learned from one’s history and past experiences, particularly from experiences that were repeatedly reinforced.
    • Reward (positive reinforcement) and punishment (negative reinforcement) affect a person’s behavior.
    • Reconditioning, where one’s learned or maladaptive behaviors are unlearned, or reinforcement, where a positive behavior becomes more likely to recur.
    • Positive punishment increases aversive consequences to reduce a behavior, while negative punishment decreases rewards to reduce a behavior.
  2. Gestalt Model: A model that links self-awareness and self-acceptance; self-awareness will eventually lead to self-acceptance and responsibility for one’s own thoughts and feelings.
  3. Mental Health and Mental Illness Continuum:
    • Mental health is a healthy behavior in which the individual remains adaptive, is able to confront issues and anxiety inducing scenarios in a healthy manner, is reality-oriented, and interacts with a real environment. Such a patient will exhibit socially acceptable behavior and proper insight.
    • Conversely, mental illness (psychosis) is maladaptive. The patient exhibits withdrawal, aggressiveness, denial of reality/creation of new environments with hallucinations and delusions. Their behavior is bizarre, with little insight and impaired judgment. Their self-concept is distorted and the ability to find meaning and purpose in life may be impaired, disturbing life-direction and productivity.

Treatment Modalities

  1. Crisis Intervention: crises are sudden events in one’s life that disturbs a person’s homeostasis. In such events, normal coping mechanisms are unable to handle the issue and disequilibrium persists for hours to days. Crises are self-limiting, not lasting longer than 6 to 8 weeks. These occur in situational, transitional, or sociocultural contexts.
  2. Group Therapy: a collection of 5 to 10 individuals participate in sessions for therapy. Depending on the group’s needs, different modalities for therapy can be used:
    • Psychoanalytical group psychotherapy
    • Transactional analysis: the group works together to analyze social interactions (“transactions”) in order to determine which ego state is appropriately used for each situation.
    • Rational emotive therapy: focusing on the source of psychological distress rooted in irrational beliefs and thoughts
    • Rogerian therapy: promoting expression of feelings from one member to other members of the group, promoting clarification of feelings and accepting clients and their feelings non-judgmentally.
    • Gestalt therapy: “here and now”, where the clients practice self-expression, self-exploration, and self-awareness in the present. Everyday problems are identified and solved.
    • Interpersonal Group Therapy
    • Self-help or Support Groups: groups of people who have experienced similar problems and are able to help others who have the same problem. Examples: Alcoholics Anonymous, Narcotics Anonymous
  3. Family Therapy: the family is the focus of therapy. Therapy sessions involve the client and their family.
  4. Milieu Therapy: management of the client’s environment to attempt to establish interpersonal relationships.
  5. Expressive Therapy: the use of innately expressive recreational activities and other tasks to promote the expression of feelings and thoughts.
  6. Interpersonal Psychotherapy: the use of therapeutic relationships to modify the client’s feelings, attitudes, and behaviors.
  7. Behavior Therapy: approaches that attempt to change behaviors, believing that most behaviors are learned and can be unlearned.
    • Operant conditioning is a method by which positive or negative reinforcement is applied with rewards and punishment respectively. The therapist selects reinforcers to elicit and strengthen desired behavioral responses.
    • Classical conditioning is based on an individual responding to a specific stimulus, but in this case they essentially serve as a passive agent.
    • Desensitization is a form of behavior therapy whereby exposure to increasing increments of a feared stimulus is paired with increasing levels of relaxation, which helps reduce the intensity of fear to a more tolerable level.
    • Aversion therapy is a form of behavior therapy whereby negative reinforcement is used to change behavior. For example, an attractive stimulus of alcohol is paired with an unpleasant event, like the effects of disulfiram (Antabuse) when alcohol is consumed. Disulfiram inhibits alcohol metabolism, which results in headaches, chest pain, hypotension, dyspnea, nausea and vomiting, etc. when the patient drinks alcohol while taking Disulfiram.
    • Modeling is behavior therapy whereby the therapist acts as a role model for specific identified behavior so that the client learns through imitation.
  8. Cognitive Therapy: an active, directive, time-limited structural approach used to treat a variety of Disorders, like anxiety, depression ,and phobias. This stage is based on the principle that the feelings and behaviors of individuals is based on the attitudes or assumptions developed from previous experiences.
    • Therapy identifies, reality-tests, and corrects distorted conceptualizations and the dysfunctional beliefs underlying these thoughts. The therapist helps the client change the way they think, relieving symptoms.

Psychopharmacotherapy

Anti-anxiety Medications

  1. Benzodiazepines: medications that enhance the action of gamma amino butyric acid (GABA), an inhibitory neurotransmitter within the central nervous system. Used to treat prolonged severe anxiety and insomnia.
    • Xanax (Alprazolam), Librium (Chlordiazepoxide), Tranxene (Chlorazepate), Valium (Diazepam), Paxipam (Halazepam), Loftam (Ketazolam), Ativan (Lorazepam), Serax (Oxazepam), Centrax (Prazepam)
    • Side effects and adverse reactions: drowsiness, sedation, dizziness, headache, dry mouth, blurred vision, constipation, leukopenia, drug dependency.
    • Considerations: avoid alcohol, which potentiates the sedative effects of benzodiazepines.
    • Overdose Antidote: Romazicon (Flumazenil)
  2. Sedating Antihistamines:
    • Vistaril, Atarax (Hydroxine)
    • Side effects: drowsiness, dizziness, dry mouth, hypotension.
  3. Mephenerine: like compounds, e.g. Miltown, Equanil (Meprobate). Used for short-term release of anxiety; promotes sleep in anxious patients.
    • Considerations: avoid alcohol intake.
  4. Selective Serotonin Re-uptake Inhibitors: Paxil (Paroxetine)
  5. Anxiolytics with sedative effects: BuSpar (Busprione), Noctec (Chloral hydrate), Sonata (Zaleplon), Ambient (Zolpidem Tartrate).
    • Side Effects: drowsiness, dizziness, dry mouth, hypotension

Summary of Side Effects and Adverse Reactions to Antianxiety

Dry mouth, blurred vision, urinary retention, ataxia, tremors, hypotension, tolerance, drowsiness, sedation, dizziness

Antipsychotics (Neuroleptics)

  1. Phenothiazines (first-generation typical antipsychotics)
    • Side effects: orthostatic hypotension, constipation, urinary retention, blurred vision, nasal congestion, drowsiness, xerostomia, edema
    • Considerations: Phenothiazines lower the seizure threshold. Addition of anticonvulsants may be necessary.
    • Chlorpromazine (Thorazine)—causes photosensitivity (red-purplish blotchy areas in the skin).
    • Fluphenazine (Prolixin)
    • Thioridazine (Mellaril)
    • Perphenazine (Trilafon)
    • Mesoridazine (Serentil)
    • Trifluoperazine (Stelazine)
  2. Butyrophenone
    • Side effects: photosensity, sedation, extrapyramidal symptoms, orthostatic hypotension, headache, xerostomia, blurred vision
    • Adverse effects: tachycardia, seizures, urinary retention, tardive dyskinesia, laryngospasm, respiratory depression, cardiac dysrhythmias, neuroleptic malignant syndrome
    • Onset: 3 to 5 hours after administration
    • Haloperidol (Haldol)
    • Loxitane (Lozapine)
    • Molindone Hydrochloride (Moban)
    • Thiothixene (Navane)
  3. Thienobenzodiazipine:
    • Side effects: headache, dizziness, insomnia, somnolence, agitation
    • Olanzapine (Zyprexa)
    • Quetiapine (Seroquel)
    • Sertindole (Serlect)
  4. Benzisoxazole:
    • Side effects (in high doses): agitation, fatigue, dizziness, extrapyramidal symptoms
    • Risperidone (Risperdal)

Adverse Effects of Antipsychotics

  1. Hepatotoxicity
  2. Sedation
    • Alcohol, hypnotics, sedatives, narcotics, and benzodiazepines potentiate the effects of antipsychotics. Additive depression is also likely to occur.
  3. Extrapyramidal Symptoms (EPS)
    • Pseudo-parkinsonism is the generic label of EPS. Its symptoms resemble those found in Parkinson’s disease—stiff, stooped posture with a shuffling, festinating gait; a mask-like expressionless face; bradykinesia; cogwheel rigidity; drooling; tremors; pill-rolling movements of the thumb and fingers while at rest. When found, management involves changing medications to those with a lower incidence of EPS, or with the addition of an anticholinergic agent or Amantadine (an antidyskinetic medicine). Atropine counteracts EPS and potentiates antipsychotics.
    • Acute dystonia is characterized by spasms and stiffness of muscle groups. It manifests as facial grimacing, oculogyric crisis (involuntary upward eye movement), torticollis, opisthotonos, muscle spasms of the tongue (tongue-thrusting), and laryngeal spasms. Management utilizes anticholinergics (Cogentin, Benadryl).
    • Akathisia is motor restlessness; an intense need to move about. The individual has trouble standing still and often paces the floor. The feet remain in constant motion even when laying or sitting. This may also be an indication to change antipsychotics or the addition of a beta-blocker, anticholinergic, or benzodiazepine.
    • Tardive Dyskinesia: a syndrome of permanent, involuntary movements caused by long-term use of typical antipsychotic drugs. This manifests as protrusion or rolling of the tongue, sucking and smacking of the lips, chewing motions, facial dyskinesia, and involuntary movements of the body and extremities. If present, prevention of further complication can be began by lowering the dose of the antipsychotic drug or the use of Clozapine, an antipsychotic drug with a low incidence of tardive dyskinesia.
  4. Endocrine Effects: breast enlargement, decreased libido, increased appetite, and weight gain.
  5. Anticholinergic side effects: hypotension, photosensitivity, agranulocytosis, retinopathy.
    • Antihypertensives can cause an additive hypotensive effect.
  6. Neuroleptic Malignant Syndrome (NMS) is a potentially life-threatening condition in antipsychotics that interfere with dopamine. Its hallmarks include changes in mental status, rigidity, fever, and dysautonomia—fever, tremors, unstable blood pressure and pulse rate, diaphoresis. Extrapyramidal symptoms may also appear.

In general, antipsychotics should be gradually removed rather than abruptly, to avoid sudden recurrences of psychotic symptoms.

Antidepressants

Antidepressants only exert their therapeutic effect at a minimum of one week. It may take three to four weeks to be fully effective. Using antidepressants is generally

  1. Tricyclic Antidepressants (TCA) block the uptake of neurotransmitters norepinephrine and serotonin in the brain. Clinical response occurs after 2 to 4 weeks. They are effective for treating unipolar depression or major depression.
    • Side Effects: skin rashes, photosensitivity, insomnia, tremors, seizures, excessive perspiration, erection/orgasm difficulty, anxiety, restlessness
    • Amitriptyline Hydrochloride (Elavil, Endep, Enovil)
    • Chlomipramine Hydrochloride (Anafranil)
    • Desipramine Hydrochloride (Nerpramin, Pertofrane)
    • Doxepine Hydrochloride (Sinequan, Zonalcon)
    • Imipramine Hydrochloride (Tofranil)
    • Nortriptyline Hydrochloride (Aventyl, Pamelor)
    • Protriptyline Hydrochloride (Vivactyl)
    • Trimipramine (Surmontil)
  2. Selective Serotonin Reuptake Inhibitors (SSRI):
    • Citalopram (Celexa)
    • Fluoxetine Hydrochloride (Prozac)
    • Sertraline Hydrochloride (Zoloft)
    • Fluvoxamine (Luvox)
    • Paroxetine (Paxil)
    • Escitalopram (Lexapro)
  3. Monoamine Oxidate Inhibitors (MAOI) are used separate from TCAs and SSRIs. They are not combined. These enhance norepinephrine activity.
    • Side/adverse effects: CNS stimulation—agitation, restlessness, insomnia; orthostatic hypotension; anticholinergic—dry mouth, tachycardia, urinary retention, constipation.
    • Considerations: MAOIs are not used with SSRIs and TCAs. They are also not used with decongestants as they often contain tyramine. Food rich in tyramine is also avoided. MAOIs combined with tyramine results in a hypertensive crisis. Examples of food that contain tyramine are aged, smoked, or fermented foods and beverages, some cheeses, cream, yogurt, coffee, chocolate, bananas, raisings, liver, pickled herring, sausage, soy sauce, yeast, beer, and red wine.
    • Isocarboxazid (Marplan)
    • Phenelzine Sulfate (Nardil)
    • Tranylcypromine Sulfate (Parnate)
  4. Atypical Antidepressants:
    • Buproprion (Wellbutrin)
    • Venlafaxine (Effexor)
    • Trazodone (Desyrel)
    • Nefazodone (Serzone)
    • Mirtazapine (Remeron)

Ego Defense 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 avoids 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.

  1. Sublimation: channeling socially unacceptable behavior to a socially acceptable one. It is the most constructive defense mechanism. An individual with aggressive tendencies might become a competitive athlete to channel their aggression constructively.
  2. Reaction-Formation: reacting in a way that is opposite of what is felt. Expressing the opposite of one’s true feelings as a way to manage uncomfortable emotions. Someone disliking a coworker might be overly friendly.
  3. Undoing: engaging in behaviors opposite of previous unacceptable actions. Engaging in actions to counteract a previous undesirable action. Someone berating their partner might later buy them gifts as a way of compensating.
  4. Isolation: blocking feelings associated with unpleasant experiences; may be physical or emotional.
    1. Suppression: consciously pushing distressing thoughts, emotions, or memories out of awareness. A student might consciously suppress thoughts about an upcoming exam to avoid feeling anxious.
    2. Repression: involuntary forgetfulness of unacceptable thoughts— pushing distressing thoughts or memories out of conscious awareness. Someone might have no memory of a car accident due to repression.
  5. Compensation: putting forth extra effort to achieve in areas in which one has a real or imagined deficiency.
  6. Projection: blaming others for one’s own undesirable feelings, thoughts, or traits to others. An individual who is competitive and sees winning as crucial may accuse others of being overly competitive.
  7. Introjection: sub-type of identification in which a person incorporates beliefs or values of other individuals into themselves. Incorporating external beliefs into one’s identity without critically evaluating them. Someone might internalize a parent’s strong political beliefs without questioning them.
  8. Intellectualization: excessive reasoning to obscure feelings. Dealing with emotions by focusing excessively on facts, logic, and intellectual aspects of a situation. Faced with loss, someone might research grief instead of experiencing their emotions.
  9. Denial: refusal to acknowledge reality or the truth to avoid facing a painful situation. For instance, a person with a drinking problem might insist they don’t have an issue despite evidence to the contrary.
  10. Rationalization: justification of behavior to make them acceptable. The individual creates logical explanations or justifications for behaviors or situations to make them appear less threatening. Someone passed over for a promotion might say they didn’t want it anyway.
  11. Regression: returning to previous developmental stages— behaviors and patterns of earlier stages of development as a way to cope with stress. An adult under stress might start biting their nails, a habit from childhood.
  12. Fixation: psychosocial development ceases to advance.
  13. Displacement: releasing anger in a less threatening way; redirecting emotions, usually anger, onto a safer target. If frustrated by a boss, someone might take out their anger on their family.
  14. Conversion: transferring emotional conflict into physical symptoms without medical basis. This can manifest as paralysis or other sensory deficits. For instance, intense anxiety might lead to temporary leg paralysis, or witnessing a traumatic injury may cause blindness.
  15. Fantasy: gratification by imaginary achievements and wishful thinking. For example, it involves living in a dream world where you imagine you are successful and popular, instead of making real efforts to make friends and succeed at a job.
  16. Identification: unconscious attempts to change oneself as another, admired person. Taking on characteristics of someone else to reduce anxiety by feeling secure with one’s self-concept.
  17. Substitution: replacing original goals or desires with a more attainable one. Someone unable to pursue a dream career might focus on building a fulfilling personal life.
  18. Dissociation: blocking off events from the conscious mind (e.g., amnesia). Separating oneself from reality or a situation to avoid distressing emotions. This can result in feeling disconnected or observing experiences from a distance.

Stages of the Nurse-Patient Relationship

  1. Pre-interaction Phase: begins before the initial contact of the nurse with the client. The nurse gathers data from secondary sources i.e. the patient’s records
  2. Orientation Phase: the introductory phase, where the nurse meets the patient to establish trust, acceptance, and boundaries. The nurse assesses the client and formulated a contract with the patient with regarding the time, place, and length of sessions, when it will terminate, who will be involved in the treatment, and the responsibilities of the client and the nurse.
  3. Working Phase: the planning and intervention phase, where goals are worked towards, specific collaborative goals are established; thoughts, feelings, and actions are explored. The nursing diagnosis can be established in this phase and problems are resolved.
  4. Termination Phase: the end of the relationship first established in the orientation phase. Goals are evaluated or referred to other support systems. The patient is assessed for separation reactions; the nurse should help the patient express and work through feelings. The nurse may also exhibit separation reactions. In any case, there should be no promises made to continue the relationship. No future appointments should be scheduled.

Therapeutic Communication

  1. Silence
  2. Accepting
  3. Giving Recognition
  4. Offering Self
  5. Giving Broad Openings
  6. Offering General Leads
  7. Placing the event in Time or In Sequence
  8. Making Observation
  9. Encouraging Description of Perception
  10. Encouraging Comparison
  11. Restating
  12. Focusing
  13. Reflection
  14. Exploring
  15. Giving Information
  16. Seeking Clarification
  17. Presenting Reality
  18. Asking Direct Questions
  19. Summarizing
  20. Voicing
  21. Seeking Consensual Validation
  22. Verbalizing the Implied
  23. Encouraging Evaluation
  24. Attempting to Translate into Feeling
  25. Suggesting Collaboration
  26. Encouraging Formulation of a Plan of Action

Non-therapeutic Communication

  1. Reassuring
  2. Giving Approval
  3. Rejection
  4. Disapproving
  5. Agreeing
  6. Disagreeing
  7. Advising
  8. Probing
  9. Challenging
  10. Testing
  11. Defending
  12. Requesting an Explanation (Why questions)
  13. Indicating the Existence of an External Source
  14. Belittling
  15. Stereotyping
  16. Giving Literal Responses
  17. Denial
  18. Interpreting
  19. Avoidance

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: verbalization of thoughts and feelings, relaxation techniques (e.g., deep breathing, mindfulness).
  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 (selective inattention)
    • 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 if indicated
  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).
TypePerceptionBehavioralCopingNursing ManagementMedical Management
MildWidenedAlert, Energetic, AttentiveAdaptiveEncourage verbalizationN/A
ModerateNarrowedDistracted, PacingPalliativeRefocus (grounding techniques), Supervision, KISSPO Anxiolytic
SevereDistortedImpaired thinking, Confusion, DisorientationExcessive, MaladaptiveRelaxation, Less Stimuli, Presence, ListeningIM Anxiolytic
PanicDisorganizedImmobilization, Mute/Hysterical, Irrational, Overwhelmed (Suicidal), Potential Hallucination/DelusionDysfunctionalSafety, 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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