MHN Questions & Answers

LOURDE COLLEGE OF NURSING, TALIPARAMBA-670143
MENTAL HEALTH NURSING

QUESTIONS & ANSWER KEY
UNIT I-INTRODUCTION
I.ESSAYS (12 each)

1. Define mental health, components of mental health?
2. Concepts of normal and abnormal behaviour?
II.SHORT ESSAYS (7 mk each)

1. Multidisciplinary team or mental health team?
SHORT NOTES (5 MKS each)

1. Etiology of mental health illness?
2. Defence mechanisms?
III. DIFFERENCIATE BETWEEN (4mks each)

1. Precipitating factors and perpetuating factors
2. Statistical model and sociocultural model
IV. ANSWER BRIEFLY(2mks each)

1. Mental health
2. Supression
3. Dissociation
ANSWER KEY
ESSAY
1. It is a state of balance between the individual and the surrounding world, a state of
harmony between oneself and others, a co-existence between the realities of the self
and that of other people and the environment.
Componenets
✓ The ability to accept self:-
A mentally healthy person feels comfortable about himself, and has self respect. He feels
reasonably secure and adequate accepts his shortcomings.
✓ The capacity to feel right toward others:-
An individual who enjoys good mental health is able to be sincerely interested in others welfare.
He has friendships that are satisfying and lasting. He is able to feel a part of a group without
being submerged by it. He takes responsibility for his neighbours and his fellow Members.
✓ The ability to fulfil lifes task:-
The third important component of mental health is that it bestows on an individual the ability to
meet the demands of life. Think of him, set reasonable goals and take his own decisions. He has
friendships that are satisfying and lasting. He is able to feel a part of a group without being
submerged by it. He takes responsibility for his neighbours and his fellow Members.
2. Several models have been put forward inorder to explain the concept of normal
abnormal behaviour.
✓ Medical model:-
Medical model considers organic pathology asthe definite cause for mental disorder. Accordingto
this model abnormal people are the ones who have disturbances in thought, perception and
psychomotor activities. The normal are the ones who are free from these disturbances.
✓ Statistic model:-
It involves the analysis of responses on a test or aquestionnaire or observations of some particular

behavioral variables.Thedegree of deviation from the standard norms arrived at
statistically,characterizes the degree of abnormality.Statisticallynormal mental health falls within
two standard deviations (SDs) of the normal
distribution curve.
✓ Sociocultural model:-
The beliefs, norms, taboos and values of a societyhave to be accepted and adopted by individuals.
Breaking any of these would be considered as abnormal. Normalcy is defined in context withsocial
norms prescribed by the culture. Thus cultural background has to be taken into account when
distinguishing between normal and abnormal behaviour.
✓ Behaviour model:-
Behaviour hat is adaptive is normal, maladaptive is abnormal. Abnormal behaviour is a set of

faulty behaviours acquired through learning.
II. SHORT ESSAY
1. It is collaboration between members of different disciplines who provide specific services o

the patient.
• A psychiatrist
• A psychiatrist nurse
• A clinical psychologist
• A psychiatric social worker
• An occupational therapist
• A pharmacist and a dietician
• A counsellor
A Psychiatrist is a medical doctor with special training in psychiatry. He is accountable for the
medical diagnosis and treatment of patient. Other important functions are:
• Admitting patient into acute care setting
• Prescribing and monitoring psychopharmacologic
agents
• Administering electroconvulsive therapy
•Conducting individual and family therapy
• Participatingininterdisciplinaryteammeetings
• Owing to their legal power to prescribe and towrite orders, psychiatrists often function as leaders
of the team.
A Psychiatric nurse is a registered nurse withspecialized training in the care and treatment of
psychiatric patients; she may have a Diploma,MSc.,M.Phil. or Ph.Din psychiatric nursing. She is
accountable for the bio-psychosocial nursing
Care of patients and their milieu. Other functions include:
• Administering and monitoring medications
• Assisting in numerous psychiatric and physical treatments
• Participate in interdisciplinary team meetings
• Teach patients and families
• Take responsibility for patient's records
• Act as patient's advocate
• Interact with patients' significant others
A Clinical psychologist should have a Masters Degree in Psychology or Ph.Din clinical

psychology with specialized training in mental health settings. He is accountable for psychological
assessments, testing, and treatments. He offers
Direct services such as individual, family or marital therapies.
A Psychiatric social worker should have a Masters Degree in Social Work or Ph.D degree with
specialized training in mental health settings. He is accountable for family case work and
community placement of patients. He
conducts group therapy sessions. He emphasizes intervention with the patient in social
nenvironment in which he will live.
An Occupational therapist or an Activitytherapist is accountable for recreational, occupational

and activity programs. He assists the patients to gain skills that help them cope more effectively
to gain or retain employment, to
use leisure time.
A Counselor provides basic supportive counseling and assists in psycho educational and
recreational activities.
III. SHORT NOTES ANSWER KEY
1. Many factors are responsible for the causation of mental illness. These factors may predispose
an individual to mental illness, precipitate or perpetuate the illness.-
✓ Predisposing factors:- These factors determine an individual's susceptibility
to mental illness. They interact with precipitating factors resulting in mental illness.These are:
• Genetic make up
• Physical damage to the CNS.
• Adverse psychosocial influence.
✓ Precipitating factors:- These are events that occur shortly before the
onset of a disorder and appear to have induced it.
• Physical stress
• Psychosocial stress
Perpetuating factors:- These factors are responsible for aggravating or prolonging the diseases
already existing in anindividual. Psychosocial stress is an example.Thus etiological factors of
mental illness can be:
• Biological factors
• Physiological changes
• Psychological factors
• Social factors
Biological Factors
Heredity
What one inherits is not the illness or its symptoms,but a predisposition to the illness, which is
determined by genes that we inherit directly.Studies have shown that three-fourths of mental
defectives and one-third of psychotic individuals owe their condition mainly to unfavourable
heredity.
Biochemical Factors
Biochemical abnormalities in the brain are considered to be the cause of some
psychologicaldisorders. Disturbance in neurotransmitters in the
Brain Damage
Any damage to the structure and functioning of the brain can give rise to mental illness. Damage
to the structure of the brain may be due to one ofthe following causes:
• Infection:E.g.Neurosyphilis, encephalitis,HIV
infection, etc.
• Injury: Loss of brain tissue due to head injury
• Intoxication: Damage to brain tissue due to toxins such as alcohol, barbiturates, lead, etc.
• Vascular: Poor blood supply, bleeding (intracranial hemorrhage, subarachnoid hemorrhage,
subdural hemorrhage)
• Alteration in brain function: Changes in blood chemistry that interfere with brain functioning
such as disturbance in blood glucose levels, hypoxia, anoxia, and fluid and electrolyte imbalance
• Tumors: Brain tumors
• Vitamin deficiency and malnutrition, in particular deficiency of vitamin B-complex
• Degenerative diseases: Dementia
• Endocrine disturbances: Hypothyroidism,
thyrotoxicosis etc.
• Physical defects and physical illness: Acute physical illness as well as chronic illnesses with all
their handicapping conditions may result in loss of mental capacities
Physiological Changes
It has been observed that mental disorders are more likely to occur at certain critical periods of
life namely-puberty, menstruation, pregnancy, delivery, puerperium and climacteric. These
periods are marked not only by physiological
(endocrine) changes, but also by psychological issues that diminish the adaptive capacity of the
individual. Thus the individual becomes more susceptible to mental illness during this period.
Psychological Factors
• It is observed that some specific personality types are Psychological factors like strained
interpersonal relationships at home, place of work, school or college, bereavement, loss of
prestige, loss of job, etc.
• Childhood insecurities due to parents with pathological personalities, faulty attitude of parents
(over-strictness, over leniency),abnormal parent-child relationship (overprotection, rejection,
unhealthy comparisons), deprivation of child's essential psychological and social needs, etc.
• Social and recreational deprivations resulting in boredom, isolation and alienation.
• Marriage problems like forced bachelorhood, disharmony due to physical, emotional, social,
educational or financial incompatibility, childlessness, too many children, etc.
• Sexual difficulties arising out of improper sex education, unhealthy attitudes towards sexual
functions, guilt feelings about masturbation, pre and extra marital sex relations, worries about
sexual perversions.
• Stress, frustration and seasonal variations are sometimes noted in the occurrence of mental
diseases.
Social Factors
• Poverty, unemployment, injustice, insecurity, migration, urbanization
• Gambling, alcoholism, prostitution, broken homes, divorce, very big family, religion,
traditions, political upheavals and other social crises.
2. DEFENCE MECHANISM:-
1. Denial
Denial is the refusal to accept reality or fact, acting as if a painful event, thought or feeling did
not exist. It is considered one of the most primitive of the defense mechanisms because it is
characteristic of early childhood development. Many people use denial in their everyday lives to
avoid dealing with painful feelings or areas of their life they don’t wish to admit. For instance, a
person who is a functioning alcoholic will often simply deny they have a drinking problem,
pointing to how well they function in their job and relationships.
2. Regression
Regression is the reversion to an earlier stage of development in the face of unacceptable
thoughts or impulses. For an example an adolescent who is overwhelmed with fear, anger and
growing sexual impulses might become clingy and start exhibiting earlier childhood behaviors
he has long since overcome, such as bedwetting. An adult may regress when under a great deal
of stress, refusing to leave their bed and engage in normal, everyday activities.
3. Acting Out
Acting Out is performing an extreme behavior in order to express thoughts or feelings the person
feels incapable of otherwise expressing. Instead of saying, “I’m angry with you,” a person who
acts out may instead throw a book at the person, or punch a hole through a wall. When a person
acts out, it can act as a pressure release, and often helps the individual feel calmer and peaceful
once again. For instance, a child’s temper tantrum is a form of acting out when he or she doesn’t
get his or her way with a parent. Self-injury may also be a form of acting-out, expressing in
physical pain what one cannot stand to feel emotionally.
4. Dissociation
Dissociation is when a person loses track of time and/or person, and instead finds another
representation of their self in order to continue in the moment. A person who dissociates often
loses track of time or themselves and their usual thought processes and memories. People who
have a history of any kind of childhood abuse often suffer from some form of dissociation.
In extreme cases, dissociation can lead to a person believing they have multiple selves people
who use dissociation often have a disconnected view of themselves in their world. Time and
their own self-image may not flow continuously, as it does for most people. In this manner, a
person who dissociates can “disconnect” from the real world for a time, and live in a different
world that is not cluttered with thoughts, feelings or memories that are unbearable.
5. Compartmentalization
Compartmentalization is a lesser form of dissociation, wherein parts of oneself are separated
from awareness of other parts and behaving as if one had separate sets of values. An example
might be an honest person who cheats on their income tax return but is otherwise trustworthy in
his financial dealings. In this way, he keeps the two value systems distinct and sees no hypocrisy
in doing so, perhaps remaining unconscious of the discrepancy.
6. Projection
Projection is the misattribution of a person’s undesired thoughts, feelings, or impulses onto
another person who does not have those thoughts, feelings or impulses. Projection is used
especially when the thoughts are considered unacceptable for the person to express, or they feel
completely ill at ease with having them. For example, a spouse may be angry at their significant
other for not listening, when in fact it is the angry spouse who does not listen. Projection is often
the result of a lack of insight and acknowledgement of one’s own motivations and feelings.
7. Reaction Formation
Reaction Formation is the converting of unwanted or dangerous thoughts, feelings or impulses
into their opposites. For instance, a woman who is very angry with her boss and would like to
quit her job may instead be overly kind and generous toward her boss and express a desire to
keep working there forever. She is incapable of expressing the negative emotions of anger and
6. Projection

6. Projection
8. Repression
Repression is the unconscious blocking of unacceptable thoughts, feelings and impulses. The key
to repression is that people do it unconsciously, so they often have very little control over it.
“Repressed memories” are memories that have been unconsciously blocked from access or view.
But because memory is very malleable and ever-changing, it is not like playing back a DVD of
your life. The DVD has been filtered and even altered by your life experiences, even by what
you’ve read or viewed.
9. Displacement
Displacement is the redirecting of thoughts feelings and impulses directed at one person or
object, but taken out upon another person or object. People often use displacement when they
cannot express their feelings in a safe manner to the person they are directed at. The classic
example is the man who gets angry at his boss, but can’t express his anger to his boss for fear of
being fired. He instead comes home and kicks the dog or starts an argument with his wife. The
man is redirecting his anger from his boss to his dog or wife. Naturally, this is a pretty
ineffective defense mechanism, because while the anger finds a route for expression, it’s
misapplication to other harmless people or objects will cause 10.
10. Intellectualization
Intellectualization is the overemphasis on thinking when confronted with an unacceptable
impulse, situation, or behavior without employing any emotions whatsoever to help mediate and
place the thoughts into an emotional, human context.
IV. DIFFERENCIATE BETWEEN

1. Precipitating factors is which occur shortly before the onset of a disorder, and perpetuating
factors is responsible for aggravating or prolonging the disease already exist in an individual
2.Statistical model involves the analysis of responses on a test or a questionnaire or observation

of some particular behaviour variables, and sociocultural model is the , norms, taboos and values
of society have to be accepted and adopted by individual’s breaking any of these would be
considered as abnormal.
V. ANSWER BRIEFLY
1.Mental health is defines as a state of well being in which an individual realizes his or her own
abilities can cope with the normal stresses of life.
2. Suppression is the act of keeping something from happening.eg. A government stopping citizens
from participating in a certain activity.
3.Dissociation is when a person loses track of time and/or person, and instead finds another
representation of their self in order to continue in the moment. A person who dissociates often
loses track of time or themselves and their usual thought processes and memories. People who
have a history of any kind of childhood abuse often suffer from some form of dissociation
UNIT II –PRINCIPLES AND CONCEPTS OF MHN
I. ESSAY (12MKS EACH)
1. Scope psychiatric nursing?

2. General principles of psychiatric nursing?
II.SHORT ESSAYS (7 mk each)
1. Qualities of a psychiatric nurse?

2. Therapeutic roles of a psychiatric mental health nurse
III.SHORT ANSWERS
1. Functions of psychiatric nursing?
IV .DIFFERENCIATE BETWEEN
1. Collaborator and case manager
2. Self awareness and self acceptance
V. ANSWER BRIEFLY
1. Direct care provider
ANSWER KEY
I. ESSAY
1. Scope of psychiatric nurse faces various challenges because of changes in patient care
approach.
✓ Demographic changes-type of family, increasing number of the elderly group
✓ Social changes changes- The need for maintaining intergroup and

intragroup loyalties and Peer pressure
✓ Economic changes-indusrialization, urbanization, raised standard of living

✓ Technological changes-mass media , electronic systems, techanology
✓ Mental health care changes-increased mental health problems.
Educational Programs for the Psychiatric Nurse

• Diploma in Psychiatric Nursing (The first program was offered in 1956 at NIMHANS,
Bangalore).
• M.Sc in Psychiatric Nursing (The first program was offered in 1976at Rajkumari Amrit Kaur
College of Nursing, New Delhi).
M.Phil in Psychiatric Nursing (1990, M.G. University, Kottayam).
• Doctorate in Psychiatric Nursing (offered at MAHE, Manipal; RAK College of Nursing,
Delhi;NIMHANS, Bangalore).
• Short-term training programs for both the degree and diploma holders in nursing
Promotion of Research in Mental Health Nursing

The nurse contributes to nursing and the mental Promotion of Research in
Mental Health Nursing The nurse contributes to nursing and the mental
New Trends in Role of a Psychiatric Nurse

Primary Mental Health Nursing:-
Psychiatric nurses are moving into the domain of primary care and working with other nurses and
physicians to diagnose and treat psychiatric illness in patients with somatic complaints.
Cardiovascular, gynecological, respiratory, and gastrointestinal and family practice settings are
appropriate for assessing patients for anxiety, depression and substance abuse disorders.
Collaborative Psychiatric Nursing Practice:-
Patients who are having difficulty being stabilized on their medications or who have co-morbid
medical illnesses are seen in a psychiatric nursing clinic where nurses and physicians collaborate
to provide high quality patient care.
Registered Psychiatric Nurse (RPN):-

A Registered Psychiatric Nurse provides psychiatric /mental health nursing care to individuals,
families, and groups to enable them to function at an optimal level of psychological wellness
through more effective adaptive behaviors and increased resilience to stress. She must be able to
provide safe, basic physical care, have a wide understanding of psychological and developmental
problems and their treatment and have a highly developed level of communication skills.
Clinical Nurse Specialist (CNS)

The Clinical Nurse Specialist provides consultative services to nursing personnel. She attends
clinical teaching programs, demonstrates therapies,
conducts in-service education programs, initiates and participates in curriculum revision/changes
and nursing research.
Case Management
Using case management a psychiatric mental health nurse is responsible for assessing needs,
identifying services, and monitoring and evaluating client status. A case manager coordinates care
through collaboration with all involved
Health professionals ensuring accessibility and availability of care.
Nurse Psychotherapist
The psychiatric nurse can take up psychotherapy roles as in individual therapy, group therapy,
counseling, etc.
2. The general principles of psychiatric nursing include:-

✓ Patient is accepted as he is:-
Accepting means being non-judgmental. Acceptance conveys the feeling of being loved and
cared. Acceptance does not mean complete permissiveness
but setting of positive behaviors to convey to him the respect as an individual human being. A
nurse should be able to convey to the patient that she may not approve everything what he does,
but he will not be judged or rejected because of his behavior. Acceptance is expressed in the
following
ways:
a) Being non-judgemental and non punitive

The patient's behavior is not judged as right or
Wrong, good or bad. Patient is not punished for
His undesirable behaviour.
Being sincerely interested in the patient:- Being sincerely interested in another individual means
considering the other individual's interest.
This can be demonstrated by:
• Studying patient's behavior pattern.
• Allowing him to make his own choices and decisions as far as possible.
a) Being aware of his likes and dislikes.
b) Recognizing and reflecting on feelings which patient may express
c) Talking with a purpose
d) Listening
e) Permitting patient to express strongly held feelings.
✓ Use self understanding as a therapeutic tool:-
A psychiatric nurse should have a realistic self concept and should be able to recognize one's
own feelings, attitudes and responses. Her ability to be aware and to accept her own strengths
and limitations should help her to see the strengths and limitations in other people too. Self
understanding helps her to be assertive in life situations without being aggressive and feeling
guilty.
✓ Consistency used to contribute to patients security:-
This means that there should be consistency in the attitude of the staff, ward routine and in
defining the limitations placed on the patient.
✓ Reassurance should be given in subtle and acceptable manner:-

Reassurance is building patient's confidence. To give reassurance, the nurse needs to
understand and analyze the situation as to how it appears to the patient.
✓ Patients behaviour is changed through emotional experience and not by rational

interpretation:-
Major focus in psychiatry is on feelings and on the intellectual aspect. Advising or rationalizing
with patients is not effective in changing
Behaviour.
✓ Unnecessary increase in patients anxiety should be avoided:-

The following approaches may increase the patient's anxiety and should, therefore,
be avoided. Showing nurse's own anxiety. Showing attention to the patient's
deficits. Making the patient to face repeated failures. Placing demands on patient
which he
Obviously cannot meet.
✓ Objective observation of patient to understand his behaviour:-
Objectivity is an ability to evaluate exactly what the patient wants to say and not
mix up one's own feelings, opinion or judgment. To be objective, the nurse should indulge in
introspection and make sure that her own emotional needs do not take a precedence over patient's
needs.
✓ Maintain realistic nurse-patient relationship:-
Realistic or professional relationship focuses upon the personal and emotional needs of the
patient and not on nurse's needs. To maintain
Professional relationship the nurse should have empathizes and understand the feelings of the
patient and the meaning of behaviour.
✓ Avoid physical and verbal force as much as possible :-

All methods of punishment must be avoided. If the nurse is an expert in predicting
patient behavior, she can mostly prevent an onset of undesirable behaviour.
✓ Nursing care is cantered on the patient as a person not on the control of symptoms:-
Analysis and study of symptoms is necessary to reveal their meaning and their significance to the
patient. Two patients showing the same symptoms
may be expressing two different needs.
✓ All explanations of procedures and other routines are given according to the
patient’s level of understanding:-
The extent of explanation that can be given to a patient depends on his span of attention, level of
anxiety and level of ability to decide.
✓ Many Procedures are Modified but Basic

Principles Remain Unaltered:-
In psychiatric nursing field, many methods are adapted to individual needs of the patients, but
the underlying nursing scientific principles remain the same. Some nursing principles to be kept
in mind are: safety, comfort, and privacy, maintaining therapeutic effectiveness, economy of
time, energy and material.
II.SHORT ESSAY
1. The qualities of a psychiatric nurse include:-

✓ Self awareness:-
A Psychiatric nurse should have a realistic self concept and should be able to recognize her own
feelings, fantasies and fears. She should analyze her own professional strengths and limitations.
Her ability to be aware and to accept her own strengths and limitations should help her see the
strengths and limitations in other people.
✓ Self acceptance:-
The nurse should not only be aware, but also accept her strengths as well as her limitations. Self-
understanding helps her to be assertive in life situations without being aggressive and feeling
guilty.
✓ Accepting the patient
Accepting means, being non-judgmental. Acceptance conveys the feeling of being loved and
cared .The nurse should accept the patient as he is, as a sick person, regardless of caste, color,
race or behavior.
✓ Being sincerely interested in patient care

Being sincerely interested in patient care means considering the patients interest. This can be
demonstrated by:
• Studying patient's behavior pattern
• Allowing him to make his own choices and decisions as far as possible
• Being aware of his likes and dislikes
• Being honest with him
• Active listening.
✓ Being available
Being available means nurse should be approachable

all the time to the patient. She should convey to the patient that she is available not only to meet
his physical needs, but also to assist him in dealing with his psychological needs.
✓ Empathetic with the patient
Being available means nurse should be approachable all the time to the patient. She should convey
to the patient that she is available not only
to meet his physical needs, but also to assist him in dealing with his psychological needs.
✓ Reliability
The nurse must demonstrate honesty, truthfulness, resourcefulness and competence in her
dealings with the patients and their families. She must prove herself to be trustworthy and as a
person who can be relied upon in any situation.
✓ Professionalism
Developing the professional skills of a psychiatric nurse is dependent upon learning as much as
possible about the patient, his illness and the helping role of the nurse as it specifically applies to
the patient.
✓ Accountability
According to Peplau (1980), the need for personal accountability and professional integrity are
greater in psychiatric practice than in any other
Type of health care. Patients in mental health settings are usually more vulnerable and defenseless
than patients in other health care settings, particularly because their conditions hinder their
thinking processes and their relationships with others.
✓ The ability to think critically
The ability to think critically is crucial for mental health nurses. A critical thinker
analyzes information before drawing conclusions about it.It is purposeful, reasonable,
reflective thinking that drives problem solving and decision making and aims to make
judgments based on evidence.
2. Therapeutic roles of a psychiatric mental health nurse :-

✓ Direct care provider:-
A Psychiatric nurse provides nursing care to individuals, families and groups to enable them to
function at an optimal level of psychological wellness. As a direct care provider the nurse assists
the client to regain health through the healing process.
✓ Provider of therapeutic environment for the patient
The psychiatric nurse has always had a central role in maintaining a therapeutic environment.The
nurse assesses potentially stressful characteristics of the environment and develops strategies to
eliminate or decrease these stresses in the environment.
✓ Teacher /educator
It is one of the primary intervention strategies the nurse uses in improving mental health.Some
topics that nurse’s address in their education includes the following:
• Medication management
• Illness management
• Communication skills
• Coping skills
• Handling of stress and anxiety
• Dealing with emergencies
✓ Coordinator:-
Nurse as a coordinator, cooperates with other professionals in various aspects of the client's care;
thereby facilitating an inter disciplinary
Approach to care.
✓ Patient advocate:-
As the health care system has become more complex with a number of different agencies and an
increasing variety of care providers concerned with different aspects of the patient's care, the
need for someone who can speak on the patient's behalf and intercede in his interests has become
Essential.
✓ Provider of preventive care:-
Preventive care includes health promotion, illness prevention, and protection against diseases.
The following activities are carried out by a psychiatric nurse for prevention of mental illnesses:-
Providing information about mental health issues, such as communication skills, parenting, stress
reduction, coping strategies and relaxation techniques and counseling
• Making appropriate referrals as indicated to prevent occurrence of mental illness
• Working with community groups on issues related to mental health
✓ Collaborator
As members of the health care team, nurses must work with other team members to ensure that
patients receive the highest quality of care possible. In psychiatry, every patient must have an
individualized treatment plan that reflects the collaborative efforts of nursing, psychiatry, social
work, occupational therapy, recreational therapy and other specialties that are involved in the
patient's care.
✓ Case manager
In case management the nurse co-ordinates the activities of the other health care providers in
collaboration with the direct care providers. The case manager focuses on moving the client
through the health care environment, assisting with scheduling of tests and procedures and
interacting with various care providers.
✓ Professional role
Nurses have a responsibility to contribute to the growth of self and of the profession. The nurse
participates in continuing professional educational activities and promotes activities designed to
improve psychiatric nursing practice and care.
✓ Researcher
A Psychiatric nurse utilizes therapeutic principle and research to understand and interpret the
client's emotions, thoughts and behaviors. She also involves in research activities to incorporate
new research findings into practice and monitor the protection of human subjects.
SHORT NOTES
1. The functions of psychiatric nursing include:-

✓ Assessing the client and planning the nursing care
✓ Providing safe nursing care ,including medication administration , and participation
in various therapies ,individual interactions, formal and informal group situations
,role playing ,advocating on behalf of the client
✓ Accurately observing and documenting the clients behaviour
✓ Providing feed back to the client based on observations of his behaviour
✓ Teaching the client and significant others
✓ Involving the client and significant others in nursing process
✓ Providing opportunities’ for the client to make his own decisions and to assume
responsibilities for his own emotions and life
✓ Cooperating with other professionals in various aspects of the clients care
✓ Continuing nursing education and the explorations of new ideas, theories and
research.
IV.DIFFERNCE BETWEEN ANSWER KEYS
1. Collaborator and case manager -

Collaborator it is one of the therapeutic role of a nurse , member of health care team, nurses must
work with other team nurses must work with other team members to ensure that patients receive
the highest quality of care.
Case manager is also one of the therapeutic roles of a nurse case manager follow a client across
all settings, including ambulatory care and home care.
2. Self awareness and self acceptance:-

Self awareness is one of the qualities of a psychiatric nurse; she should have a realistic self concept
and should be able to recognize her own feelings, fantasies and fears. Self acceptance is also one
of the other qualities of a psychiatric nurse, not only be aware but also accept her strengths as well
as her limitations.
V. SHORT ANSWERS
1. Direct care provider is one the therapeutic role of a psychiatric nurse, who provides
direct nursing care to individuals, families and groups to enable them to function at an
optional level of psychological wellness.
UNIT-III – PSYCHIATRIC ASSESSMENT

History collection
Mental status examination
Differentiate between:
1. Thought insertion Thought withdrawal

Thought insertion: The delusional belief that Thought withdrawal: The delusional belief
thoughts are being put into one's mind. These that one's thoughts are taken away by some
thoughts external
are recognized as being foreign. agent, often associated with thought block.
2. Transference Counter transference

Transference: A process in which feelings, Counter transference is the reverse of
attitudes and wishes originally linked with transference.
significant figures in one's early life are The nurse may have unresolved
projected onto the therapist. problems from an earlier relationship. She
may
unconsciously transfer inappropriate
attributes
to a client that was experienced in that
earlier relationship. The client's transference
provokes the nurse's counter transference
reactions.
3. Thought block Thought broadcast

Thought block: A sudden interruption in the Thought broadcast: The delusional belief that
thought process before the thought is one's thoughts are being broadcast or
completed. After a projected into the
pause, the subject cannot recall what he had environment.
meant to say. This may be associated with
thought
withdrawal. Thought block is strongly
suggestive of schizophrenia.
4. Tangentiality: Circumstantiality
Tangentiality: A form of thinking/ speech in Circumstantiality: A pattern of
which the client tends to wander away from communication that is demonstrated by the
the intended speaker's inclusion of
point, and never returning to the original idea. many irrelevant and unnecessary details in his
speech before he is able to come to the point.
5. Stupor Stereotypes
Stupor: A state in which the individual does Stereotypes: Persistent mechanical repetition
not react to his surroundings and appears to of speech or motor activity.
be unaware
of them. Commonly seen in catatonic and
depressive disorders.
6. Perseveration Verbigeration
Perseveration: Persistent repetition of words Verbigeration: Senseless repetition of some
or themes beyond the point of relevance. words or phrases over and over again.
7. Phobia Delusion:
Phobia: Persistent, irrational, exaggerated and Delusion: A false, unshakeable belief, which
invariably pathological dread of a specific is not amenable to reasoning and is not in
stimulus or keeping with
situation; results in a compelling desire to the patient's sociocultural and educational
avoid the feared stimulus. background.
8. Obsession Compulsion
Obsession: Pathological persistence of an Compulsion: Pathological need to act on an
irresistible thought or feeling that cannot be impulse that, if resisted, produces anxiety;
eliminated from repetitive
consciousness by logical effort; associated behavior in response to an obsession or
with anxiety. performed according to certain rules, with no
true end in itself
other than to prevent something from
occurring in the future (the patient fears
something bad will
occur in future if he does not indulge in such
behaviors).
9. Neologism Clang association

Neologism: Aword newly coined or an Clang association: Client uses two words with
everyday word used in a special way, not a similar sound, i.e. his choice of words is
readily understood determined
by others. by their sound and not by their meaning,
which often reduces the intelligibility of
speech. It may lead
to punning (humorous use of words to
suggest different meanings) and rhyming, and
is often seen in
manic patients.
10. Loosening of associations Flight of ideas

Loosening of associations: A pattern of Flight of ideas: The client's thoughts and
spontaneous speech in which things said lack conversation move quickly from one topic to
a meaningful another, so that
relationship, or there is idiosyncratic shifting one train of thought is not completed before
from one frame of reference to another; it is another appears. These rapidly changing
usually the topics are
general lack of clarity in the client's understandable because the links between
conversation that makes the most striking them are normal, a point that differentiates
impression. them from
loosening of associations. Flight of ideas is
characteristic of mania.
11. Illusion Hallucinations

Illusion: The misinterpretation of a real, Hallucinations: Afalse sensory perception in
external sensory experience. the absence of an actual external stimulus.
Hallucinations
may be described in terms of their sensory
modality as visual, auditory,
olfactory,gustatory, tactile.
12. Echolalia Echopraxia

Echolalia: Pathological repetition by imitation Echopraxia: Pathological repetition by
of the speech of another. imitation of the behavior of another
.
13. Confabulation Amnesia

Confabulation: The unconscious filling of Amnesia: Pathological impairment of
memory gaps by imagined or untrue memory.
experiences due to Anterograde amnesia: Amnesia of events
memory impairment. It is most often occurring after the episode which precipitated
associated with organic pathology the disorder.
Retrogradeamnesia:Amnesia of events
occurring prior to the episode which
precipitated the disorder.
14. Anhedonia Apathy
Anhedonia: Inability to experience pleasure in Apathy: Lack of emotional feeling
any activity.
.
15. Therapeutic relationship Social relationship

Technique A planned therapeutic Just happens with mutual interests.
relationship.
Objective Helping the patient. Satisfying the needs of each other.
Duration Usually time is limited. Varies, may last for years.
Accountability Nurse is accountable for the Both are responsible and

goals of the relationship. Accountable.
Acceptance Nurse accepts patient as Personal/ emotional

"here and now", without attachment and interest
any personal or emotional involved.
attachments and interests.
Termination An important part of the Relationship may exist

relationship, it is planned lifelong or terminate
and discussed with the gradually.
patient.
16. Physical Investigations for Psychiatric Patients

(A)Routine: general screening e.g. hemogram, urinalysis (Additional investigations may be
ordered in special populations)
(B)Routine: specific
Based on diagnosis-e.g. liver function tests in alcoholics
Based on treatment-e.g, pre-lithium, pre-ECT work-up investigations
Based on ongoing management-e.g. blood counts in patients on clozapine treatment
(C) Non-routine:
Based on need and index of suspicion e.g. thyroid function tests in suspected hypothyroidism
during lithium therapy; pregnancy tests in amenorrhea during treatment with potential
teratogens.
(D) Common neuropsychiatry investigations

• Electroencephalogram (EEG)
• Computed tomographic (CT) scanning
• Magnetic resonance imaging
• The sleep EEG (polysornnogram)
UNIT –IV - THE THERAPUTIC NURSE-PATIENT RELATIONSHIP
ESSAY (12 MKS EACH)

1. Phases of therapeutic nurse patient relationship?
2. Therapeutic communication techniques?
II. SHORT ESSAY (7MKS EACH)

3. 1. Types of relationship, explain phases task of therapeutic communication?
III.SHORT NOTES (5 MKS)

1. List the characteristics of therapeutic nurse patient relationship?
2. Components of therapeutic relationship?
1. Therapeutic and social relationship
2. Transference and counter transference
3. Rapport and resistance
4. Empathy and sympathy
V. ANSWER BRIEFLY
1. Rapport
2. Countertransference
ANSWER KEY
ESSAY (12)
1. There are mainly four phases in therapeutic relationship they are as follows:-
✓ Pre-interaction phase :-
During the introductory phase that the nurse And patient meet for the first time. One of
the primary concerns is to find out why the patient sought help. This forms the basis of
the nursing assessment and helps the nurse to focus the patient's problem and to
determine patient's level of motivation.
✓ Introductory or orientation phase: -
This phase begins when the nurse is assigned to initiate a therapeutic relationship and includes
all that the nurse thinks, feels or does immediately
Prior to the first interaction with the patient. The nurse's initial task is one of self-exploration.
The nurse may have misconceptions and prejudices about psychiatric patients and may have
feelings and fears common to all novices. Many nurses express feelings of inadequacy and fear
of hurting or exploiting the patient. Another common fear of nurses is related to the stereotyped
psychiatric patients' abusive and violent behaviour.
Working phase: -
Most of the therapeutic work is carried out during the working phase. The nurse and the patient
explore relevant stressors and promote the development of insight in the patient. By linking
perceptions, thoughts, feelings and actions, the nurse helps the patient to master anxieties,
increase independence and coping mechanisms. Actual behavioural change is the focus of
attention
Termination phase: - This is the most difficult, but most important phase of the therapeutic
nurse-patient relationship. The goal of this phase is to bring a
Therapeutic end to the relationship. Criteria for determining patient's readiness for termination:
• Patient experiences relief from presenting problems
• Patient's social function has improved and isolation has decreased
• Patient's ego functions are strengthened and he has attained a sense of identity
• Patient employs more effective and productive defense mechanisms
• Patient has achieved the planned treatment goals
2. The Therapeutic communication techniques include:-
✓ Listening: - it is an active process of receiving information’s. Responses on the part of the

nurse such as maintaining eye-to-eye contact, nodding, gesturing and other forms of receptive
non-verbal communication convey
To the patient that he is being listened to and understood.
✓ Broad opening: - encouraging the client selects the topics for discussion.
For example, "What are you thinking about?"Therapeutic value Indicates acceptance by the
nurse and the value of patient's initiative
✓ Restating: - Repeating the main thought expressed by the patient. For example,
"What are you thinking about?" Therapeutic value Indicates acceptance by the nurse and the
value of patient's initiative
✓ Clarification: - attempting to put vague ideas or unclear thoughts of the patient into words.
✓ Reflection: - directing back the patient’s ideas feelings, questions and content. For example
"You are feeling tense and anxious and it is
Related to a conversation you had with your husband last night."
Therapeutic value Validates the nurse's understanding of what the patient is saying and signifies
empathy, interest and respect for the patient.
✓ Humor: - the discharge of energy through comic enjoyment of the imperfect. For example,
"That gives a whole new meaning to the word 'nervous'," said with shared kidding between
the nurse and the patient.
✓ Informing: - the skill of information giving e.g. think you need to know more about your
medications. For example, "I think you need to know more About your medications."
Therapeutic value Helpful in health teaching or patient education about relevant aspects of
patient's well-being and self-care
✓ Focusing: - questions or statements that help the client expand on a topic of importance.
Sharing perceptions: - asking the patient to verify the nurses understanding of what the patient is
thinking or feeling. The skill of information giving.
For example, "I think you need to know more about your medications."
Therapeutic value Helpful in health teaching or patient education about relevant aspects of
patient's well-being and self-care.
✓ Theme identification: - this involving the identification of underlying issues or problems

experienced by the patient.
II. SHORT ESSAY
1. There are mainly three types of relationship they are as follows :-
✓ Social relationship: - it is defined as a relationship that is primarily initiated with the

purpose of friendship, socialization, enjoyment or accomplishing a task.
✓ Intimate relationship: - occurs between two individuals who have an emotional

commitment to each other.
✓ Therapeutic relationship: - this relationship is between the nurse and client differs
from both social and intimate relationship.
The phases are:-

✓ Pre-interaction phase :-
During the introductory phase that the nurse And patient meet for the first time. One of
the primary concerns is to find out why the patient sought help. This forms the basis of
the nursing assessment and helps the nurse to focus the patient's problem and to
determine patient's level of motivation.
✓ Introductory or orientation phase: -
This phase begins when the nurse is assigned to initiate a therapeutic relationship and includes
all that the nurse thinks, feels or does immediately
Prior to the first interaction with the patient. The nurse's initial task is one of self-exploration.
The nurse may have misconceptions and prejudices about psychiatric patients and may have
feelings and fears common to all novices. Many nurses express feelings of inadequacy and fear
of hurting or exploiting the patient. Another common fear of nurses is related to the stereotyped
psychiatric patients' abusive and violent behaviour.
Working phase: -
Most of the therapeutic work is carried out during the working phase. The nurse and the patient
explore relevant stressors and promote the development of insight in the patient. By linking
perceptions, thoughts, feelings and actions, the nurse helps the patient to master anxieties,
increase independence and coping mechanisms. Actual behavioural change is the focus of
attention
Termination phase: - This is the most difficult, but most important phase of the therapeutic
nurse-patient relationship. The goal of this phase is to bring a
Therapeutic end to the relationship. Criteria for determining patient's readiness for termination:
• Patient experiences relief from presenting problems
• Patient's social function has improved and isolation has decreased
• Patient's ego functions are strengthened and he has attained a sense of identity
• Patient employs more effective and productive defense mechanisms
• Patient has achieved the planned treatment goals
III. SHORT NOTES
1. The characteristics of therapeutic nurse patient relationship are as follows:-
✓ The therapeutic relationship is the corner stone of psychiatric mental health nursing. It is
a mutual leaning experience.
✓ It is characterised by the mutual growth other individuals who dare to become related to
discover love , growth and freedom
✓ In a therapeutic relationship the nurse and the patient work together towards the goal.
2. The Components of therapeutic relationship are as follows they are :-
✓ Rapport: - it is a communication especially when useful and harmonious .it is the crux of
a therapeutic relationship between the nurse and the patient. The nurse establishes
rapport through demonstration of understanding warmth and non-judgemental attitude.
✓ Empathy: - it is the ability to feel with the patient while retaining the ability to critically
analyse the situation. It is the ability to put oneself in another person’s circumstances and
feelings.
✓ Warmth: - Warmth is the ability to help the client feel cared for and comfortable. It
shows acceptance of the client as a unique individual. It involves a non-possessive
caring for the client as a person and a willingness to share the client's joys and sorrows.
✓ Genuineness: - Genuineness involves being one's own self. This implies that the nurse
is aware of her thoughts, feelings, values and their relevance in the immediate interaction
with a client. The nurse's response to the client is sincere and reflects her internal
response. It is also important that the nurse's verbal and non-verbal communication
correspond with each other.
IV DIFFERENCE BETWEEN
1. Therapeutic and social relationship: - Therapeutic relationship is primarily initiated with

the purpose of friendship, socialization, enjoyment or accomplishing a task. Therapeutic
relationship is between the nurse and client differs from both social and intimate
relationship.
2. Transference and Counter transference - transference is the unconscious transfer of
qualities or attributes originally associated with another individual by the patient.
Counter transference is the reverse of transference the nurse may have unresolved
problems from an earlier relationship; she may unconsciously transfer inappropriate
attributes to a client that was experienced in the earlier relationship.
3. Rapport and Resistance: - it is a communication especially when useful and harmonious

it is the crux of a therapeutic relationship between the nurse and the patient. The nurse
establishes rapport through demonstration of understanding warmth and non-
judgemental attitude. Resistance is patients attempt to remain unaware of anxiety
producing aspects within him.
4. Empathy and sympathy: - it is the ability to feel with the patient while retaining the
ability to critically analyse the situation. It is the ability to put oneself in another person’s
circumstances and feelings. sympathy is understanding the patients thoughts and feelings
and the nurse is able to maintain sufficient objectivity to allow the patient to achieve
problem solution with minimal résistance
V. ANSWER BRIEFLY
1. Rapport: - it is a communication especially when useful and harmonious .it is the

crux of a therapeutic relationship between the nurse and the patient. The nurse
establishes rapport through demonstration of understanding warmth and non-
judgemental attitude.
2. Counter transference is the reverse of transference the nurse may have unresolved
problems from an earlier relationship; she may unconsciously transfer inappropriate
attributes to a client that was experienced in the earlier relationship.
UNIT-V – Treatment Modalities and therapies used in mental disorders
1. Explain Lithium carbonate. What are the roles of nurse during lithium toxicity?
Mood stabilizers are used for the treatment of bipolar affective disorders. Some commonly used
mood stabilizers are:
• Lithium
• Carbamazepine
• Sodium valproate
Lithium
Lithium is an element with atomic number 3 and atomic weight 7. It was discovered by FJ Cade
in 1949,and is a most effective and commonly used drug in the treatment of mania.
Indications
• Acute mania
• Prophylaxis for bipolar and unipolar mood disorder.
Schizoaffective disorder
• Cyclothymia
• Impulsivity and aggression
• Other disorders:
• premenstrual dysphoric disorder
• bulimia nervosa
• borderline personality disorder
• episodes of binge drinking
• trichotillomania
• cluster headaches
Pharmacokinetics
Lithium is readily absorbed with peak plasma levels occurring 2-4hours after a single oral dose
of lithium carbonate. Lithium is distributed rapidly in liver and kidney and more slowly in
muscle, brain and bone. Steady state levels are
achieved in about 7 days. Elimination is predominantly via kidneys. Lithium is reabsorbed in the
proximal tubules and is influenced by sodium balance. Depletion of sodium can precipitate
lithium toxicity.
Mechanism of Action
The probable mechanisms of action can be:
• It accelerates presynaptic re-uptake and destruction of catecholamines, like norepinephrine
• It inhibits the release of catecholamines at the synapse.
• It decreases postsynaptic serotonin receptor sensitivity.
All these actions result in decreased catecholamine activity, thus ameliorating mania.
Dosage
Lithium is available in the market in the form of the following preparations:
Lithium carbonate: 300mg tablets (e.g. Licab); 400mg sustained release tablets (e.g.Lithosun-
SR)
Lithium citrate: 300mg/ 5ml liquid.
The usual range of dose per day in acute mania is 900-2100mg given in 2-3divided doses. The
treatment is started after serial lithium estimation estimation is done after a loading dose of
600mg or 900 mg of lithium to determine the pharmacokinetics.
Blood Lithium Levels

• Therapeutic levels = 0.8 - 1.2 mEq/L (for treatment of acute mania)
• Prophylactic levels = 0.6 - 1.2 mEq/L (for prevention of relapse in bipolar disorder)
• Toxiclithium levels > 2.0mEq/L
Side Effects
1. Neurological: Tremors, motor hyperactivity, muscular weakness, cogwheel rigidity, seizures,
neurotoxicity (delirium, abnormal involuntary movements, seizures, coma).
2. Renal: Polydipsia, polyuria, tubular enlargement, nephrotic syndrome.
3. Cardiovascular: T -wave depression.
4. Gastrointestinal: Nausea, vomiting, diarrhea, abdominal pain and metallic taste.
5. Endocrine: Abnormal thyroid function, goiter and weight gain.
6. Dermatological: Acneiform eruptions, popular eruptions and exacerbation of psoriasis.
7. Side-effects during pregnancy and lactation: Teratogenic possibility, increased incidence of
Ebstein's anomaly (distortion and downward displacement of tricuspid value in right
ventricle)when taken in first trimester. Secreted
in milk and can cause toxicity in infant.
8. Signs and symptoms of lithium toxicity (serum lithium level >2.0 mEq/L):
• ataxia,
• coarse tremor (hand)
• nausea and vomiting
• impaired memory
• impaired concentration
• nephrotoxicity
• muscle weakness
• convulsions
• muscle twitching
• dysarthria
• lethargy
• confusion
• coma
• hyperreflexia
Management of Lithium Toxicity

• Discontinue the drug immediately.
• For significant short-term ingestions, residual gastric content should be removed by induction
of emesis, gastric lavage and adsorption with activated charcoal.
• If possible instruct the patient to ingest fluids.
• Assess serum lithium levels, serum electrolytes, renal functions, ECGas soon as possible.
• Maintenance of fluid and electrolyte balance.
• In a patient with serious manifestations of lithium toxicity, hemodialysis should be initiated.
Contraindications of Lithium Use

• Cardiac, renal, thyroid or neurological dysfunctions
• Presence of blood dyscrasias
• During first trimester of pregnancy and lactation
• Severe dehydration
• Hypothyroidism
• History of seizures
Nurse's Responsibilities for a

Patient Receiving Lithium
The pre-lithium work up: A complete physical history, ECG, blood studies (TC,DC, FBS,BUN,
creatinine, electrolytes) urine examination (routine and microscopic) must be carried out. It is
important to assess renal function as renal side effects are common and the drug can be
dangerous in an individual with compromised kidney function. Thyroid functions should also be
assessed, as the drug is known to depress the thyroid gland.
To achieve therapeutic effect and prevent lithium

toxicity, the following precautions should be taken:
• Lithium must be taken on a regular basis, preferably at the same time daily (for example, a
client taking lithium on TID schedule, who forgets a dose should wait until the next scheduled
time to take lithium and not take twice the amount at one time, because lithium toxicity can
occur).
When lithium therapy is initiated, mild side effects such as fine hand tremors, increased thirst
and urination, nausea, anorexia etc may develop. Most of them are transient and do not represent
lithium toxicity.
• Serious side-effects of lithium that necessitate its discontinuance include vomiting, extreme
hand tremors, sedation, muscle weakness and vertigo. The psychiatrist should be notified
immediately if any of these effects occur.
• Since polyuria can lead to dehydration with the risk of lithium intoxication, patients should be
advised to drink enough water to compensate for the fluid loss.
• Various situations may require an adjustment in the amount of lithium administered to a client,
such as the addition of a new medicine to the client's drug regimen, a new diet or an illness with
fever or excessive sweating. In this
connection, people involved in heavy outdoor labor are prone to excessive sodium loss through
sweating. They must be advised to consume large quantities of water with salt, to prevent lithium
toxicity due to decreased sodium levels. If severe vomiting or gastroenteritis develops, the
patient should be told to report immediately to the doctor.
These are the conditions that have a high potential for causing lithium toxicity by lowering
serum sodium levels..
• Frequent serum lithium level evaluation is important. Blood for determination of lithium levels
should be drawn in the morning approximately 12-14hours after the last dose was taken.
• The patient should be told about the importance of regular follow up. In every six months,
blood sample should be taken for estimation of electrolytes, urea, creatinine, a full blood count,
and thyroid function test.
1. Electroconvulsive Therapy, types, indication, role of nurse in pre-ECT procedures.

Electroconvulsive therapy is a type of somatic treatment first introduced by Bini and Cerletti in
April 1938. From 1980 onwards ECT is being considered as a unique psychiatric treatment.
Electroconvulsive therapy is the artificial induction of a grandma! seizure through the

application of electrical current to the brain. The stimulus is applied through electrodes that are
placed either bilaterally in the fronto-temporal region, or unilaterally on the non-dominant side
(right side of head in a right-handed individual).
Methods and Types:
• Direct ECT: ECT is given in the absence of anesthesia and muscular relaxation.
• Modified ECT: ECT is given with the use of anesthesia, muscular relaxation and
oxygenation.
Electrodes are placed bilaterally and unilaterally:
• Bilateral ECT: Electrodes are placed 2.5 – 4 cm. above the midpoint, on a line joining the
tragus of the ear and the lateral canthus of the eye.
• Unilateral ECT: Electrodes are placed only on one side, right side of the head in right
handed person.(non dominant side)
INDICATIONS OF ECT:
The indication of ECT depends upon the availability or non availability of psychotropic drugs.
The common conditions for ECT treatment are:
❖ Major depressive episode is primary indication for ECT; 80 percent patients with
major depressive episode respond to ECT treatment.
❖ Involutional Melancholia: 80 to 90 percent of patients show marked improvement
with ECT treatment, better than with drugs.
❖ Psychotic depression.
❖ Unipolar-Bipolor depression.
❖ Depression of old age as long as there is no arteriosclerosis and brain changes.
❖ Post-partum depression.
❖ Manic phase if the patient is terribly disturbed and exhausted.
❖ Catatonia.
❖ Schizophrenia when they are not responding to other therapies.
❖ Other responsive groups to ECT treatment are patients with:
- Premorbid personality
- Stupor (catatonic)
- Previous depressive episode
- Paranoid delusion.
- Anorexia
- Early morning insomnia
- Weight loss
- Lack of concentration
- Ideas of guilt and worthlessness.
- Suicidal thought and suicidal attempts.
ROLE OF NURSE IN ECT TREATMENT:
The psychiatric patients are most frequently hospitalized for ECT treatment. Though some
of the outpatients are also given ECT treatment, it is very important that the patients neither see
nor hear one another during or after treatment until they are in a reasonably improved condition to
understand the effect of therapy.
In a hospital setting where the electroconvulsive therapy is given, the nurse should see to
the set-up which includes:
i. Waiting room or resting room

ii. Treatment room or ECT room
iii. Recovery room or after-care room.
i. WAITING ROOM OR RESTING ROOM:
In this room patients are asked to wait or take rest before electroconvulsive therapy. The room
should be calm with dim lights, light colour of the walls. Put some flowers to give pleasant feelings
to the patient. There should be some magazines to read, so that the patient can divert his mind and
reduce anxiety. Lavatory (toilet) should be attached, because the patient needs to empty his
bladder and bowels before getting ECT. The nurse should always be available in this room so that
the patient and relatives can clarify their doubts. Preanasthetic drugs should be kept ready.
ii. TREATMENT ROOM/ECT ROOM:

In the treatment room the nurse needs to do the following preparations:
ARTICLES FOR COMFORT OF THE PATIENT:
The room should be near the waiting room. For privacy a bedside screen, well-padded low
level beds with railings should be placed to prevent injury due to fall.
ARTICLES FOR PREPARATION OF THE PATIENT:
Small pillows to put under the patient’s waist to prevent injury. Mouth gag to prevent injury
to the tongue during convulsion and to keep the airway patent. Tongue spatula, endotrachial
tube and sterile catheter for suction of the respiratory tract. O 2 cylinder and an ambu bag to
give O2 immediately after the therapy and to give artificial respiration, if required.
ARTICLES FOR THE PROCEDURE:
A trolly with an ECT machine in working order, check all the electric plug points. Jelly or
normal saline for putting on electrodes as normal saline is a good conductor of electricity and
it facilitates in passing current. Emergency drugs and a resuscitation tray, mouth wipes, B.P.
apparatus, sterile syringes and spirit swabs. Adequate light. Doctors and nurses should be
present in the ECT room.
NURSING INTERVENTION BEFORE GIVING ECT

❖ Check that a thorough physical examination (heart including ECG, lungs bone, blood for
Hb, urine for sugar and other tests and albumin, and X-rays) is completed.
❖ Written consent or declaration for the treatment from the nearest relative after explaining
the method of treatment and risks. DO NOT TELL THE PATIENT THAT ECT WILL BE
GIVEN. The word current may cause fear in the patient. He may be told that “injection”
will be given unless he is aware of the treatment. Relatives should be explained in detail.
❖ The patient should be given nothing orally before treatment. If he is to be treated in an
emergency it should be two to three hours after breakfast or meals.
❖ Remove metallic articles from his or her body; for example, watch, bangles, ring.
❖ Remove artificial dentures.
❖ Remove lipstick, nail polish or any other make up.
❖ Loosen the tight clothes like necktie in men and blouse or other tight garments in women,
preferably give hospital clothes.
❖ Replace the long acting sedatives with hypnotics.
❖ Encourage the patient to empty his bladder and bowels. He/she should void immediately
before the treatment.
❖ Encourage the patient to maintain his personal hygiene. Remove oil from hair.
❖ Give premedication to the patient, Inj. Atropine and calmpose.
❖ Take the patient on a stretcher to the waiting room.
2. Extra Pyramidal symptoms.

o Neurolepiic-induced parkinsonism: Symptoms include rigidity, tremors, bradykinesia,
stooped posture, drooling, akinesia, ataxia, etc. The disorder can be treated with
anticholinergic agents.
o Acute dystonia: Dystonic movements results from a slow sustained muscular spasm that
lead to an involuntary movement. Dystonia can involve the neck, jaw, tongue and the
entire body (opisthotonos). there is also involvement of eyes leading to upward lateral
movement of the eye known as oculogyric
o crisis. Dystonias can be prevented by anticholinergics, antihistaminergics, dopamine
agonists, beta- adrenergic antagonists, benzodiazepines, etc.
o Akathisia: Akathisia is a subjective feeling of muscular discomfort that can cause

patients to be agitated, restless and feel generally dysphoric. Akathisia can be treated
with propranolol, benzodiazepines and clonidine.
o Tardivedyskinesia:It is a delayed adverse effect of antipsychotics. It consists of

abnormal, irregular choreoathetoid movements of the muscles of the head, limbs and
trunk. It is characterized by chewing, sucking, grimacing and peri-oral movements.
o Neuroleptic malignant syndrome: This is a rare but serious disorder occurring in a small
minority of patients taking neuroleptics, especially high-potency compounds.
3. Classification of Benzodiazepines: Presently benzodiazepines are the drugs of first choice in

the treatment of anxiety, and for the treatment of insomnia.
• Very short-acting: Example, Triazolam, Midazolam.
• Short-acting: Example, Oxazepam (Serepax), Lorazepam (Ativan, Trapex, Larpose),

Alprazolam (Restyl, Trika, Alzolam, Quiet, Anxit)
• Long-acting: Example, Chlordiazepoxide (Librium),Diazepam(Valium,Calmpose),

Clonazepam (Lonazep), Flurazepam (Nindral), Nitrazepam (Dormin).
4. Antabuse Drugs/ Disulfliram therapy
Alcohol deterrent therapy: Deterrent agents are those which are given to desensitize the
individual to the effects of alcohol and maintain abstinence. The most commonly used drug is
disulfiram (tetraethyl thiuram disulfide) or antabuse.
Disulfiram is an important drug in this class and is used to ensure abstinence in the treatment of
alcohol dependence. Its main effect is to produce a rapid and violently unpleasant reaction in a
person who ingests even a small amount of alcohol while taking disulfiram.
Mechanism of action Disulfiram is an aldehyde dehydrogenase inhibitor that interferes with the
metabolism of alcohol and produces a marked increase in blood acetaldehyde levels. The
accumulation of acetaldehyde (to a level of 10times more than that which occurs in the normal
metabolism of alcohol) produces a wide array of unpleasant
reactions called the disulfiram-ethanol reaction (DER), characterized by nausea, throbbing
headache, vomiting, hypotension, flushing, sweating, thirst, dyspnea, tachycardia, chest pain,
vertigo, blurred vision and a sense of impending doom associated with severe anxiety. There
action occurs almost immediately after the ingestion of even one alcoholic drink and may last up
to 30minutes.
Therapeutic indications The primary indication for disulfiram use is as an aversive conditioning
treatment for alcohol dependence.
Side-effects The adverse effects of disulfiram in the absence of alcohol consumption include
fatigue, dermatitis, impotence, optic neuritis, mental changes, acute polyneuropathy and hepatic
damage.
With alcohol consumption the intensity of the disulfiram-alcohol reactions varies with each
patient. In extreme cases it is marked by convulsions, respiratory depression, cardiovascular
collapse, myocardial in infarction and death.
Contraindications
• Pulmonary and cardiovascular disease.
• Disulfiram should be used with caution in patients with nephritis, brain damage,
hypothyroidism, diabetes, hepatic disease, seizures, poly-drug dependence or an abnormal
electroencephalogram.
• Patients at high risk of alcohol ingestion.
Dosage Disulfiram is supplied in tablets of 250and 500mg. The usual initial dose is 500 mg/ day
orally for the first 2 weeks, followed by a maintenance dosage of250mg/ day. The dosage should
not exceed 500mg/ day.
Nurse's responsibility
• An informed consent should be taken before starting treatment.
• Ensure that at least 12hours have elapsed since the last ingestion of alcohol before
administering the drug.
• Patient must be instructed that ingestion of even the smallest amount of alcohol brings on a
disulfiram-ethanol reaction with all its unpleasant effects ; he should therefore be strictly warned
not to take any alcohol whatever.
• The patient should also be warned against ingestion of any alcohol-containing preparations
such as cough syrups, drops of any kind, and alcohol-containing foods and sauces. Advise not to
use alcohol based aftershave lotions and advise against inhalation of paints, warnishes, etc.,
containing alcohol. Any topical applications containing alcohol should also be avoided.
• Caution patient against taking CNS depressants or any OTC(over-the-counter) medications

during disulfiram therapy.
• Instruct patient to avoid driving or other activities requiring alertness until response to drug is
known.
• Patients should be warned that the disulfiram-alcohol reaction may continue for as long as 1 to
2 weeks after the last dose of disulfiram.
Patients should carry identification cards describing disulfiram-alcohol reaction and listing the
name and telephone
number of the physician to be called.
• Emphasize the importance of follow-up visits to the physician to monitor progress in long-term
therapy.
5. What are the psychological therapies? Explain behaviour therapy

There are several kinds of psychological therapies:
• Psychoanalytic therapy
• Behavior therapy
• Cognitive therapy
• Hypnosis
• Abreaction therapy
• Relaxation therapies
• Individual psychotherapy
• Supportive psychotherapy
• Group therapy
• Family and marital therapy
Behavior Therapy
It is a form of treatment for problems in which a trained person deliberately establishes a
professional relationship with the client, with the objective of removing or modifying existing
symptoms and promoting positive personality,
growth and development.
Behavior therapy involves identifying maladaptive behaviors and seeking to correct these by
applying the principles of learning derived from the following theories:
• Classical conditioning model by Ivan Pavlov (1936)
• Operant conditioning model by BF Skinner (1953)
Major Assumptions of Behavior Therapy

Based on the above-mentioned theories, the following are the assumptions of behavior therapy:
• All behavior is learned (adaptive and maladaptive).

• Human beings are passive organisms that can be conditioned or shaped to do anything if
correct responses are rewarded or reinforced.
• Maladaptive behavior can be unlearned and replaced by adaptive behavior if the person
receives exposure to specific stimuli and reinforcement for the desired adaptive behavior.
• Behavioral assessment is focused more on the current behavior rather than on historical
antecedents.
• Treatment strategies are individually tailored.
Behavior therapy is a short duration therapy, therapists are easy to train and it is cost-effective.
Thetotal duration of therapy is usually 6-8weeks.
Initial sessions are given daily but the later sessions are spaced out. Unlike psychoanalysis where
the therapist is a shadow person, in behavior therapy both the patient and therapist are equal
participants. There is no attempt to
unearth an underlying conflict and the patient is not encouraged to explore his past.
Behavior Techniques
(A)Systematic desensitization It was developed by Joseph Wolpe, based on the behavioral
principle of counter conditioning. In this patients attain a state of complete relaxation and are
then exposed to the stimulus that elicits the anxiety response.
The negative reaction of anxiety is inhibited by the relaxed state, a process called reciprocal
inhibition.
It consists of three main steps:
1. Relaxation training
2. Hierarchy construction
3. Desensitization of the stimulus
1. Relaxation training: There are many methods which can be used to induce relaxation, some of
them are:
• Jacobson's progressive muscle relaxation
• Hypnosis
• Meditation or yoga
• Mental imagery
• Biofeedback
2. Hierarchy construction: Here the patient is asked to list all the conditions which provoke
anxiety. Then he is asked to list them in a descending order of anxiety provocation.
3. Desensitization of the stimulus: This can either be done in reality or through imagination. At
first, the lowest item in hierarchy is confronted. The patient is advised to signal whenever
anxiety is produced. With each signal he is asked to relax.
After a few trials, patient is able to control his anxiety gradually.
Indications:
Phobias
Obsessions
Compulsions
Certain sexual disorders
B. Flooding:Thepatient is directly exposed to the phobic stimulus, but escape is made

impossible. By prolonged contact with the phobic stimulus, the therapist's guidance and
encouragement and his modeling behavior reduce anxiety.
Indications: Specific phobias

C. Aversion therapy: Pairing of the pleasant stimulus with an unpleasant response, so that even
in absence of the unpleasant response the pleasant stimulus becomes unpleasant by association.
Punishment is presented immediately
after a specific behavioral response and the response is eventually inhibited.
Unpleasant response is produced by electric stimulus, drugs, social disapproval or even fantasy.
Indications:
Alcohol abuse
Paraphilias
Homosexuality
Transvestism.
D. Operant conditioning procedures for increasing adaptive behavior
1. Positive reinforcement: When a behavioral response is followed by a generally rewarding

event such as food, praise or gifts, it tends to be strengthened and occurs more frequently than
before the reward. This technique is used
to increase desired behavior.
2. Tokeneconomy:Thisprogram involvesgiving token rewards for appropriate or desired target

behaviors performed by the patient. The token can later be exchanged for other rewards. For
example on inpatient hospital wards, patients receive a reward for performing a desired behavior,
such as tokens which they may use to purchase luxury items or
certain privileges.
E. Operant conditioning procedures to teach new behavior

1. Modeling: Modeling is a method of teaching by demonstration, wherein the therapist shows
how a specific behavior is to be performed. In modeling the patient observes other patients
indulging in target behaviors and getting rewards for those behaviors. This will make the patient
repeat the same behavior and earn rewards in the same manner.
2. Shaping: In shaping the components of a particular skill, the behavior is reinforced step by
step. The therapist starts shaping by reinforcing the existing behavior. Once it is established he
reinforces the responses which
are closest to the desired behavior, and ignores the other responses.
For example, to establish eye-to-eye contact, the therapist sits opposite the patient and reinforces
him even if he moves his upper body towards him. Once this is established, he reinforces the
person's head movement in his direction and this procedure continues till eye-to-eye contact is
established.
3. Chaining: Chaining is used when a person fails to perform a complex task. The complex task
is broken into a number of small steps and each step is taught to the patient. In forward chaining
one starts with the first step,
goes on to the second step, then to the third and so on. In backward chaining, one starts with the
last step and goes on to the next step in a backward fashion. Backward chaining is found to be
more effective in training the mentally disabled.
F. Operant conditioning procedures for decreasing maladaptive behavior

1. Extinction/Ignoring: Extinction means removal of attention rewards permanently, following a
problem behavior. This includes actions like not looking at the patient, not talking to the patient,
or having no physical contact with the patient etc, following the problem behavior. This is
commonly used when patient exhibits odd behavior.
2. Punishment: Aversive stimulus (punishment) is presented contingent upon the undesirable

response. The punishment procedure should be administered immediately and consistently
following the undesirable behavior with clear explanation.
Differential reinforcement of an adaptive or desirable behavior should always be added when a

punishment is being used for decreasing an undesirable behavior. Otherwise the problem
behaviors tend to get maintained because of the lack of adaptive behaviors and skill defect.
3. Timeout: Timeout method includes removing the patient from the reward or the reward from
the patient for a particular period of time following a problem behavior. This is often used in the
treatment of childhood disorders.
For example, the child is not allowed to go out of the ward to play if he fails to complete the
given work.
4. Restitution (Over-correction): Restitution means restoring the disturbed situation to a state that
is much better than what it was before the occurrence of the problem behavior.
For example, if a patient passes urine in the ward he would be required to not only clean the dirty
area but also mop the entire/ larger area of the floor in the ward.
5. Response cost: This procedure is used with individuals who are on token programs for
teaching adaptive behavior. When undesirable behavior occurs, a fixed number of tokens or
points are deducted from what the
individual has already earned.
G. Assertiveness and socialskill training: Assertive training is a behavior therapy technique in

which
the patient is given training to bring about change in emotional and other behavioral pattern by
being assertive. Client is encouraged not to be afraid of showing an appropriate response,
negative or positive, to an idea or suggestion.
Assertive behavior training is given by the therapist, first by role play and then by practice in a
real life situation. Attention is focused on more effective interpersonal skills.
Social skills training helps to improve social manners like encouraging eye contact, speaking
appropriately, observing simple etiquette, and relating to people.
6. Individual psychotherapy vs Supportive Psychotherapy

Individual Psychotherapy Supportive Psychotherapy
Psychotherapy can be defined as the In this, the therapist helps the patient to
treatment for problems of an emotional relieve emotional distress and symptoms
nature, in which a trained person deliberately without probing into the past and changing the
establishes a professional relationship with personality.
the patient to remove, modify or retard
existing symptoms, mediate disturbed He uses various techniques such as:
patterns of behavior and promote positive
personality growth and development.
• Ventilation: It is a free expression of
Individual psychotherapy is conducted on a feelings or emotions. Patient is encouraged to
one-to-one basis, i.e. the therapist treats one talk freely whatever comes to his mind.
client at a time. The patient is encouraged to
discover for himself the reasons for his • Environmental modification/manipulation:
behavior. The therapist listens to the patient Improving the well-being of mental patients
and offers explanation and advice when by changing their living condition.
necessary. By this
he helps the patient to come to a greater • Persuasion: Here the therapist attempts to
understanding of himself and to find a way of modify the patient's behavior by reasoning.
dealing with his problems.
Re-education: Education to the patient
Indications: Stress-related disorders, alcohol regarding his problems, ways of coping, etc.
and drug dependence, sexual disorders and
marital disharmony. • Reassurance
7. THERAPEUTICCOMMUNITY
The concept of therapeutic community was first developed by Maxwell Jones in 1953.He wrote a
book entitled "SocialPsychiatry" which was first published in England. Later on when it was
published in the United States, its title was changed to "Therapeutic Community."
Definition
Stuart and Sundeen defined therapeutic community as "a therapy in which patient's social
environment would be used to provide a therapeutic experience for the patient by involving him
as an active participant in his own care and the daily problems of his community."
Objectives
• To use patient's social environment to provide a therapeutic experience for him.
• To enable the patient to be an active participant in his own care and become involved in daily
activities of his community.
• To help patients to solve problems, plan activities and to develop the necessary rules and
regulations for the community.
• To increase their independence and gain control over many of their own personal activities.
• To enable the patients become aware of how their behavior affects others.
Elements of Therapeutic Community

• Free communication
• Shared responsibilities
• Active participation
• Involvement in decision making
• Understanding of roles, responsibilities, limitations and authorities
Components of Therapeutic Community
Daily Community Meetings

• These meetings are composed of 60-90 patients. All levels of unit staff are involved, including
administrative personnel. Acute patients are not involved in the meetings.
• Meetings should be held regularly for 60 minutes.
• Discussion should focus mainly on day-today life in the unit.
• During discussions patients' feelings and behaviors are examined by other members.
• Frank discussions are encouraged, these may take place with much outpouring of emotions and
anger
Patient Government or Ward Council
• The purpose of patient government is to deal with practical unit details such as housekeeping
functions, activity planning and privileges.
• A group of 5-6patients will have specific responsibilities, such as housekeeping, physical
exercise, personal hygiene, meal distribution, a group to observe suicidal patients, etc. Staff
members should be available always.
• All decisions should be fedback to the community through the community meetings
Staff Meetings or Review

A staff meeting should be held following each community meeting (Patients are excluded and
only staff are present). In this meeting the staff would examine their own responses,
expectations, and prejudices.
Living and Learning Opportunities

Learning opportunities are to be provided within the social milieu, which should provide realistic
learning experiences for the patients.
Advantages of Therapeutic Community

• Patient develops harmonious relationships with other members of the community.
• Gains self-confidence.
• Develops leadership skills.
• Learns to understand and solve problems of self and others.
• Becomes socio-centric.
• Learns to live and think collectively with the members of the community.
• Lastly therapeutic community provides opportunities to participate in the formulation of
hospital rules and regulations that affect patient's personal liberties like bedtime, meal time,
weekend permission, control of radio or
TV, social activities, late night privileges, etc.
Disadvantages of Therapeutic Community

• Role blurring between staff and patient.
• Group responsibility can easily become nobody's responsibility.
• Individual needs and concerns may not be met.
• Patient may find the transition to community difficult
Role of the Nurse

• Providing and maintaining a safe and conflict free environment through role modeling and
group leadership.
• Sharing of responsibilities with patients.
• Encouraging patient to participate in decision making functions.
• Assisting patients to assume leadership roles.
• Giving feedback.
• Carrying out supervisory functions.
In conclusion, therapeutic community is an approach which is:

• Democratic as opposed to hierarchial.
• Rehabilitative rather than custodial.
• Permissive instead of limited and controlled.
UNIT – VI
NURSING MANAGEMENT OF PATIENT WITH SCHIZOPHRENIA &OTHER
DELUSIONAL DISORDER
1. ESSAY (15)
1. List classification of schizophrenia? Explain signs and symptoms of catatonic
schizophrenia?
2. Enumerate the positive and negative symptoms of schizophrenia, explain clinical features of
schizophrenia and narrate the nursing management of patient with schizophrenia?
II SHORT ESSAY
1. Types of auditory hallucination?
III.SHORT NOTES (5 MKS)
1. Classification of mood disorders?

2. Clinical features of mania?
3. Catatonic schizophrenia
1. Echolalia and Echopraxia
2. Delusion of persecution and Delusion of jealousy
3. Mutism and negativism
4. Waxy flexibility and posturing
5. Thought insertion and thought withdrawal
6. Perseveration and verbigeration
7. Marital schism and skew.
V. ANSWER BRIEFLY
1. Waxy flexibility
2. Loosening of association
3. Ambitendency
4. Double –bind communication
ESSAY
1. Classification of schizophrenia is:-

• Paranoid schizophrenia :- the word paranoid means delusional, the characteristics are,
Delusion of persecution, Delusion of jealousy, Increase in speech production, mutism,
rigidit, Negativism ,Posturing ,Stupor , Echolalia , Echopraxia ,Waxy flexibility.
• Hebephrenic schizophrenia:-
It has an early and insidious onset and is often associated with poor pre-morbid personality. The
essential features include marked thought disorder, incoherence, severe loosening of associations
and extreme social impairment. Delusions and hallucinations are fragmentary and changeable.
Other oddities of behavior include senseless giggling, mirror-gazing, grimacing, mannerisms and
so on. The course is chronic and progressively downhill without significant remissions.
• Catatonic schizophrenia:-
Catatonic (Cata-disturbed) schizophrenia is characterized by marked disturbance of motor

behavior. This may take the form of catatonic stupor, catatonic excitement and catatonia
alternating between excitement and stupor.
• Residual schizophrenia:-
Catatonic (Cata-disturbed) schizophrenia is characterized by marked disturbance of motor

behavior. This may take the form of catatonic stupor, catatonic excitement and catatonia
alternating between excitement and stupor.
• Undifferentiated schizophrenia:-
This category is diagnosed either when features of no subtype are fully present or features of
more than one subtype are exhibited
• Simple schizophrenia:-
It is characterized by an early and insidious onset, progressive course, and presence of

characteristic negative symptoms, vague hypochondriacal features, wandering tendency, self-
absorbed idleness and aimless activity. It differs from residual schizophrenia in that there never
has been an episode with all the typical psychotic symptoms. The prognosis is very poor.
• Post schizophrenic depression :-
Depressive features develop in the presence of residual or active features of schizophrenia and
are associated with an increased risk of suicide.
The signs and symptoms of catatonic schizophrenia include:-
• Delusion of persecution
• Delusion of jealousy
• Increase in speech production
• Loosening of association and frank incoherence
• mutism
• Rigidity
• Negataivism
• Posturing
• Stupor
• Echolalia
• Echopraxia
• Waxy flexibility
II. SHORT NOTES
1. Auditory hallucination:-
Auditory hallucination is also a well recognized feature of bipolar disorder and dementia,
although they can occur in the absence of mental health conditions. Auditory hallucinations can
be extremely distressing, although some people can learn to live with the voices, particularly if
the words they hear are neutral or complimentary rather than negative. Auditory hallucination
can also occur as a result of bereavement, which can lead to the person believing they can hear
the voice of a loved one.
Olfactory hallucination
These hallucinations involve smelling odours that do not exist. The odours are usually
unpleasant such as such as vomit, urine, feces, smoke or rotting flesh. This condition is also
called phantosmia and can occur as a result of neurological damage in the olfactory system. The
damage might be caused by a virus, trauma, a brain tumor or exposure to toxic substances or
drugs. Phantosmia can also be caused by epilepsy.
Tactile hallucination
This refers to when a person senses that they are being touched when they are not. One of the
most common complaints is the sensation of bugs crawling over the skin. This is associated with
the abuse of substance such as cocaine or amphetamine.
Gustatory hallucination
These are hallucinations that cause a person to taste something that is not present.
General somatic hallucination
This refers to when a person experiences a feeling of their body being seriously hurt through
mutilation or disembowelment, for example. Patients have also reported experiencing animals
trying to invade their bodies, such as snakes crawling into their stomach.
III .1. According to ICD 10(F3) mood disorders are classified as follows:-
✓ Manic episode :-
• Hypomania
• Mania without psychotic symptoms
• Mania with psychotic symptoms
• Manic episode unspecified
✓ Depressive episode:-
• Mild depression
• Moderate depression
• Severe depression
• Severe depression with psychotic symptoms.
✓ Bipolar mood disorders
✓ Recurrent depressive disorder
✓ Persistent mood disorder
✓ Other mood disorders.
2. Clinical features of manic episode is characterised by the following features :-
✓ ELEVATED, EXPANSIVE OR IRRITABLE MOOD:- Elevated mood in mania
has four stages depending on the severity of has four stages depending on the
severity of manic episode :-
• Euphoria (stage I) Increased sense of psychological well being and happiness.
• Elation (stage II) moderate elevation mood.
• Exaltation (stage III) intense elevation of mood.
• Ecstasy (stage IV) severe elevation of mood.
✓ Psychomotor activity:-over activeness and restlessness.
✓ Speech and thought :-
• Flight of ideas –rapid shifts from one topic to another
• Pressure of speech
• Delusion of grandeur
• Delusion of persecution
• distractibility
✓ Other features :-
• Increased sociability
• Impulsive behaviour
• Disinhibition
• Hypersexual and promiscuous behaviour
• Poor judgement
• Decreased need for sleep
• Decreased food intake
• Decreased attention and concentration
• Poor judgement
• Absent insight
3. Catatonic schizophrenia :- (Cata-disturbed) is characterised by marked disturbance of motor

behaviour. This may take the form of catatonic stupor , excitement , aggressiveness to
violent behaviour.
✓ Clinical features excited catatonia include :-
• Increase in psychomotor activity
• Increase in speech production
• Loosening of association and frank coherence
✓ Clinical features of retarded catatonia:-
• Mutism: Absence of speech.

• Rigidity: Maintenance of rigid posture against efforts to be moved.
• Negativism: A motiveless resistance to all commands and attempts to be moved, or doing just
the opposite.
• Posturing: Voluntary assumption of an inappropriate and often bizarre posture for long periods
of time.
• Stupor: Does not react to his surroundings and appears to be unaware of them.
• Echolalia: Repetition or mimicking of phrases or words heard.
• Echopraxia: Repetition or mimicking of actions observed.
• Waxy flexibility: Parts of body can be placed in positions that will be maintained for long
periods of time, even if very uncomfortable.
TREATMENT: - Pharamacotherapy –
• Chlorpromazine 300-500mg
• Haloperidol 5-100mg
• Clozapine 25-450 mg
• Risperidone 2-10 mg
✓ Psychological therapies :-
• Group therapy
• Behaviour therapy
• Family therapy
• Social skill training
✓ Psychosocial rehabilitation
III. DIFFERENCIATE BETWEEN
1. 1. Echolalia and Echopraxia: - Echolalia is the repetition or mimicking of phrases or

words heard. Echo-praxia is the repetition or mimicking of the action observed.
2. Delusion of persecution and Delusion of jealousy: - Delusion of persecution is individual
believe that they are being malevolently treated in some way. Delusion of jealousy
centers around the theme that the person’s sexual partner is unfaithful.
3. Mutism and negativism: - mutism is absence of speech and negativism is a motiveless

resistance to all commands and attempts to be moved.
4. Waxy flexibility is parts of can be placed in positions that will be maintained for long
periods of time. Posturing is voluntary assumption of an inappropriate and often bizzare
posture for long periods of time.
5. Thought insertion and thought withdrawal: - thought insertion is where the subject
experiences thoughts imposed by some external force on his passive mind, thought
withdrawal is thoughts cease and subject experiences them as removed by an external
force.
6. Perseveration and verbigeration: - perseveration is persistent repetition of words or

themes beyond the point of relevance. Verbigeration senseless repetition of some words
or phrases over and over again.
7. Marital schism and skew: - marital schism is severe chronic disequilibrium and discord
.marital skew is relative equilibrium is achieved but with family life distorted by shared
aberrant.
IV ANSWER BRIEFLY
1. Waxy flexibility is parts of can be placed in positions that will be maintained for long
periods of time.
2. Loosening of association is a pattern of spontaneous speech in which the things said in
juxtaposition lack a meaningful relationship with each other.
3. Ambitendency is a conflict to do or not to do, e.g. on asking to put out tongue; it is
slightly protruded but taken back again.
4. Double –bind communication is where parents convey two or more conflicting and
incompatible message at the same time.
UNIT-VII -NURSING MANAGEMENT OF PATIENT WITH MOOD AND AFFECTIVE
DISORDER
ESSAY
1. List the types of depression .explain the etiological factors related to depression and
write the nursing management of patient with severe depression
2. Define B P A D . Enlist steps of history collection s and mental status examination of
BPAD client.
SHORT NOTE
3. Clinical features of mania.

4. Clinical features of severe depression
DIFFERENCE BETWEEN
5. Mania and depression
6. flight of ideas and neologism
ANSWER KEY UNIT-7
Depression –it is a common mental health disorder, that the patient with depressed mood , loss of
interest or pleasure , feeling of guilt or law self worth. disturbed sleep or appetite, law energy,
and poor concentration.
Types
Atypical depression ,Post partum depression ,catatonic depression, sessional affective

depression, manic depression , Dysthymic depression, situational depression ,Psychotic
depression, Endogenous depression
Etiology-genetic cause, environmental cause, Biochemical factors-Biochemical theory of

depression postulates a deficiency of Neurotransmitters in certain areas of brain(noradrenaline,
serotonin and dopamine) Dopaminergic activity reduced in case of depression, Endocrine factors
–Hypothyroidism ,cushing syndrome, Abuse of drug or alcohol, Hormone level changes,
Physical illness and side effect of medication.
NURSING DIAGNOSIS
• High risk of self directed violence related to depressed mood ,feelings of worthlessness
and anger directed inward on the self .objective – patient will not harm self. create a
environment for the patient remove all potentially harmful object from patient vicinity
for eg.sharp object, glass items, close observation is especially required when the patient
is recovering from the disease
• Dysfunctional grieving related to real or perceived loss, bereavement, evidenced by
denial loss, inappropriate expression of anger , inability to carry out activities of daily
living. objective-patient will be able to verbalise normal behaviour associated with
grieving, Assess the fixation in grief process, explore feelings of anger and help patient
direct them toward the intended object or person, provide simple activities which can be
easily and quickly accomplished. gradually increase the activity .
• Powerlessness related to dysfunctional grieving process, life-style of helplessness,
evidenced by feeling of lack of control over life situation ,objective-the patient will be
able to take control of life situations, allow the patient to take decision regarding own
care. ensure that the goals are realistic and that patient is able to identify the situations ,
encourage the patient top verbalise the feeling
Altered sleep and rest ,related to depressed mood and depressive cognition evidenced by
difficulty in falling sleep, early morning awakening ,objective –patient will sleep adequately
during the night, plan day time activities according to the patient s interest ,do not allow him to
site idle. Ensure a quit and peaceful environment when patient is preparing for sleep. provide
comfort measures
Discuss the family members regarding manage side effect of medication , tell the family
member to offer the patient some household responsibilities ,teach the family members
regarding suicidal ideation.
2 .BPAD-It is characterised by recurrent episode of mania and depression in the same patient at
different time .Typically the patient experience s extreme highs(mania or hypomania) perform
through clinical assessment for patient with manic , hypomanic,
or mixed type.
Identification data ,chief complaint, present history ,Past history , family history, Personal
history, Educational history , occupational history, premorbid personality, monitor mood and
suicidal ideation,
General and physical examination
MSE-
Talk,mood,Thought,Orientation,place,person,memory,abstraction,attention,concentration,judge
ment,insight.
3 . Mania refer to a syndrome in which the central features are over activity ,mood change, and
self important ideas .
Clinical features
Elevated ,Expansive or Irritable mood –Euphoria, Elation, Exaltation, Ecstasy,
Increased psychomotor activities,
Speech and thought-flight of ideas ,pressure of speech, Delusion of grandeur, delusion of

persecution, distractibility,
Other features
Increased sociability’s, impulsive behaviour, Dis-inhibition, Hypersexual and Promiscuous
behaviour, poor judgement, High risk activities, Dressed up in gaudy and flamboyant clothes all
through in severe mania there may be poor self care, Decreased need for sleep, Decreased food
intake due to over activity Decreased attention and concentration, Poor judgement, absent
insight, distractability,
4 Depressed mood –sadness of mood or loss of interest and loss of pleasure in almost all
activities, present throughout the day
Depressive cognition –Hopelessness (a feeling of no hope in future due to pessimism

,helplessness, Worthlessness,
Suicidal thought – ideas of hopelessness are often accompanied by the thought that life is no
longer worth living and that death come as a welcome release
Psychomotor activity – psychomotor retardation is frequent. the retarded patient thinks walks
and act slowly
Delusion and hallucination, Significant decrease in appetite or weight
Early morning Awakening at least 2or more hours before the usual time of waking up
Depression being worst in the morning
Pervasive lack of interest and lack of reactivity to pleasurable stimuli
Psychomotor agitation or retardation, Menstrual or sexual disturbance, Difficulty in thinking and

concentration, Hopelessness ,Helplessness, Worthlessness, Guilt ,Anger
Mania Depression
Increased energy ,increase activity and goal Loss of energy, decrease in activity and
directed activities, spend more money interest in activities
Decreased need for sleep with out feeling Disturbed sleep pattern trouble falling or
tired staying in sleep, waking too early, sleeping
too much
Feeling down ,low
6
FLIGHT OF IDEAS NEOLIGISM

Rapid shift of ideas with only superficial New word that is coined especially by a
associative connections between them that is person affected with schizophrenia and is
expressed as a disconnected rambling from meaningless
subject to subject
UNIT-VIII -NURSING MANAGEMENT OF PATIENT WITH NEUROTIC STRESS
RELATED SOMATOFORM DISORDER
Essay
1.Define somatoform disorder ,describe the signs and symptoms of somatisation disorder.
Prepare a nursing care plan for a patient with somatoform disorder
SHORT NOTE
2.Clinical manifestations of phobia
3. OCD
DIFFERENCE BETWEEN
4.Agoraphobia and acrophobia
5. Psychosis and neurosis
6. Obsession and compulsion
7.Dissociative amnesia and dissociative fuge
ANSWER KEY- 8
1.A mental disorder characterised by a group of condition in which the physical pain and
symptoms a person feels are related to psychological factors
May include frequent headaches,back pain,abdominal cramping and pelvic pain
Other symptoms include pain in the joints,legs and arms,also may cause gastrointestinal
problems such as nausea,bloating,vomiting andfood intolerence.it can also cause problem with
sexual function for both men and women , abnormal movements,
Pseudoneurological symptoms-impaired coordination,aphonia,blindness
NURSING DIAGNOSIS FOR SOMATOFORM DISORDER
• Chronic pain related to severe level of anxiety,repressed

• Ineffective coping related to inadequate coping skill
• Disturbed body image related to low self esteem,severe level of anxiety
• Disturbed sensory perception related to regression to or fixation in,an earlier level of
development
• Self care deficit related to paralysis of body part, pain discomfort
• Deficient knowledge related to lack of interest in learning severe anxiety
Goals- the client will identify the relation ship between stress and physical symptoms
• The client will verbally express emotional feelings

• The client will demonstrate alternative ways to deal with stress, anxiety ,and other
feelings
• Client will demonstrate healthier behaviour regarding rest, activity, and nutritional intake
NURSING INTERVENTION
• Providing health teaching,

• Assisting the client to express emotions
• Teaching coping strategies
EVALUATION
The client was able to identify the relationship between stress and physical symptoms
Verbalise and express emotional feeling client was able to follow daily routine
2. Phobia is an unreasonable fear of a specific object, activity or situation
SIGNS AND SYMPTOMS OF SPECIFIC PHOBIA
• Irrational and persistent fear of object or situation

• Immediate anxiety on contact with feared object or situation
• Loss of control , fainting ,or panic response
• Avoidance of activities involving feared stimulus
• Anxiety when thinking about stimulus
• Worry with anticipatory anxiety
• Possible impaired social or work functioning
SIGNS AND SYMPTOMS OF SOCIAL PHOBIA
• Hyperventilation
• Sweating, cold and clammy hands
• Blushing
• Palpitations
• Confusion
• Gastrointestinal symptoms
• Trembling hands and voice
• Urinary urgency
• Muscle tension
• Anticipatory anxiety
• Fear or embarrassment
SIGNS AND SYMPTOMS OF AGORAPHOBIA
Overriding fear of open or public spaces, deep concern that help might not be available in such
places, avoidance of public places and confinement to home
3.Obsessive-compulsive disorder (OCD) is a mental illness that causes repeated unwanted
thoughts or sensations (obsessions) or the urge to do something over and over again
(compulsions). Some people can have both obsessions and compulsions.
OCD isn’t about habits like biting your nails or thinking negative thoughts. An obsessive thought
might be that certain numbers or colors are “good” or “bad.” A compulsive habit might be to
wash your hands seven times after touching something that could be dirty. Although you may
not want to think or do these things, you feel powerless to stop.
OCD Types and Symptoms
Checking, such as locks, alarm systems, ovens, or light switches, or thinking you have a medical
condition like pregnancy or schizophrenia
Contamination, a fear of things that might be dirty or a compulsion to clean. Mental

contamination involves feeling like you’ve been treated like dirt.
Symmetry and ordering, the need to have things lined up in a certain way
Ruminations and intrusive thoughts, an obsession with a line of thought. Some of these thoughts
might be violent or disturbing.
Obsessive thoughts can include:
Worries about yourself or other people getting hurt
Constant awareness of blinking, breathing, or other body sensations
Suspicion that a partner is unfaithful, with no reason to believe it
OCD Diagnosis
Your doctor may do a physical exam and blood tests to make sure something else isn’t
causing your symptoms. They will also talk with you about your feelings, thoughts, and
habits.
OCD Treatment
There’s no cure for OCD. But you may be able to manage how your symptoms affect
your life.
Treatments include:
Psychotherapy. Cognitive behavioural therapy can help change your thinking patterns. In
a form called exposure and response prevention, your doctor will put you in a situation
designed to create anxiety or set off compulsions. You’ll learn to lessen and then stop
your OCD thoughts or actions.
Relaxation. Simple things like meditation, yoga, and massage can help with stressful
OCD symptoms.
Medication. Psychiatric drugs called selective serotonin reuptake inhibitors help many
people control obsessions and compulsions. They might take 2 to 4 months to start
working. Common ones include citalopram (Celexa), escitalopram (Lexapro), fluoxetine
(Prozac), fluvoxamine, paroxetine (Paxil), and sertraline (Zoloft). If you still have
symptoms, your doctor might give you antipsychotic drugs like aripiprazole (Abilify) or
risperidone (Risperdal).
Neuromodulation. In rare cases, when therapy and medication aren’t making enough of a
difference, your doctor might talk to you about devices that change the electrical activity
in a certain area of your brain.
4.
ACROPHOBIA AGORAPHOBIA
Fear of heights Fear of wide open spaces ,crowds
Belongs to specific phobia Same as that of generalised anxiety
- Acrophobia is an extreme fear of very disorders Fear of places and situations that
tiny bugs. If you suffer from acrophobia, might cause panic, helplessness or
the idea of getting head lice is completely embarrassment.
terrifying. Most people have a dislike or -Agoraphobia is an anxiety disorder that
even disgust for creepy crawly bugs, but often develops after one or more panic
when that normal feeling becomes attacks.
overwhelming and exaggerated, it might -Symptoms include fear and avoidance of
be diagnosed as acrophobia. places and situations that might cause
feelings of panic, entrapment, helplessness
or embarrassment.
Treatments include talk therapy and
medication
-
5.
PSYCHOSIS NEUROSIS
Etiology
Genetic factors More important Less important
Stressful life events Less important More important
Clinical features
Disturbances of Common Rare
thinking and
perception Common Rare
Disturbance in
cognitive function Markedly affected Not affected
Behaviour Impaired Intact
Judgement Lost Present
Insight Lost Present
Reality testing
Treatment Major tranquilizers Minor tranquilizers and anti depressants
Drugs commonly used are commonly used
Very useful Not useful
ECT Not much useful Very useful
psychotherapy
6.
OBSESSION COMPULSION
Having intrusive thought of needing to say a It is a repetitive behaviour performed in
specific word response to uncontrollable urges or
Unwanted thought word phase or image that according to a ritualistic set of rules eg,
persistently and repeatedly comes into a washing hands, brushing teeth,
persons mind and cause distress
eg.contaminated,excessive washing
7.
Dissociative amnesia Dissociative fuge

Follows a traumatic or stressful life situation Sudden unexpected travel away from home
sudden inability to recall important personal or work place,with the assumption of new
information particular concerning the identity inability to recall the past .onset is
stressful life event sudden,often the presence of severe
Forgetfulness stress,following recovery there is no
Amnesia may be localised ,generalised, recollection
selective or continuing nature Duration-hours to days and sometimes month
UNIT-IX
NURSING MANAGEMENT OF PATIENT WITH SUBSTANCE ABUSE
ESSAY (15)
1. Define substance abuse .explain withdrawal symptoms of alcohol. Develop a teaching plan
for a client receiving anatbuse ?
2. What are the causes of substance abuse? Describe clinical features of delirium tremors
.explain nursing management?
II.SHORT ESSAY (7 MKS)
1. Prevention of substance use disorder?
III.SHORT NOTES
1. Psychiatric disorders due to alcohol dependence?
2. Agencies Concerned with Alcohol related Problems ?
1. Alcoholics Anonymous and Al-A teen

2. LSD & Amphetamines
V. ANSWER BRIEFLY
1. Dependence
2. Delirium tremens
3. Detoxification
4. Alcohol deterrent therapy
5. Disulfiram
I.1.ANSWER KEY
1. Substance abuse is a maladaptive pattern of substance use that impairs health in a

broad sense.
Disorders due to psychoactive substance use refer to conditions arising from the abuse of
alcohol, psychoactive drugs and other chemicals such as
Volatile solvents.
Withdrawal symptoms are a group of symptoms recurring when a drug is reduced in amount or
withdrawn which last for a limited time. The withdrawal syndrome is two types:-
✓ Simple withdrawal syndrome:- characterised by mild tremors, nausea , vomiting
,weakness, irritability, insomnia, and anxiety.
✓ Delirium tremens: - occurs 2- 4 days of complete abstinence. Characterised by:-
• Disordered mental activity
• Poor attention span
• Vivid hallucination –visual and tactile
• Severe psychomotor agitation
• Grossly tremulous hands –truncal ataxia
• Autonomic disturbances –sweating, fever, tachycardia, raised blood
pressure, pupialry dilatation.
• Dehydration with electrolyte imbalances
• Insomnia
• Death may occure due to cardiovascular collapse, infection, and hyperthermia.
2. Causes of substance abuse include :-

✓ Biological factors-genetic vulnerability.
✓ Biochemical factors-role of dopamine
✓ Psychological factors-sense of inferiority, low self esteem, sexual immaturity.
✓ Social factors-peer pressure, religious reason, urbanization , overcrowding.
✓ Easy availability of drugs
✓ CLINICAL FEATURES OF DELIRIUM TREMENS INCLUDE:-
Occures 2- 4 days of complete abstinence. Characterised by:-

• Disordered mental activity
• Vivid hallucination –visual and tactile
• Severe psychomotor agitation
• Grossly tremulous hands –truncal ataxia
• Autonomic disturbances –sweating, fever, tachycardia, raised blood
pressure, pupialry dilatation.
• Insomnia
• Death may occure due to cardiovascular collapse,infection,hyperthermia.
I.2. ETIOLOGICAL FACTORS IN PSYCHOACTIVE SUBSTANCE USE
Biological Factors
• Genetic vulnerability: family history of substance use disorder, e.g. twin studies suggest that
genetic mechanisms might account for alcohol consumption.
• Biochemical factors: for example, role of dopamine and norepinephrine have been implicated in
cocaine, ethanol and opioid dependence. Abnormalities in alcohol dehydrogenase or in the
neurotransmitter mechanism are thought to play a role in alcohol dependence.
• Withdrawal and reinforcing effects of drugs (they serve as maintaining factors).
• Co-morbid medical disorder (e.g. to control chronic pain) .
Psychological Factors
• General rebelliousness
• Sense of inferiority
• Poor impulse control
• Low self-esteem
• Inability to cope with the pressures of living and society .
• Loneliness, unmet needs
• Desire to escape from reality
• Desire to experiment, a sense of adventure
• Pleasure-seeking
• Machoism
• Sexual immaturity
Social Factors
• Religious reasons
• Peer pressure
• Urbanization
• Extended periods of education
• Unemployment
• Overcrowding
• Poor social support
• Effects of television and other mass media
• Occupation: substance use is more common in chefs,barmen, executives, salesmen, actors,
entertainers, army personnel, journalists, medical personnel, etc
Easy Availability of Drugs

• Taking drugs prescribed by doctors (e.g. benzodiazepine dependence.
Delirium tremens:-
It occurs usually within 2-4 days of complete or significant abstinence from
Heavy alcohol drinking. The course is short, with recovery occurring within 3-7 days. It is
characterized by:
• A dramatic and rapidly changing picture of disordered mental activity, with clouding of
consciousness and disorientation in time and place
• Vivid hallucinations which are usually visual; tactile hallucinations can also occur
• Severe psychomotor agitation, shouting and evident fear
• Grossly tremulous hands which sometimes pick up imaginary objects; truncal ataxia
• Autonomic disturbances such as sweating, fever, tachycardia, raised blood pressure, pupillary
dilatation
• Reversal of sleep-wake pattern or insomnia
• Blood tests reveal leukocytosis and impaired liver function
II.1 PREVENTION OF SUBSTANCE USE DISORDER
1. Primary Prevention
• Reduction of over prescribing by doctors
• Identification and treatment of family members who may be contributing to the drug abuse.
• Introduction of social changes is likely to affect drinking patterns in the population as a whole.
This is made possible by:
• Putting up the price of alcohol and alcoholic beverages
• Controlling or abolishing the advertising of alcoholic drinks
• Controls on sales (by limiting hours or banning sales in supermarkets)
• Restricting availability and lessening social deprivation (Governmental measures)
• Other approaches are to strengthen the individual's personal and social skills to increase self-
esteem and resistance to peer pressure.
• Health education to college students and the youth about the dangers of drug abuse through the
curriculum and mass media. Health education should also include certain specific groups where
a substance likes alcohol
May be culturally accepted.
2. Secondary Prevention
• Early detection and counseling.
• Brief intervention in primary care (simple advice by a general practitioner plus an educational
leaflet).
• Motivational interviewing which involves providing feedback to the patient on the personal risks
that alcohol poses, together with a number of options for change.
• A full assessment including an appraisal of current medical, psychological and social problems.
Assessment also includes ascertaining whether alcoholism is the primary or secondary problem.
For example, a patient with diabeticneuropathy may be using alcohol to numb pain. Alcohol is
also used by some to relieve asthmatic symptoms. In such instances, treatment of the medical
problem can help to control alcoholism.
• Detoxification with benzodiazepines (diazepam, chlordiazepoxide).
3. Tertiary Prevention
Specific measures include:
• Alcohol deterrent therapy (Disulfiram or Antabuse).
• Other therapies include assertiveness training, teaching coping skills (some take drugs to combat
stress), behavior counseling, supportive psychotherapy and individual psychotherapy.
• Agencies concerned with alcohol-related problems: Alcoholics Anonymous (AA), AlAnon, Al-
Ateen, etc.
III.1. SHORT NOTES:-
1. Acute intoxication
2. Withdrawal syndrome
3. Alcohol induced amnestic disorders
4. Alcohol induced psychiatric disorders
1. Acute intoxication: Acute intoxication develops during or shortly after alcohol ingestion. It is
characterized by clinically significant maladaptive behavior or psychological changes, e.g.
inappropriate sexual or aggressive behavior, mood lability,impaired judgment, slurred speech,
incoordination, unsteady gait, nystagmus, impaired attention and memory finally resulting
In stupor or coma.
2. Withdrawal syndrome: In persons who have been drinking heavily over a prolonged period of
time, any rapid decrease in the amount of alcohol in the body is likely to produce withdrawal
symptoms. These are:
• Simple withdrawal syndrome
• Delirium tremens
Simple withdrawal syndrome: It is characterized by mild tremors, nausea, vomiting, weakness,

irritability, insomnia and anxiety.
Delirium tremens: It occurs usually within 2-4days of complete or significant abstinence from
heavy alcohol drinking. The course is short, with
Recovery occurring within 3-7 days. It is characterized by:
Consciousness and disorientation in time and place
• Vivid hallucinations which are usually visual; tactile hallucinations can also occur
• Severe psychomotor agitation, shouting and evident fear
• Grossly tremulous hands which sometimes pick up imaginary objects; truncal ataxia
• Autonomic disturbances such as sweating, fever, tachycardia, raised blood pressure, papillary
dilatation
• Blood tests reveal leukocytosis and impaired liver function Death may occur due to
cardiovascular collapse, infection, hyperthermia or self inflicted Injury.
3. Alcohol- induced amnestic disorders:-

Chronic alcohol abuse associated with thiamine (vitamin 'B') deficiency is the most frequent
cause of arnnestic disorders. This condition is divided into:
a) Wernicke's syndrome: This is characterized
by prominent cerebellar ataxia, palsy of the 6th cranial nerve, peripheral neuropathy and mental
confusion.
b) Korsakoff' s syndrome: The prominent symptom in Korsakoff' s syndrome is gross memory
disturbance. Other symptoms include:
• Disorientation
• Confusion
• Confabulation
• Poor attention span and distractibility
• Impairment of insight.
4. Alcohol- induced psychiatric disorders:-

a) Alcohol-induced dementia: It is a long term complication of alcohol abuse, characterized by
global decrease in cognitive functioning. This disorder tends to improve with abstinence, but
most of the patients may have permanent disabilities.
b) Alcohol-induced mood disorders: Excess drinking may induce persistent depression or
anxiety.
c) Suicidal behavior: Suicidal rates are higher in alcoholics when compared to non-alcoholics of
the same age. The risk factors for suicidal behavior are continued drinking, co-morbid major
depression, serious medical illness, unemployment and poor social support.
d) Alcohol-induced anxiety disorder: Alcohol persons report panic attacks during acute
withdrawal, similarly during the first 4 to 6 weeks of abstinence.
e) Impaired psychosexual function: Erectile dysfunction and delayed ejaculation are common in
chronic alcoholics.
f) Pathological jealousy: Excessive drinkers may develop an overvalued idea or delusion that the
partner is being unfaithful.
g) Alcoholic seizures (rum fits): Generalized tonic clonic seizures occur usually within 12- 48
hours after a heavy bout of drinking. Sometimes, status epilepticus may be precipitated.
h). Alcoholic hallucinosis: This is characterized by the presence of hallucinations (auditory)
during abstinence, following regular alcohol Intake. Recovery occurs within one month
III .2 Agencies Concerned with Alcohol related Problems
1. Alcoholics Anonymous (AA)

This is a self-help organization founded in the USA by two alcoholic men, Dr. Bob Smith and
Bill Wilson, a stockbroker on the 10th of June,1935. It has since then spread to many countries
in the world. AA considers alcoholism as a physical, mental and spiritual disease, a progressive
one, which can be arrested but not cured. Members attend group meetings usually twice a week
on a long-term basis. Each member Is assigned a support person from whom he may Seek help
when the temptation to drink occurs. In Crisis he can obtain immediate help by telephone. Once
sobriety is achieved he is expected to help others. The organization works on the firm belief that
abstinence must be complete. The only requirement for membership is a desire to stop drinking.
"Twelve Steps" of A.A.

The "Twleve Steps" are the core of the A.A. program of personal recovery from alcoholism.
They are not abstract theories; but are based on the trial-and-error experience of early members
of A. A. They describe the attitudes and activitiesthat these early members believe were
important in helping them to achieve sobriety. Acceptance of the "Twelve Steps" is not
mandatory in any sense.
1. We admitted we were powerless over alcohol-that our lives had become unmanageable.
2. Came to believe that a Power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and became willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure
them or others.
10. Continued to take personal inventory and when we were wrong promptly admitted it.
11. Sought through prayer and meditation to improve our conscious contact with God, as we
understood Him, praying only for knowledge of His will for us and the power to carry that out.
12. Having had a spiritual awakening as the result of these steps, we tried to carry this message
to alcoholics, and to practice these principles in all our affairs.
"Twelve Traditions" of A.A.

The Traditions are important to both old timers and newcomers as reminders of the true
foundations of A.A. as a society of men and women whose primary concern is to maintain their
own sobriety and help others to achieve
sobriety:
1. Our common welfare should come first; personal recovery depends upon A.A. unity.
2. For our group purpose there is but one ultimate authority- a loving God as He may express
Himself in our group conscience. Our leaders are but trusted servants; they do not govern.
3. The only requirement for A.A. membership is a desire to stop drinking.
4. Each group should be autonomous except in matters affecting other groups or A.A. as a
whole.
5. Each group has but one primary purpose to carry its message to the alcoholic who still suffers.
6. An A.A. group ought never endorse, finance, or lend the A.A.name to any related facility or
outside enterprize, lest problems of money, property, and prestige divert us from our primary
purpose.
7. Every A.A. group ought to be fully self-supporting, declining outside contributions.
8. Alcoholics Anonymous should remain forever non-professional, but our service centres may
employ special workers.
9. A.A., as such ought never be organized; but we may create service boards or committees
directly responsible to those they serve.
10. Alcoholics Anonymous has no opinion on outside issues; hence the A.A. name ought never
to be drawn into public controversy.
11. Our public relations policy is based on attraction rather than promotion; we need always
maintain personal anonymity at the
12. Anonymity is the spiritual foundation of all our traditions, ever reminding us to place
principles before personalities.
Al-Anon
Al-Anon is a group started by Mrs. Anne, wife of Dr. Bob to support the spouses of alcoholics.
Al-A teen
Provides support to their teenage children. Hostels These are intended mainly for those rendered
homeless due to alcohol-related problems. They provide rehabilitation and counseling. Usually
abstinence is a condition of residence.
IV.1. Alcoholics Anonymous (AA)

This is a self-help organization founded in the USA by two alcoholic men, Dr. Bob Smith and
Bill Wilson, a stockbroker on the 10th of June,1935. It has since then spread to many countries
in the world. AA considers alcoholism as a physical, mental and spiritual disease, a progressive
one, which can be arrested but not cured. Members attend group meetings usually twice a week
on a long-term basis.
Al-A teen
Provides support to their teenage children. Hostels These are intended mainly for those rendered
homeless due to alcohol-related problems. They provide rehabilitation and counseling. Usually
abstinence is a condition of residence.
IV.2. LSD
LSD is a powerful hallucinogen, and was first synthesized in 1938.It presumably produces its
effects by actingon 5-HT levelsinbrain. A common pattern of LSD use is 'trip'
Amphetamines are powerful CNS stimulants with peripheral sympathomimetic effects.
Commonly used amphetamines arepemoline and
Methylphenidate.
V.1. Alcohol dependence syndrome
Alcoholism refers to the use of alcoholic beverages to the point of causing damage to the
individual, society or both.
2. Delirium tremens:
It occurs usually within 2-4 days of complete or significant abstinence from heavy
alcohol drinking. The course is short, with recovery occurring within 3-7 days. It is
characterized by:
consciousness and disorientation in time and place
• Poor attention span, Dehydration with electrolyte imbalances
• Blood tests reveal leukocytosis and impaired liver function
3. Detoxification:- Detoxification is the treatment
For alcohol withdrawal symptoms. The drugs of choice arebenzodiazepines.
The most commonly used drugs from this class are chlordiazepoxide 80-200 mg/ day and
diazepam 40-80 mg/ day, in divided doses.
4. Alcohol deterrent therapy:- Deterrent agents are those which are given to desensitize the
individual to the effects of alcohol and maintain abstinence. The most commonly used
drug is disulfiram (tetraethyl thiuram disulfide) or antabuse.
5. Disulfiram :- Disulfiram is used to ensure abstinence in the treatment of alcohol
dependence. Its main effect is to produce a rapid and violently unpleasant reaction in a
person who ingests even a small amount of alcohol while taking disulfiram.
UNIT-10-NURSING MANAGEMENT OF PATIENT WITH

BEHAVIOURAL SYNDROME ASSOCIATED WITH PSYCHOLOGICAL
DISTURBANCE AND PHYSICAL FACTORS,SLEEP
SHORT NOTE
1. Nutrition plan for a patient with anorexia nervosa
DIFFERENCE BETWEEN
2. Anorexia nervosa and bulimia nervosa
3. Insomnia and Hypersomnia
4. Insomnia and Somnambulism
5. Transsexualism and Transvestism
6. Paraphilia and sexual dysfunction
ANSWER KEY UNIT -10
Referral criteria for anorexia nervosa
Advice and Management should be offered to those who:
• Are newly diagnosed with Anorexia Nervosa

• Have continuing weight loss
• Are severely emaciated
• Have a BMI below 17.5Kg/m2
• Have marked vomiting or laxative abuse.
Nutritional Management Aim
• To provide help with nutritional rehabilitation, weight restoration, cessation of weight

reduction behaviours,
improvement in eating behaviours and improvement in psychological and emotional state
Nutritional Management Goals
• To determine the level of malnutrition and muscle wasting present
• To ascertain the level of eating disturbance based on food beliefs, and present eating
patterns
• To understand the weight, exercise and diet histories of clients. Nutritional Assessment
Anthropometry
• Height and Weight – BMI

• Skinfold thickness.
Biochemistry
Dietician should have access to the following:

• Blood Tests- complete blood count, serum chemistry
• Blood Pressure, Urinalysis
• Bone Density Measurements.
History
• The length of time the client has had the eating disorder
• Medical History – menstrual cycle, skin, teeth, energy, gastrointestinal function
• Weight History - usual and current weight, desired weight, attitude towards weight,
weight fluctuations, and
significant events associated with changes.
• Weight Management History - previous diets and weight management methods,
presence or history of bingeeating, purging and/or fasting, nutrition counselling
• Physical Activity History
• Family History - family eating patterns, food avoidance or allergy
• Social and Work History- work and home environment
• Emotional State
• Mental Health - depression, borderline personality, and obsessive compulsive disorder
• Medication and substance – use history – medications including thyroid replacement,
vitamin/herbal
supplement use, alcohol consumption, diet pills, diuretics, laxatives.
Initial Consultation
• Assess clients understanding of condition and need for treatment. Educate as
appropriate
• Nutritional History
Meal Pattern -The usual distribution of meals and snacks throughout the day and the
extent to which this
varies from day to day, between weekdays and weekends, or is influenced by factors such
as shift work,business, school meals, travel.
Food Choices - Food beliefs, and rituals, food preferences and aversions, ‘safe vs scary’ or
forbidden foods, ‘trigger foods’, portion sizes, nutrient content of meals, and meal or food
supplements.
Overall Dietary Balance - How the dietary pattern compares with recommendations for all food
groups in the food pyramid
Nutritional Adequacy - The likelihood of dietary surplus or deficiency
Alcohol Consumption - Typical intake and whether this exceeds safe limits
Eating Pattern - Where client eats meals, alone, with family or friends. Length of time client
takes to prepare and eat foods.
• Assess readiness to change eating pattern and lifestyle. Using motivational interviewing
techniques and ‘stages of change’ model discuss behaviour change
• Address any specific actions requiring change as identified by client
• Agree dietary and physical activity plan until next appointment
• Agree level of weight gain in short and long term
• Offer support and reassurance with respect to gastric discomfort
• Provide support literature and written action plan
• Liaise with patient’s spouse/guardian/parents where appropriate
• Liaise with other members of multidisciplinary team as appropriate.
On Review
• Follow procedure for anthropometry, biochemistry, and nutritional assessment.

• Discuss positive and negative changes in the diet and behaviour since initial
appointment
• Using behavioural therapy, assess and motivate client
• Assess dietary intake and physical activity levels
• Agree dietary and physical activity action plan until next appointment
• Provide ongoing nutrition education to the client, dispelling any myths that may arise
• Provide ongoing support to client.
ANOREXIA NERVOSA BULIMIA NERVOSA
Anorexia Nervosa mainly refer to Bulimia nervosa refers to binge
starving on purpose,to create a skeltel Eating followed by purging resulting in
like body an average or overweight body due to
the residual amount of calory
Patient are very thin or emaciated most Patient usually have an average weight
of the time ideal for their height and age or in
some cases, an obese body
Patient eat heavy meals followed by
Patients prefer to starve or eat less purging
May result in heart failure and damage
May result in conditions like to esophagus and teeth
amenorrhea,osteoporosis,infertility
INSOMNIA HYPERSOMNIA
Inability to sleep Excessive sleepiness
Insomnia disorder persistent for at least three Sudden weakness of muscle associated with
month and may not resolve with out strong emotion and laughter
treatment Depression ,a persistent feeling of
Fatigue,reduced ability to learn and grogginess,trouble concentrating
concentrate,increased hunger,decreased
motivation A diagnosis of hypersomnia is typically more
Insomnia diagnosis rarely include sleep complex
studies Medication +treating underlying condition
Treatment –medication+ sleep restriction
Insomnia Somnambulism
Difficulty falling or staying sleep Sleep walking
Inability to sleep Stage 3 and 4 sleep
Insomnia disorder persistent for at least three On walking patient have amnesia
month and may not resolve with out Common triggers for sleep walking include,
treatment sedative agents,febrile illness, and certain
Fatigue,reduced ability to learn and medication
concentrate,increased hunger,decreased Sleep walking is much higher in children
motivation 3yrs to 7yrs
Insomnia diagnosis rarely include sleep Common symptoms-inability to recall sleep
studies walking after awakening, excessive day time
Treatment –medication+ sleep restriction sleepiness,
treatment
Transsexualism Transvestism
-Consistently strong desire to change one's Transvestism, commonly termed as cross-
anatomical gender. Some transsexuals were dressing, means to dress in the clothing of
miss signed gender at birth (for example, opposite sex.
being anatomically male but raised as -We describe a series of three cases with
female), either on purpose or due to indistinct transvestism as one of their primary
anatomy. complaints. The discussion sheds light on the
- Transsexuals may dress and behave as various ways in which transvestism as a
individuals of the opposite sex, symptom can present in Psychiatry. In the
use hormones or surgery to develop --- first two cases, there was lower intelligence.
desired secondary sex characteristics. In first and third case, there were other
Surgery to change the appearance of the paraphilia along with transvestism. Second
external genitals is known as sex case had co-morbid obsessive-compulsive
reassignment surgery. Surgery and hormonal disorder (OCD) and had good response to
treatments for gender reassignment are selective serotonin reuptake inhibitor (SSRI)
available for both male and female
transsexuals. Transsexualism is distinct from
transvestitism (cross-dressing), and it does
not always indicate a change in the
individual's sexual preference.
Paraphilia Sexual dysfunction

In paraphilias sexual arousal occur Sexual dysfunction is a significant
persistently and significantly in response to disturbance in the sexual response cycle,
object, which are not a part of normal sexual which is not due to an underlying organic
arousal cause.
These disorder include –fetishism, These include-frigidity, impotence,
transvestism, sexual sadism, sexual premature ejaculation, non-organic
masochism, exhibitionism dysparenuria
Treatment –behaviour therapy, Treatment –psycho analysis, hypnosis, group
psychoanalysis, drug therapy psycho therapy
Unit XI: Nursing management of childhood and adolescent disorders including mental
deficiency
Essay:
1) Classify Mental retardation.Explain the etiological factors of MR.Explain the

rehabilitation process of client with mild MR.(4+5+6=15).
Short notes: (5marks)
1) Careofclientwithmildmentalretardation
2) Causesofmentalretardation
3) Attention deficit hyperactivity disorder
Answer key:
Essay:
1) Definition:
“It refers to significantly sub average general intellectual functioning resulting in
or associated with concurrent impairments in adaptive behaviour and manifested
during the developmental period”(American Association on Mental
deficiency,1983)
Classification
Intelligent Quotient(IQ)
Mild(Educable) 50-70
Moderate(Trainable) 35-50
Severe(Dependent retarded) 20-35
Profound <20
Etiology:
Genetic factor
• Chromosomal abnormalities
• Metabolic disorders
• Cranial malformation
• Gross disease of brain
Prenatal factors
• Infections
• Endocrine disorders
• Physical damage and disorders
• Intoxication
• Placental dysfunction
Perinatal factors
Postnatal factors
• Infections
• Accidents
• Lead poisoning
Environmental and sociocultural factors
Rehabilitation process of child with MR:
Elements:-
• Prevention and early detection

• Regular assessment
• Advice,support and practical measures for family
• Provision for education,training,occupation
• Housing and social support
• Medical,nursing and other services
• Psychiatric and psychological services
For mildly retarded children;
➢ Fostering,boarding,school placements,residential care.
Short notes:
1) Care of client with mild mental retardation:

❖ Elements:-
• Prevention and early detection
• Regular assessment
• Advice,support and practical measures for family
• Provision for education,training,occupation
• Housing and social support
• Medical,nursing and other services
• Psychiatric and psychological services
❖ General provision:
❖ Education and training
❖ Vocational training
❖ Helps for families:-
▪ Parent counselling
▪ Residential care
▪ Specialist medical services
▪ Psychiatric services
2) Causes of mental retardation
Genetic factor
• Chromosomal abnormalities
• Metabolic disorders
• Cranial malformation
• Gross disease of brain
Prenatal factors
• Infections
• Endocrine disorders
• Physical damage and disorders
• Intoxication
• Placental dysfunction
Perinatal factors
Postnatal factors
• Infections
• Accidents
• Lead poisoning
Environmental and sociocultural factors
4) Attention deficit hyperactivity disorder :

Definition:
It is persistent pattern of inattention and or hyperactivity more frequent and severe
than is typical of children at a similar level of development.
Etiology:
❖ Biological influences:
• Genetic factors
• Biochemical theory
• Pre, peri and postnatal factors
• Environmental influences
• Psychosocial factors
Clinical features:
✓ Sensitive to stimuli
✓ More active in crib,less sleep
✓ Short attention span
✓ Failure to finish tasks
✓ Impulsivity
✓ Memory and thinking deficits
✓ Specific learning disabilities
Diagnosis:
• Detailed prenatal history and early developmental history

• Direct observation,teacher’s school report,parent’s report
Treatment:
➢ Pharmacotherapy
▪ CNS stimulant:dextroamphetamine
▪ Tricyclic antidepressants
▪ Antipsychotics
▪ Serotonin specific re-uptake inhibitors
▪ Clonidine
➢ Psychological therapies
▪ Behaviour modification technique
▪ Cognitive behaviour therapy
▪ Social skills training
Nursing intervention:
• Develop trusting relationships

• Safe environment
• Establish goals
• Provide quiet environment
• Provide education to parents as well as child
• Assess parents skills
• Co-ordinate overall treatment
Unit -12-Nursing management of organic brain disorder
Short note
1. Role of a nurse in organic mental disorder

2. Nursing management of a patient with Alzheimer’s disease
3. Clinical manifestation of dementia
Difference between
4. . Delirium and dementia
ANSWERKEY UNIT-12
1. Provide safe environment-keep unit calm ,protect patient from harming self .
• Meet the physical needs of the patient-conduct physical assessment on the patient
regularly
• Alleviate patients fear and anxiety
• Manage client confusion
• Facilitate orientation
• Facilitate adequate rest and sleep
• Establish good interpersonal relationship
• Facilitate adequate hygiene need
• Maintain adequate food and fluid intake
• Facilitate the development of socially acceptable behaviour
• Increase interest in surrounding
2. Daily routine, Nutrition and body weight, personal hygiene ,toilet habit and incontinence,
accidents, fluid management, wandering, disturbed sleep, interpersonal relation ship,follow up,
Home care and rehabilitation,
Personality changes-lack of interest in day to day activities, easy mental fatigability, self centred
, withdrawn, decreased self care,
Memory impairment –recent memory is prominently affected ,
Cognitive impairment- Disorientation , poor judgement, difficulty in abstraction, decreased

attention span,
Affective impairment-labile mood, irritableness, depression,
Behavioural impairment- stereotyped , alteration in sexual drives and activities, neurotic

psychotic behaviour,
Neurological impairment –aphasia, apraxia, agnosia, seizure, head ache,,
Catastrophic reaction- agitation, Sundowner syndrome
4.
Dementia Delirium
Dementia is typically begins slowly and is Is usually a sudden change in a condition
gradually noticed over time Acute confusional state
Triggered by aspecific illness, such as
Cause of dementia is alzhemers ,vascular urinary tract infection, pneumonia
dementia, lewy body dementia,
frontotemporal dementia Delirium can last for a couple of days to even
Dementia is generally a chronic , progressive a couple of month –hours to days
disease that is incurable Clouded consciousness
Month to year Short attention span
Consciousness not clouded Potentially reversible
Attention span may not be reduced
irreversible
UNIT-XIII –Psychiatric Emergencies and Crisis Intervention
ESSAY (15)
1. Define crisis, types of crisis, and techniques of crisis?
II.SHORT ESSAY (7 MKS)
1. Phases of crisis?
2. Crisis intervention. Aims of crisis intervention?
III.SHORT NOTES
1. Grief Process
2. Crisis intervention. Aims of crisis intervention?
3. Stress management techniques
1. Resistance Reaction & Alarm reaction
V. ANSWER BRIEFLY
1. Maturational crisis
2. Catharsis
3. Alarm reaction
ANWER KEY
1.1. Crisis : Definition
Crisis is a state of disequilibrium resulting from the interaction of an event
With the individual’s or family’s coping mechanisms, which are inadequate to meet .
The demands of the situation combined with the individual’s or family’s perception Of
the meaning of the event. – Taylor
Types of crisis
There are three types of crisis.
• Maturational or developmental crisis

• Situational crisis
• Adventitious crisis
Maturational Crisis
o Also known as internal crisis.
o It may occur at any transitional period in normal growth and development.
o Transitional period means where individual moves into successive stage often
generates disequilibrium.
o Eg : adolescence, retirement, marriage, etc.
Situational Crisis
o Also called as accidental or external crisis.

o It is a response to a sudden and unavoidable traumatic event that largely affects
person’s identity and roles.
o E.g. : unexpected job loss, loss of spouse, academic failure.
Adventitious Crisis
o Also called as social crisis.

o It is an accidental, uncommon, and unanticipated and result in multiple loss and
radical environmental changes.
o It occurs outside the person precipitated by an unexpected event.
o E.g. : Natural disaster, Floods, etc.
Techniques of crisis intervention
✓ Catharsis
✓ Clarification
✓ Manipulation
✓ Reinforcement of behavior
✓ Support of defenses
✓ Increasing self esteem
✓ Exploration of solutions
✓ Suggestion
Catharsis :
The release of feelings that takes place as the patient talks about emotionally
charged areas.
Clarification :
Encouraging the patient to express more clearly the relationship between
certain events.
Manipulation :
Using the patient’s emotions, wishes or values to benefit the patient in the
Therapeutic process.
Reinforcement of behavior :
Giving the patient positive reinforcement to adaptive behavior.
Support of defences
Encouraging the use of healthy, adaptive defenses and discouraging those that are
unhealthy or maladaptive.
Increasing self esteem
Helping the patient to regain feelings of self worth.
Exploration of solutions :
Examining alternative ways of solving the immediate problem.
Suggestion :
Influencing a person to accept an idea or belief, particularly the belief that
the nurse can help and that person will in time feel better.
II.1. Phases of crisis

There are mainly 4 phases.
Phase I
Perceived threat acts as a precipitant that generates increased anxiety. Normal coping strategies
are activated, and if unsuccessful, the individual moves into Phase II.
Phase II
The ineffectiveness of the Phase I coping mechanisms leads to further disorganization. The
individual experiences a sense of vulnerability.
The individual may attempt to cope with the situation in a random fashion. If the anxiety continues
and there is no reduction, the
Individual enters Phase III.
II. 2. Crisis Intervention

Crisis intervention is a technique used to help an individual or family to understand and cope
with the intense feelings that are typical of a crisis.
Nurses function as part of the interdisciplinary team in the use of crisis intervention as a
therapeutic modality. ).."nurses may employ crisis techniques in their work with high-risk groups
such as clients with chronic diseases, new parents and bereaved persons. Nurses may also use
crisis intervention in dealing with intra-group issues and client management issues.
Aims of Crisis Intervention Technique

• To provide a correct cognitive perception of the situation.
• To assist the individual in managing the intense and overwhelming feelings associated with the
crisis.
Intervention
A Steps to provide a correct cognitive perception Assessment of the situation.
• This may be achieved by direct questioning with the purpose of identification of the problem
and the people involved.
• It is necessary to identify- the support systems available and to know the depth in which the
individual's feeling.-re affected
Develop a plan of action

• The victim and the people closely associated with him should have active involvement in
developing the plan of action.
• The therapist must be aware that the victim may not be in a condition to mentally comprehend
complicated information due to the overwhelming anxiety experienced by him. The instructions
given by the therapist must be simple and clear, and too much information should not be given at
a time. The instructions may have to be written down, as the victim may not be able to retain all
the information.
B. Steps to assist the victim in managing the intense feelings Helping the individual to be aware
of the feelings
• The victim needs help in identifying his own feelings, which is the first step in handling them.
• The therapist should use appropriate communication technique so that the victim will feel
comfortable to express his feelings without the fear of being judged or criticized.
• The therapist should also be efficient in observing verbal and non-verbal behaviour of the
victim, so that he will be able to make a careful assessment of his feelings.
Help the individual to attain mastery over the feelings

• The individual should be given adequate support and guidance through process in order to
handle feelings associated with crisis but special care should be taken not to give any false
reassurance.
• He should not in any way be encouraged to blame others, as this will only let him escape from
taking any responsibility.
• Care must be taken to ensure that the individual does not develop too much
Dependency on the therapist, which is unhealthy.
• After the victim and the support groups prepare the plan of action under the guidance of the
therapist, it should be discussed with the victim and the concerned others, so that they will have a
clear understanding of the methods of implementation of the plan.
• To improve coping with the situation necessary environmental manipulation must be done in
physical or interpersonal areas.
• It is advisable to have another appointment for the victim to visit the therapist within a week, in
order to assess how the plan is working out, and if needed, to revise and modify the plan.
III.1. Grief Process Definition

Grief is a reaction of an individual to a significant loss, shock, disbelief, anger,
resentment and depression are common features of affected individuals.
Types
✓ Anticipatory Grief
✓ Conventional grief
Theories of Grief
→ By Kubler – Ross
STAGE I: denial
Stage II: Anger

Stage III: Bargaining
Stage IV: Depression
Stage V: Acceptance
Denial: this is a stage of shock and disbelief. Denial is a protective mechanism. The
Response may be “no, it cant be true.”

Anger: Anger may be directed at self or at loved ones or may be to God. “Why me?”
Or “it is not fair “are the comments often expressed in anger stage.
Bargaining: it is not visible in this stage or evident to others,a bargain is made with
God in an attempt to reverse or postpone the loss.
Depression: full impact of loss is experienced in this stage.

Acceptance: final stage brings a feeling of peace regarding the loss that has
occurred.
→ By John Bowlby
Stage I: Numbness or protest
Stage II : Disequilibrium
Stage III : Disorganization
Stage IV : Reorganization
Grief Process
It describes a series of occurrences in the resolution of loss. It provides time to
Put things into perspective to place into memory that which is gone. The length of grief
Process may prolong based on certain factors:
• If the relationship between lost entity become ambivalence and reaction to loss may be
burdened which lengthens the process.
• The number of recent loss experienced by an individual also affects the length of grief
process.
Maladaptive grief responses
It occurs when an individual is not able to satisfactorily progress through the stages
of grieving to achieve resolution.
Management and treatment
o Evaluation of any primary psychiatric disorder
o Patient is encouraged to talk about their feelings
o Provide reassurance
Nursing interventions
o Provide an open accepting environment
o Provide various diversional activities
o Provide teaching about various symptoms
o Reinforce goal directed activities
o Provide positive feedback
o Encourage participate in group activities
III.2.Crisis Intervention
Definition
Crisis intervention refers to the methods used to offer immediate, short term
.Help to individual who experience an event that produces emotional, mental, Physical
and behavioural distress or problems.
Aims of Crisis Intervention techniques
To provide a correct cognitive perception situation
To assist the individuals to overwhelming the situations
Techniques of crisis intervention
• Catharsis
• Suggestion
• Clarification
• Reinforcement of behaviour
• Support of defences
• Increasing self esteem
• Exploration of solutions
Interventions
To provide correct cognitive perception
ASSESSMENT
By direct questioning
Identify the support systems to know depth of individual’s feeling affected
To identify strength and limitation of victim
DEFINING AN EVENT
It may be important to elaborate the event of 1 – 2 week by therapist in order to

identify the exact factor that precipitate the crisis of the patient.
DEVELOP A PLAN OF ACTION
The information that given by the therapist should be in clear. It should
Understand by the victim and relatives. Therapist should assess the feelings of victim
Before a plan of action.
To assist the victim in managing intense feeling
HELPING THE INDIVIDUAL TO BE AWARE OF THE FEELINGS
COMMON ADAPTIVE COPING TECHNOUES
i) Problem solving
ii) Assertiveness
iii) Positive self talk
iv) Conflict resolution
v) Time management
vi) Community living skills
vii) Stress and anger management
STRATEGIES THAT THEMPORARILY DECREASE THE EFFECTS OF ANXIETY

✓ Visualization
✓ Guided imagery
✓ Prayer and meditation
✓ Engaging in yoga
✓ Relaxation training
✓ Avoiding smoking and alcohol
✓ Reducing competitive activities
✓ Decreasing unhealthy and destructive behavior
✓ Listening to music
III.3. Stress Management Strategies
1. Take a Deep Breath

When you feel 'uptight' try taking a minute to slow down and breathe deeply. Breathe in through
your nose and out through your mouth.
Try to inhale enough so that your lower abdomen rises and falls. Count as you exhale - slowly.
2. Practice Specific Relaxation Techniques

Relaxation techniques are extremely valuable tools in stress management. Most of the techniques
like meditation, self hypnosis, and deep muscle relaxation work in a similar fashion. In this state
both the body and the mind are at rest and the outside world is screened out for a time period.
The practice of one of these techniques on a regular basis can provide a wonderfully calming and
relaxing feeling that seems to have a lasting effect for many people.
Manage Time
One of the greatest sources of stress is poor time management. Give priority to the most
important ones and do those first. If a particularly unpleasant
Task faces you, tackle it early in the day and get over with it; the rest ofyour day will include
much less anxiety. Most importantly, do not overwork you, and schedule time for both work and
recreation.
4. Connect with Others

A good way to combat sadness, boredom and loneliness is to see out activities involving others.
5. Talk it out
When you feel something, try to express it. Share your feelings. "Bottled Up" emotions increase
frustration and stress. Talking with someone else can help clear your mind of confusion so that
you can focus on problem solving. Also consider writing down thoughts and feelings. Putting
problems on paper can assist you in clarifying the situation and allow you a new perspective.
6. Take a "Minute" Vacation

Imagining a quiet country scene can take you out of the turmoil of a stressful situation. When
you have the opportunity, take a moment to close your eyes and imagine a place where you feel
relaxed and comfortable. Notice all the details of you chosen place, including pleasant sounds,
smells and temperature or change your mental "channel" by reading a good book or playing
relaxing music to create a sense of peace and tranquility.
7.Monitor Your Physical Comfort
Wear comfortable clothing. If it's too hot, go somewhere where it's not. If your chair is
uncomfortable, change it. If your computer screen causes eye-strain or backaches, change that,
too. Don't wait until your discomfort turns into a real problem. Taking five minutes to arrange
back support can save you several days of back.
8. Get Physical
When you feel nervous, angry or upset, release the pressure through exercise or physical activity.
Running, walking or swimming are good options for some people, while others prefer dance or
martial arts. Working in the garden, washing your car, or playing with children can relieve that
"uptight" feeling, relax you and often will actually energize you. Remember, your body and
mind work together. Most experts recommend doing 20 minutes of aerobic activity daily will
reduce stress.
9. Take Care of Your Body

Healthy eating and adequate sleep fuels your mind as well as your body. Avoid consuming too
much caffeine and sugar. Take time to eat breakfast in the morning, it really will help keep going
through the day. Well-nourished bodies are better prepared to cope with stress. If you are
irritable and tense from lack of sleep or not eating right, you will be less able to" go the distance
in dealing with stressful situations". Increase the amount of fruits and vegetables in daily diet.
Take time for personal interests and hobbies. Listen to one's body.
10.Laugh
Maintain your sense of humor, including the ability to laugh at yourself.
11.Know Your Limits

There are many circumstances in life beyond your control, consider the fact that we live in an
imperfect world. Know your limits. If a problem is beyond your control and cannot be changed
at the moment, don't fight the situation. Learn to accept what is, for now, until such time when
you can change things.
12. Think Positively

Refocus the negative to be positive. Make an effort to stop negative thoughts.
13.Clarify Your Values and Develop a Sense of Life Meaning

Clarify your values and deciding what you really want out of your life, can help you feel better
about yourself and have that sense of satisfaction and centeredness that helps you deal with the
stresses of life. A sense of spirituality can help with this.
14.Compromise
Consider co-operation or compromise rather than confrontation. A little give and take on both
sides may reduce the strain and help you feel more comfortable.
15.Have a Good Cry

A good cry during periods of stress can be a healthy way to bring relief to your anxiety, and it
might prevent a headache or other physical consequences of "bottling" things up.
16.Avoid Self Medication
Alcohol and other drugs do not remove the conditions that cause stress. Although they may seem
to offer temporary relief, these substances only mask or disguise problems.
IV.1. Resistance reaction and alarm reaction

• The resistance reaction is the second stage in the stress response. It is initiated by regulating
hormones secreted by the hypho-thalamus, and is a long-term reaction.
The alarm reaction or fight-or-flight response is the body's initial reaction to a stressor. It is a set
of reactions initiated when the hypothalamus stimulates the sympathetic division of the
autonomic nervous system, and the adrenal medulla.
V.1. MaturationalCrisis
A maturational crisis is a stage in a person's life where adjustment and adaptation to new
responsibilities and life patterns are necessary.
The transition points where individuals move into successive stage often generate disequilibrium.
Individuals are required to make cognitive and behavioral changes and to integrate those physical
changes that accompany development.
2. Catharsis: It is one of the crisis intervention techniques. The release of feelings that takes place
as the patient talks about emotionally charged areas.
3.Alarm Reaction
The alarm reaction or fight-or-flight response is the body's initial reaction to a stressor. It is a set
of reactions initiated when the hypothalamus stimulates the sympathetic division of the
autonomic nervous system, and the adrenal medulla.
4. General Adaptation Syndrome (GAS) Hans Selye, 1945)

• Homeostatic mechanisms are aimed at counteracting the everyday stress of living. If they are
successful, the internal environment maintains normal physiological limits of temperature,
chemistry and pressure. If stress is extreme or long lasting, the normal mechanisms may not be
sufficient .In this case, the stress triggers a wide-ranging set of bodily changes called General
Adaptation Syndrome:
• When stress appears, it stimulates the hypothalamus to initiate the GAS through two pathways:
The first pathway is stimulation of the sympathetic division of the autonomic nervous system
and adrenal medulla.
The second pathway, called the resistance reaction involves the anterior pituitary gland and
adrenal cortex; the resistance reaction is slower to start, but its effects last longer.
Unit: XIV Disorders of adult personality and behaviour
Essay:
1.Cluster A Personality disorder

Cluster A: includes people whose behavior appears odd or eccentric & includes paranoid,
schizoid, and schizotypal PDs
Cluster B: includes people who appear dramatic, emotional, or erratic and includes
antisocial, borderline, histrionic, & narcissistic PDs
➢ Cluster C includes people who appear anxious or fearful and includes avoidant,
dependent, & obsessive-compulsive PDs
➢ Proposed personality disorder categories: depressive and passive-aggressive PDs
Cluster A: PARANOID PD
➢ Characterized by pervasive mistrust and suspiciousness of others
➢ Clients interpret others’ actions as potentially
➢ Clients may develop transient psychotic symptoms.
➢ More common in men than in women
PARANOID PD: Clinical Picture

➢ Clients use the defense mechanism of projection, which is blaming other people, institutions,
or events for their own difficulties.
➢ Conflict with authority figures on the job is common
PARANOID PD: Interventions

1. Approach clients in a formal, business-like manner and refrain from jokes.
2. Because they need to feel in control, involve them in formulating their plans of care.
3. Help clients to learn to validate ideas with another person before taking action.
Cluster A: SCHIZOID PD
➢ Characterized by a pervasive pattern of detachment from social relationships and a
restricted range of emotional expression in interpersonal settings
➢ More common in men than women
SCHIZOID PD: Clinical Picture

➢ Clients display a constricted affect and little, if any, emotion.
➢ They are aloof and indifferent, appearing emotionally cold, uncaring, or unfeeling.
➢ Passive and disinterested even under stress.
➢ Marked difficulty experiencing and expressing emotions, particularly anger or aggression
➢ Usually have a rich and extensive fantasy life
➢ Accomplished intellectually and involved with computers or electronics in hobbies or work
SCHIZOID PD: Clinical Picture

➢ Clients may be indecisive and lack future goals or direction.
➢ They see no need for planning and really have no aspirations.
➢ They have little opportunity to exercise judgment or decision making because they rarely
engage in these activities.
SCHIZOID PD: Interventions

1. Improve client’s functioning in the community.
2. Assist client to find case manager.
3. Help agency personnel find suitable housing that accommodates the client’s desire and
need for solitude.
Cluster A: SCHIZOTYPAL PD
➢ Characterized by a pervasive pattern of social & interpersonal deficits marked by acute
discomfort with and reduced capacity for close relationships as well as by cognitive or
perceptual distortions and behavioral eccentricities.
➢ Slightly more common in men than in women
➢ May experience transient psychotic episodes in response to extreme stress
➢ May be unkempt and disheveled, and their clothes are often ill-fitting, do not match, and may
be stained or dirty.
➢ May wander aimlessly and, at times, become preoccupied with some environmental detail
➢ Speech is coherent but may be loose or vague and they frequently use words incorrectly,
which makes their speech sound bizarre.
SCHIZOTYPAL PD: Interventions

1. Help client develop self-care and social skills
2. Improve the client’s functioning in the community.
3. Encourage client to establish a daily routine for hygiene and grooming
Cluster B: ANTISOCIAL PD
➢ Characterized by a pervasive pattern of disregard for and violation of the rights of others
➢ Displays central characteristics of deceit and manipulation
➢ A.k.a. psychopathy, sociopathy, or dyssocial personality disorder
➢ 4x more common in men than in women.
➢ In prison populations, about 50% are diagnosed with antisocial PD.
DSM-IV-TR Criteria: Antisocial PD

1. Violation of the rights of others, lack of remorse for behavior
2. Shallow emotions, lying, rationalization of own behavior
3. Poor judgment, impulsivity, irritability and aggressiveness
4. Lack of insight, Thrill-seeking behaviors
5. Exploitation of people in relationships
6. Poor work history, consistent irresponsibility
Interventions: Limit Setting

1. Stating the behavioral limit (describing the unacceptable behavior) e.g. “It is not
acceptable for you to ask personal questions.”
2. Identifying the consequences if the limit is exceeded e.g. “If you continue, I will
terminate our interaction.”
3. Identifying the expected or desired behavior e.g. “We need to use this time to work on
solving your job-related problems.”
Interventions: Confrontation
➢ Points out a client’s problematic behavior while remaining neutral and matter-of-fact
➢ Avoids accusing the client.
➢ Use confrontation to keep clients focused on the topic and in the present.
Nurse: “You’ve said you’re interested in learning to manage angry outbursts, but you’ve missed
the last three group meetings.”
Client: “Well, I can tell no one in the group likes me. Why bother?”
Nurse: “The group meetings are designed to help you and the others, but you can’t work on
issues if you’re not there.”
Interventions: Problem-Solving
1. Identify the problem.
2. Explore alternative solutions and related consequences.
3. Choose and implement an alternative.
4. Evaluate the results.
Interventions: Manage Emotions

➢ When frustrated, teach the client to take a time out or leave the area and go to a neutral place
to regain internal control to engage in constructive problem solving.
Short essay:
1. Gender Identity Disorders (F6)
In these disorders, the sense of one's masculinity or femininity is disturbed. They include:
• Transsexualism.
• Gender identity disorder of childhood.
• Dual-role transvestism.
• Intersexuality.
a. Transsexualism: In this, there is a persistent and significant sense of discomfort regarding
one's anatomic sex and a feeling that it is inappropriate to one's perceived gender. The person
will be preoccupied with the wish to get rid of one's genitals and secondary sex characteristics
and to adopt the sex characteristics of the other sex.
Treatment
• Counseling to help the individual reconcile with the anatomic sex.
• Sex change to the desired gender [sex reassignment surgery (SRS)]in selected cases
b. Gender identity disorder of childhood: This is a disorder similar to transsexualism, with a very
early age of onset.
c. Dual-role transvestism: It is characterized by wearing clothes of the opposite sex in order to

enjoy the temporary experience of membership of the opposite sex but without any desire for
permanent sex change.
d. Intersexuality: The patients have gross anatomical or physiological features of the other sex.
For example, pseudohermaphroditism, Turner's syndrome, congenital adrenal hypoplasia.
2. Describe Sexual Dysfunctions

Sexual dysfunction is a significant disturbance in the sexual response cycle, which is not due to
an underlying organic cause .
The common dysfunctions are:
a. Frigidity: Absence of desire for sexual activity.
b. Impotence: This disorder is characterized by an inability to have or sustain penile erection till
the completion of satisfactory sexual activity.
c. Premature ejaculation: Ejaculation before the completion of satisfactory sexual activity for
both partners.
d. Non-organic vaginismus: An involuntary spasm of lower l/3rd of vagina, interfering with
coitus.
e. Non-organic dyspareunia: Pain in the genital area of either male or female during coitus.
Treatment
• Psychoanalysis
• Hypnosis
• Group psychotherapy
• Behavior therapy
Differentiate between:
1. Fetishism Transvestism
Fetishism: Sexual arousal occurs with a Transvestism: Sexual arousal occurs by
nonliving wearing clothes of the opposite sex.
object which is usually intimately associated
with the human body. The fetish object may
include bras, underpants, shoes, gloves, etc.
2. Sexual sadism Sexual masochism

Sexual sadism: The person is sexually Sexual masochism:Here the person is sexually
aroused aroused by physical or psychological
by physical and psychological humiliation, humiliation
suffering or injury of the sexual partner. or injury inflicted on self by others.
3. Exhibitionism Voyeurism
Exhibitionism: In this the person is sexually Voyeurism: This is a persistent or recurrent
aroused by the exposure of one's genitalia to tendency to observe unsuspecting persons
an unsuspecting stranger. naked (usually of the other sex) and engaged
in sexual activity.
4. Frotteurism Pedophilia
Frotteurism: This is a persistent or recurrent Pedophilia:It is characterized by persistent or
involvement in the act oftouching and rubbing recurrent involvement of an adult in sexual
against an unsuspecting, non-consenting activity with prepubertal children.
person.
Unit -XV–Geropsychiatry
Essay
1. Explain the developmental tasks of old age according to Erikson theory of psycho social
development . Describe two mental health problem s of old age .list the areas of care a
nurse can teach the family members
Short note
2. Theories of aging.
Answer key – unit -15
1 The stages that make up his theory are as follows:
Stage 1: Trust vs. Mistrust
Stage 2: Autonomy vs. Shame and Doubt
Stage 3: Initiative vs. Guilt
Stage 4: Industry vs. Inferiority
Stage 5: Identity vs. Confusion
Stage 6: Intimacy vs. Isolation
Stage 7: Generativity vs. Stagnation
Stage 8: Integrity vs. Despair,
Stage 7: Middle Adulthood (40 to 65 years)
Basic Conflict: Generativity vs. Stagnation
Important Events: Work and Parenthood
Outcome: Adults need to create or nurture things that will outlast them, often by having children
or creating a positive change that benefits other people. Success leads to feelings of usefulness
and accomplishment, while failure results in shallow involvement in the world.
Stage 8: Maturity (65 to death)
Basic Conflict: Ego Integrity vs. Despair
Important Events: Reflection on life
Outcome: Erikson's theory differed from many others because it addressed development
throughout the entire lifespan, including old age. Older adults need to look back on life and feel a
sense of fulfillment. Success at this stage leads to feelings of wisdom, while failure results in
regret, bitterness, and despair. At this stage, people reflect back on the events of their lives and
take stock.
Stage 8: Integrity vs. Despair
The final psychosocial stage occurs during old age and is focused on reflecting back on life. At
this point in development, people look back on the events of their lives and determine if they are
happy with the life that they lived or if they regret the things they did or didn't do. Those who are
unsuccessful during this stage will feel that their life has been wasted and will experience many
regrets. The individual will be left with feelings of bitterness and despair. Those who feel proud
of their accomplishments will feel a sense of integrity. Successfully completing this phase means
looking back with few regrets and a general feeling of satisfaction. These individuals will attain
wisdom, even when confronting death.
Mental disorders in old age-dementia, delirium-it is a condition of severe confusion and rapid
changes, and brain disorder is usually caused by a treatable physical or mental illness.
schizophrenia, delusional disorder, sleeping disorder, addictive disorder, depressive disorder,
C) primary prevention, secondary prevention, Tertiary prevention
Geriatric health assessment-health history, physical assessment, educational assessment,,

Comprehensive assessment-fluid, nutrition, communication, activity, pain, elimination, Physical
health,
2. Biological theories- cellular theory, programmed aging theory, somatic mutation theory, wear
and tear theory, error theory, auto immune theory, free radical theory, cross linkage theory
Psychological theory-disengagement theory, activity theory, continuity theory, social exchange

theory,
Environmental theory-radiation theory, stress theory, population theory, exposure theory,
Nursing theory,
Environmental theory
UNIT-XVI – Legal Issues in Mental Health Nursing
Short Notes:
1. Describe Mental health Act
• Indian Lunancy Act-1912
• It is derived from English Lunancy Act 1890
• Contains eight chapters
• Chapter –I Terms of Psychiatry, Defectivness of reasoning
• Chapter-II Admission procedure
• Chapter-III Administering drug, care, treatment. Parole-90 days
• Chapters-4 to 8 Establishment of Asylums, expenses of lunatics, rules by govt
regarding care of patients.
Mental Health Act-1987
o MHA bill passes on 22nd May 1987
o Act enforce w.e.f 1st April 1993
o Reasons for enactment-
o Attitude of the society has changed.
o Rapid advancement of medical science and understanding of nature of malady
(Trouble)
2. What are the Objectives of the Indian Mental Health Act?

• To regulate admission into psychiatric hospitals and psychiatric nursing homes.
• To protect society from the presence of mentally ill persons.
• To protect citizens from being detained in psychiatric hospitals I nursing homes without
sufficient cause.
• To regulate maintenance charges of psychiatric hospitals/nursing homes.
• To provide facilities for establishing guardianship of mentally ill persons who are
incapable of managing their own affairs.
• To establish central and state authorities for mental health services.
• To regulate the powers of the government for establishing, licensing and controlling
psychiatric hospitals/nursing homes.
• To provide legal aid to mentally ill persons at state expense in certain cases.
3. Role of the Nurse in Admission Procedure

• A most important feature of the admission procedure involves settling the patient in the
ward. It begins with introducing him to the other staff members and patients.
• Before assigning him a bed consider his biological and emotional needs. If he seems to
be nurturing suicidal ideation or is floridly psychotic, he should be located in a place
where he can be closely observed.
• He should be shown various facilities like eating, recreation, bathroom facilities, etc.
• Acquaint him with some of the ward rules, e.g. meal time, ward activities, visiting hours,
how to make appointments to see staff members, timings of any group meetings, etc.
• The patient and his relatives are likely to have all sorts of anxieties about various
procedures and investigations. The nurse needs to be sensitive to these feelings, and give
enough time and attention and allow them to express their feelings about the patient's
condition, treatment and outcome. All information should be provided as appropriate.
4. Role of the Nurse in Discharge Procedure
• Nurse must ensure that the patient leaves the unit with all belongings and personal
effects, has the appropriate medications with him, and appointment for follow-up has
been made and understood.
• All necessary instructions especially regarding his medication regimen, side-effects etc.
must be clearly given to the patient and his family members.
• Any paper work, signing of documents should be completed. The hospital file along with
all charts and notes should be sent to the medical records section.
• The nurse should ascertain his travel plan and offer assistance if necessary.
• The nurse must bear in mind that the patient may have mixed feelings about leaving the
hospital and going back to his home environment. She should help him cope with any
distress about separating from his newfound friends and staff members.
5. What are the Basic Rights of Psychiatric Patients and Nurse's Responsibilities
Psychiatric patients are often the least capable of protecting their own rights. It is therefore one
of the responsibilities of the nurse to guide the patients and relatives in matters related to their
rights and protect the patient from any mistreatment.
Some of the Rights of Psychiatric Patients

• The right to wear their own clothes.
• The right to have individual storage space for their private use.
• The right to keep and use their own personal possessions.
• The right to spend a sum of their money for their own expenses.
• The right to have reasonable access to all communication media like telephone, letter
writing and mailing.
• The right to see visitors every day.
• The right to treatment in the least restricted setting.
• The right to hold civil service status.
• The right to refuse electroconvulsive therapy.
• The right to manage and dispose of property and execute wills.
Nurse's implications for protecting patient's rights

• To protect patient's rights, the nurse should be aware of these rights in the first place.
• She should ensure that ward procedures and policies should not violate patient's rights.
• Discussing these rights with the mental health team and including these rights in the
nursing care plan is all part of her responsibility in protecting the patient's rights.
Short Essay:
3. Explain the admission procedure based on Indian mental health act-1987
Admission on Voluntary Basis

Any person who considers himself to be mentally ill and wishes to be admitted to a psychiatric
hospital may apply to the medical officer-incharge; if he is a minor, the guardian can make this
application on his behalf.
The medical officer should make inquiry within 24 hours and should admit the patient if he opines
that treatment is required. The voluntary patient thus admitted is now bound to abide by the rules
made by the institution.
Admission under Special Circumstances

Any mentally ill patient who is unwilling for admission on a voluntary basis may be admitted and
kept as an inpatient in a psychiatric hospital/ nursing home. For such purpose an application should
be made out on his/her behalf by a relative or a friend of the mentally ill person, provided the
medical officer deems fit.
Admission under Reception Order

On application: Only a relative not other than
husband, wife, guardian or a friend can make out an application for the admission of a mentally ill
patient. Such an application should be made out to the magistrate in writing supported by two
medical certificates, one of them issued by a gazetted medical officer. However no person being a
minor or one who has not seen the mentally ill patient in the last 14 days can make such an
application. The patient may now be admitted after the magistrate obtains consent from the medical
officer in-charge of the mental hospital.
The medical officer in-charge can extend inpatient treatment to more than 6 months by making
such an application to the magistrate.
On production before the magistrate: Mentally ill patients exhibiting violent behavior, creating
obscene scenes and dangerous to the society can be detained by the police officer and produced in
court within 24 hours of such detention, supported by two medical certificates, subsequent to
which the magistrate issues a reception order.
4. Admission in Emergencies
The medical officer in-charge may order the admission of a mentally ill patient if he thinks he is
dangerous to himself or others. However the patient should be produced before the magistrate
within 24hours (maximum time limit is 72hours, which is exclusive of the examination period), or
the magistrate himself may visit the psychiatric
hospital/ nursing home and pass reception order on examination.
5. Temporary Treatment Order

It is an order issued by the magistrate in cases where the risk is perceived to the patient's life or to
that of others. If the medical officer in-charge feels it necessary to bring legal authorities into the
picture he can do so by applying to the magistrate. Alternatively the relatives can get the magistrate
to issue an order for treatment. In such case a single medical certificate is required which is valid
for 6 months.
6. Admission of Mentally Ill Prisoners

A mentally ill prisoner may be admitted into a mental hospital on the order of the presiding officer
or a court.
7. Miscellaneous Admission
A mentally ill patient can be admitted either on humanitarian grounds (e.g. wanderers) or for
observation purpose. Social workers can obtain an order from the magistrate pending report from
medical officer.
4. Explain the discharge procedure based on Indian mental health act-1987
CHAPTERV
It deals mainly with the procedure to be followed for the discharge of mentally ill persons from
a mental hospital under different circumstances.
1. Discharge of a Patient Admitted on Voluntary Basis

Medical officerin-charge of psychiatric hospital/ nursing home on recommendation from two
medical practitioners preferably a psychiatrist, can issue directions for discharge of the patient.
2. Discharge of a Patient Admitted under Special Circumstances
A relative or a friend may make an application to the medical officer for care and custody of the
patient. The relatives are required to furnish a bond with or without sureties, along with an
undertaking that the mentally ill person shall be prevented from causing injury to self or others.
3. Discharge of a Patient Admitted on Reception Order

An applicant who feels that the patient has recovered from illness may make an application for
discharge to the magistrate. A certificate should accompany such an application from medical
officer in-charge of the psychiatric
hospital/ nursing home. If the magistrate deems fit he may issue an order for discharge.
4. Discharge of a Patient Admitted by Police

In cases where the police detain the mentally ill individual in hospital, he may be discharged
after the family members agree in writing to take proper care, and the medical officer-in-charge
opines that he is fit to be discharged.
5. Discharge of a Mentally Ill Prisoner

The hospital authorities have to report every 6 months about the person's state of mind to the
authority, which had ordered detention. As soon as they find that the person is fit to stand the
trial, they have to inform about the same to the authority concerned. The person is then handed
over to the prison officer for further legal action.
Leave of Absence
On application by a relative or others to the medical officer-in-charge and a bond duly signed
stating that the patient will be taken proper care of and prevented from injuring self or others,
leave of absence may be granted (for a period of maximum 60 days).
5. Legal Aspects of psychiatric nursing
Nursing Malpractice
When a prudent nurse expected to meet the normal standards of care, causes a breach by
deviating from the norms, it is termed as nursing malpractice. Such breach of act can invoke
legal proceedings against the nurse for not discharging her duty diligently and in good faith.
If the malpractice suit has to stand and be decreed in favor of the aggrieved patient, he will have
to prove various facets which contributed to the breach. However it is to be noted that the burden
of proof lies with the patient who in this case is the plaintiff.
The various facets include:

• the nurse had a duty to discharge due standards of care to the patient
• the nurse's performance was well below the expected standards, thus causing a breach
• substandard care provided should be construed to have adversely affected the patient and
family
• the actual proof of adverse effects/injury caused.
Informed Consent
In the course of normal treatment a series of interactions result between a patient and a
physician. During such interactions the patient is allowed to fully consider and comprehend the
information about the proposed treatment. Such consent is termed as informed consent. It
includes the mode of administering the treatment, prognosis, side- effects and the risks.
However, in the case of psychiatric patients the ability to give informed consent as regards a
procedure is highly debatable due to the nature of the problem. Though most of the patients
perceive and act in their own best interests, some may not be capable of giving a valid consent.
Due to such variations, the patients have to be screened for the following:
• whether the patient is competent to give informed consent

• whether information provided to the patient is assimilated on a regular basis and understood
• whether enough opportunity and freedom are vested with the patient to reject/ revoke the
consent during a specific course of treatment.
Substituted Consent
When it is deemed that a patient is incapable of giving informed consent, health service
providers should obtain substituted consent for the procedure I treatment. It refers to an
authorization given by another individual, being a guardian appointed by the court or the kith
and kin on behalf of the patient.
Confidentiality
During the nurse-patient relationship a lot of information is gathered through direct and indirect
sources, which is both verbal and written. Keeping in view the ethics of the nursing practice,
such information gathered is kept confidential and best used for providing enhanced care rather
than for other purposes such as gossip or personal gain.
Any breach of confidentiality could jeopardize the best interests of the patient, be it social or
economical, keeping in view the social stigma attached to mental illness.
Record Keeping
Nursing notes and progress records constitute legal documents and hence should be maintained
carefully. They should be non-judgemental and the statements made should be objective in
nature.
6. Explain the Civil Responsibilities of a Mentally Ill Person
Management of Properly
The court may on an application from any relative direct an inquiry to ascertain whether a person
is of unsound mind and incapable of managing his property. In such a case a manager is appointed
by the court of law to take care of his property, which may include sale or disposal of the property
to settle his debts expenses.
Marriage
As per the Hindu Marriage Act (1955),marriage between any two individuals one of whom was of
unsound mind at the time of marriage is considered null and void in the eyes of the law.
Unsoundness of mind for a continuous period can be sighted as a ground for obtaining divorce.
The other party can file for divorce when lunacy continues for a period of more than 2 years after
marriage. However if divorce is filed after a 3- year period, divorce is granted with a precondition
that the other party has to pay maintenance charges for the mentally ill person.
Testamentary Capacity
As per the Indian Succession Act, testamentary capacity of the mental ability of a person is a
precondition
for making a valid will. The testator must be a major, free from coercion, understanding and
displaying soundness of mind. At times doctors and nurses are called upon to witness the will of
an ailing person. Under such circumstances the doctor tests the testator for orientation,
concentration and memory. A person affected by delusional disorder can also make a valid will if
those delusions are not related to the disposal of the property.
Right to Vote
A person of unsound mind cannot contest for elections or exercise the privilege of voting. In
conclusion, nursing practice must confirm to pre-set legal standards and continuously reorient
itself to the ever evolving legal standards.
It is only the motivated and capable nurse who can incorporate legal knowledge while dispensing
patient care, and it is to her that many patients will turn for information and care.
UNIT-17-COMMUNITY MENTAL HEALTH NURSING
SHORT NOTE
1. Roles mental health nurse.

2. National mental health program.
3. Counselling for a HIV positive patient
4. Half way home
DIFFERENCE BETWEEN
5. Halfway home Quarter way home .
ANSWER KEY UNIT -17
1. Psychiatric-Mental Health Nurse – Nurses with various levels of preparation serve as

direct care providers in contracted facilities and practices. These roles include staff
nurses, managers and administrators, practitioners in psychiatric home health and
community mental health settings, primary care providers and independent providers of
psychotherapy to individuals, groups and families across the life span. While the
advanced practice registered nurse, psychiatric-mental health (APRN-PMH) has
prescriptive authority in most states, all registered nurses administer and monitor
pharmacologic agents and monitor their effects.
Care Manager
Nurses in this role assess patients and develop treatment plans, coordinate resources and care
provided by others. The Care Manager also manages patient needs and resources episodically
and is skilled in managing psychiatric rehabilitation as well as relapse prevention.
Assessment, Evaluation, Triage and Referral Nurse
In this role, the nurse evaluates patients in direct encounters or by telephone in order to triage
the patient to the most appropriate level of care, including referrals to credentialed providers,
contracted facilities and community resources.
Utilization Review Nurse

Many managed care companies employ psychiatric nurses to function as utilization reviewers
in which they review aspects of the patient’s care and influence decisions about treatment
assignment. In this role they serve as "gatekeepers" to mental health services.
Patient Educator
Some settings hire nurses with responsibility assigned to them for patient and family
education. This role has grown with the growing emphasis that is being placed on patient
compliance and disease management programs. In public sector programs, this role could
include prevention, education and outreach.
Risk Manager
Nurses who work as risk managers are charged with the task of decreasing the probability of
adverse outcomes related to patient care. They engage in identifying risk factors, individual and
system-wide problems, corrective actions and the implementation of strategies to reduce risk and
prevent loss.
Chief Quality Officer
Nurses have assumed primary responsibility for formulating and implementing

comprehensive quality management and improvement programs for managed care
companies. They engage in training other staff on-site and synthesize data related to
performance improvement, outcomes management and other health services research
activities.
Marketing and Development Specialist
Some psychiatric nurses work in the managed care growth areas of sales (proposal writing),
marketing and program development. In these roles, they interface with consumers,
employers, providers and regulators and they make recommendations for furthering the
mission and goals of the managed care organization.
Corporate Managers and Executives
Psychiatric nurses are also present in middle management positions, as well as senior
management positions where they participate in the development of corporate policy and
strategic planning. Nurses hold positions in various departments including: Provider
Relations, Quality Management, Care Management/Clinical Operations, Service Operations
and Clinical/Medical Affairs.
2.The Government of India has launched the National Mental Health Programme (NMHP) in
1982, keeping in view the heavy burden of mental illness in the community, and the absolute
inadequacy of mental health care infrastructure in the country to deal with it.
The district Mental Health Program was added to the Program in 1996
2 NMHP has 3 components:

Treatment of Mentally ill
Rehabilitation
Prevention and promotion of positive mental health.
Aims
• Prevention and treatment of mental and neurological disorders and their
associated disabilities.
• Use of mental health technology to improve general health services.
• Application of mental health principles in total national development to improve
quality of life.
Objectives
• To ensure availability and accessibility of minimum mental health care for all in
the forseeable future, particularly to the most vulnerable and underprivileged
sections of population.
• To encourage application of mental health knowledge in general health care and
in social development.
• To promote community participation in the mental health services development
and to stimulate efforts towards self-help in the community.
Strategies
• Integration mental health with primary health care through the NMHP
• Provision of tertiary care institutions for treatment of mental disorders
• Eradicating stigmatization of mentally ill patients and protecting their rights
through regulatory institutions like the Central Mental Health Authority, and State
Mental health Authority.
Mental Health care

• The mental morbidity requires priority in mental health treatment
• Primary health care at village and sub centre level
• At Primary Health Centre level
• At the District Hospital level
• Mental Hospital and teaching Psychiatric Units
.
Aims of counselling in HIV infection Prevention
• Determining whether the lifestyle of an individual places him or her at risk
• Working with an individual so that he or she understands the risks
• Helping to identify the meanings of high risk behaviour
• Helping to define the true potential for behaviour change
• Working with the individual to achieve and sustain behaviour change

Support
• Individual, relationship, and family counselling to prevent and reduce

psychological morbidity associated with HIV infection and disease
• Different HIV counselling programmes and servicesCounselling before the test is

done
• Counselling after the test for those who are HIV positive and HIV negative
• Risk reduction assessment to help and prevent transmission
• Counselling after a diagnosis of HIV disease has been made
• Family and relationship counselling
• Bereavement counselling
• Telephone “hotline” counselling
• Outreach counselling
• Crisis intervention
• Structured psychological support for those affected by HIV
Pre-test discussion
A discussion of the implications of HIV antibody testing should accompany any offer of
the test itself. This is to ensure the principle of informed consent is understood and to
assist patients to develop a realistic assessment of the risk of testing HIV antibody
positive. This process should include accurate and up to date information about
transmission and prevention of HIV and other sexually transmitted infections. Patients
should be made aware of the “window period” for the HIV test—that a period of 12
weeks since the last possible exposure to HIV should have elapsed by the time of the test.
Pre-test discussion checklist

• Indications for further counselling and referral to counsellor
• People who have been sexually active in areas of high HIV prevalence
• Men who have sex with men
• Current or previous sexual partners HIV positive
• Client presenting with clinical symptoms of HIV infection

• High risk sexual behaviour
• High risk injecting drug practices
• Learning or language difficulties
• Points for counsellor and/or physician to cover
• What is the HIV antibody test (including seroconversion)
• The difference between HIV and AIDS
• The window period for HIV testing
• Medical advantages of knowing HIV status and treatment options
• Transmission of HIV
• Safer sex and risk reduction
• Safer injecting drug use
• If the client were positive how would the client cope: personal resources, support
network of friends/partner/family
Psychological responses to an HIV positive result
Many reactions to an HIV positive diagnosis are part of the normal and expected range of
responses to news of a chronic, potentially life threatening medical condition. Many patients
adjust extremely well with minimal intervention. Some will exhibit prolonged periods of
distress, hostility, or other behaviours which are difficult to manage in a clinical setting. It should
be noted that serious psychological maladjustment may indicate pre-existing morbidity and will
require psychological/psychiatric assessment and treatment. Depressed patients should always be
assessed for suicidal ideation.
Psychological issues in HIV/AIDS counselling
• Shock, Fear and anxiety, uncertain prognosis

• Effects of medication and treatment/treatment failure of isolation and abandonment and
social/sexual rejection of infecting others and being infected by them of partner's reaction
• Depression, Anger and frustration
• Guilt
• Counselling can also be offered to patients and their partner together.
• Social isolation
3. Half way home is a transitory residential centre for mentally ill patient who no longer
need the full services of a hospital , but are not yet ready for a hospital but are not yet
ready for completely independent living ,main role of half way home is rehabilitation of
mentally ill individual.
Objectives
• To ensure a smooth transition from hospital to the family

• To integrate the individual into the main stream of life
Activities
Community mental health nurse play a vital role in monitoring the progress of discharged
patient. In half way home i
Interventions of half way home
Assessment –clinical assessment include residual psychiatric symptoms which may affect his
ability to function
Social assessment- assessing the family support ,attitude of the family member,and economic
status
Psychological assessment assessing self-esteem,confidence,patient level of motivation
Vocational assessment
Self helpgroup ,Suicidal prevention centre
5.
QUARTERWAY HOMES HALF WAY HOME
Located with in the hospital campus Transitory residential centre

Lack regular services of hospital Patents are not completely independent
Most of the care by patient them self Maintains a climate of health
Aids to develop individual capacities

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LOURDE COLLEGE OF NURSING, TALIPARAMBA-670143

MENTAL HEALTH NURSING

I.ESSAYS (12 each)

II.SHORT ESSAYS (7 mk each)

SHORT NOTES (5 MKS each)

III. DIFFERENCIATE BETWEEN (4mks each)

IV. ANSWER BRIEFLY(2mks each)

✓ The capacity to feel right toward others:-

✓ The ability to fulfil lifes task:-

It involves the analysis of responses on a test or aquestionnaire or observations of some particular

Behaviour hat is adaptive is normal, maladaptive is abnormal. Abnormal behaviour is a set of

II. SHORT ESSAY

1. It is collaboration between members of different disciplines who provide specific services o

A Clinical psychologist should have a Masters Degree in Psychology or Ph.Din clinical

An Occupational therapist or an Activitytherapist is accountable for recreational, occupational

III. SHORT NOTES ANSWER KEY

Projection is the misattribution of a person’s undesired thoughts, feelings, or impulses onto

IV. DIFFERENCIATE BETWEEN

2.Statistical model involves the analysis of responses on a test or a questionnaire or observation

UNIT II –PRINCIPLES AND CONCEPTS OF MHN

I. ESSAY (12MKS EACH)

1. Scope psychiatric nursing?

II.SHORT ESSAYS (7 mk each)

1. Qualities of a psychiatric nurse?

1. Direct care provider

✓ Demographic changes-type of family, increasing number of the elderly group

✓ Social changes changes- The need for maintaining intergroup and

✓ Economic changes-indusrialization, urbanization, raised standard of living

Educational Programs for the Psychiatric Nurse

Promotion of Research in Mental Health Nursing

New Trends in Role of a Psychiatric Nurse

Collaborative Psychiatric Nursing Practice:-

Registered Psychiatric Nurse (RPN):-

Clinical Nurse Specialist (CNS)

2. The general principles of psychiatric nursing include:-

a) Being non-judgemental and non punitive

✓ Consistency used to contribute to patients security:-

✓ Reassurance should be given in subtle and acceptable manner:-

✓ Patients behaviour is changed through emotional experience and not by rational

✓ Unnecessary increase in patients anxiety should be avoided:-

✓ Maintain realistic nurse-patient relationship:-

✓ Avoid physical and verbal force as much as possible :-

✓ Many Procedures are Modified but Basic

1. The qualities of a psychiatric nurse include:-

✓ Accepting the patient

✓ Being sincerely interested in patient care

Being available means nurse should be approachable

✓ Empathetic with the patient

2. Therapeutic roles of a psychiatric mental health nurse :-

✓ Provider of therapeutic environment for the patient

✓ Provider of preventive care:-

1. The functions of psychiatric nursing include:-

IV.DIFFERNCE BETWEEN ANSWER KEYS

1. Collaborator and case manager -

2. Self awareness and self acceptance:-

UNIT-III – PSYCHIATRIC ASSESSMENT

1. Thought insertion Thought withdrawal

2. Transference Counter transference

3. Thought block Thought broadcast

9. Neologism Clang association