Workshop on Clinical skills in Nursing for Staffs at Schools of Nursing

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Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing

Interviewing requires linguistically and culturally effective

communication skills, interviewing, behavioral observation,

data base record review and compressive assessment of the

client and relevant systems enables the psychiatric mental

nurse to make sound clinical judgments and plan appropriate

interventions with the client.

Interviewing is a specific type of guided and limited

intercommunication with an identified purpose. An interview

is usually conducted to collect a database for analysis and

decision making purpose.

The goal of the initial diagnostic interview is to collect specific,

detailed information about 15 topics. These topics constitute

the psychiatric evaluation.

1. Identifying data: Patient's name, sex, age, marital status,

address, occupation, income, etc

2. Chief complaints: The chief complaint in the patient's

own words. Alternatively signs of disordered functioning

observed by the interviewer.

3. Informants: A list of all informants, their reliability, and

level of cooperation; also previous hospital records, if

available. Such informants are essential in

circumstances that prevent the patient from providing

adequate information. Choosing the right set of

informants is more important than having a great

number of informants.

4. Reason for admission/consultation: the referral source;

in case of hospitalisation, statement of legal status -

voluntary - and the reason why hospitalisation is the

safest and least restrictive environment for treatment.

5. History of present illness: Early manifestations and

recent exacerbations of all psychiatric disorders

present; review of diagnosis and treatments given by

other providers.

6. Psychiatric disorders in remission: Psychiatric

disorders presently in remission; especially substance

abuse disorders; psychiatric disorders first diagnosed

in childhood and adolescence and their treatments.

UNIT- 1 PSYCHIATRIC INTERVIEW

Dr. R. ParthasarathyProfessor

7. Medical history: All medical disorders past and present

and their treatments and childhood disorders that

involve the central nervous system. For females,

pregnancy status - especially if on psycho tropics or

expecting the use of psycho tropics and precautions

against pregnancy and concomitant pharmacological

treatment can all patients, but particularity in consult-

liason work, the medical history includes the

interrelation of medical and psychiatric conditions.

8. Social history, pre-morbid personality - early

developmental history: Early developmental history,

description of pre-morbid personality as baseline for

patient's best level of functioning. The patient's

psychosocial and environmental conditions

predisposing to precipitating, perpetuating and

protecting against psychiatric disorders. Pre morbid

versus morbid functioning. Present support system.

9. Family history: Psychiatric history of first-degree

relatives, including treatment response as possible

genetic predisposition for the patient.

10. Mental status examination: Appearance,

consciousness, psychomotor functions, speech,

thinking, affect, mood, suggestibility and thought

content; cognitive functions such as orientation,

memory, intelligence and executive functions; insight

and judgement.

11. Diagnostic formulation: Summary of biological,

psychological and social factors contributing to patient's

psychiatric disorders.

12. Differential diagnosis: Discussion of diagnostic options

based on overlapping symptomatology

13. Multiaxial classification: Information on all five axes

14. Assets and strengths: Inventory of patient's knowledge,

interests, aptitudes, education, and employment status

to be used in the treatment plan.

15. Treatment plan and prognosis: Account of

psychopharmacological, psychological and social

Ms.ShobithaPh.D Scholar & Psy.Social Worker

Dept. of psychiatric social workNIMHANS, Bangalore-29

Dr.NagarajaiahAssociate professor

Dept. of NursingNIMHANS, Bangalore-29

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treatment modalities planned, frequency of visits and

list of providers; discharge criteria if inpatient.

For collecting such comprehensive information the interviewer

has to master the styles of interviewing and apply them to the

four components of the interview: rapport, techniques, mental

status and diagnosing.

2. Five phases of the psychiatric interview and four

components

The psychiatric interview progresses over time, which can be

arbitrarily subdivided into five phases. These phases cover

the 15 topics of the psychiatric evaluation

Phase I: Warm up and chief complaint (I to IV)

Phase II: The diagnostic decision loop (V)

Phase III: History and database (VI to X)

Phase IV: Diagnosing and Feedback (XI to XIV)

Phase V: Treatment plan and Prognosis (XV)

The five phases divide the psychiatric interview longitudinally.

Cross-sectionally, the interview consists of four components,

which the interviewer must continuously monitor and propel

throughout.

1. RAPPORT: focuses on the therapist - patient

relationship; a good rapport is prerequisite for an effective

interviewer. Rapport is established in the opening; with a

cooperative and insightful patient, there is often little problem

in establishing and maintaining a good rapport. However in

patient's who are uncooperative or show poor insight,

establishing a workable rapport with the patient becomes a

central issue.

2. TECHNIQUE: refers to the approaches the interviewer

uses to keep an interview 'on track'. It includes skills to

appropriately select questions to arrive at a diagnosis. Good

technique is necessary to therapeutically engage and work

with difficult patient's.

3. MENTAL STATUS: assessment captures the patient's

experiences, symptoms, signs behaviours, thought content,

cognitive level of functioning, insight and judgement during

actual time of the interview; however, in a patient with a

significantly altered mental status - whether it be a boisterous,

irritable and uninterruptible manic patient, a minimally

responsive depressed patient or a paranoid patient - his or

her mental status plays a significant role in the interview.

4. DIAGNOSIS: Pursues a progression in the diagnostic

decision process from chief complaint to final diagnosis.

3. Guidelines for interviewing

1. Build rapport with the patient

2. Conduct sessions seated in a private, comfortable area

with adequate lighting and hearing distance

3. At the beginning of each session, plan and discuss

with the client the length and purpose of the session.

4. Observe, listen and use facilitative communication

techniques

5. Convey a professional demeanour through dress and

manner

6. Summarize the interaction at the end of the session

and make arrangement with the client for the next

session

7. Positively reinforce the client for his attention, effort and

involvement

8. Maintain unity, progression and thematic continuity

9. Develop a good confidence so that the client is prepared

for self disclosure

10. Maintain non-judgemental attitude and respond to self

disclosure with honesty, support and acceptance

11. Limit your self-disclosure to a minimal level

4. Interview skills

Careful listening

Attending

Demonstration of sincere interest

Expression of attentiveness through eye contact, body

language, verbal back and appropriate use of silence

Concreteness in questions/probing

Immediacy - immediate importance

Experimental and didactic confrontation

5. Some do's and don'ts while conducting interview

1. Maintain eye to eye contact

2. Interrupt only when necessary

3. Ask always open ended questions

4. Don't be in a hurry

5. Do not pass judgments

6. Do not threaten

7. Don't belittle

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8. Be reassuring and supportive

9. Clarify

10. Give time

11. Prepare

12. Record the information after the interview is over

Getting maximum information, in a short time as possible,

without causing any distress to the client is "good interviewing"

and it is an art. By practice one can master it.

Conclusion:

Interview is a method by which the nurse starts establishing a

therapeutic relationship with the patient. The nurses need to

use her verbal and non verbal communication techniques and

also assess the patient's non verbal cues in order to get an

accurate picture of the patients mental status.

Reference:

1. Booklet on clinical skills in psychiatric nursing.

Department of nursing. National Institute of Mental

Health and Neuro Sciences Bangalore-560 029.india/

2009.

2. Kathy Neeb. Fundamentals of mental health nursing.

3rd ed. Jaypee. New Delhi. 2008

3. Sreevani R. a guide to mental health and psychiatric

nursing. 3rd ed. Jaypee. New Delhi.2010.

4. Vracarolis EM, Halter MJ. Foundations of psychiatric

mental health nursing- A clinical approach. 6th ed.

Saunders. St. Louis . 2010.

4


Dr.NagarajaiahAssociate professor

Dept. of NursingNIMHANS, Bangalore-29

A comprehensive, accurate and adequate history from thepatient and reliable informant will help in understanding the

problems of the patient and also in planning the appropriatemanagement. With regards to psychiatric patients it is veryimportant to obtain information from a close relative or a person

who knows well about the patient. This is because psychiatricpatients are not aware of the extent of their symptoms always.For example a schizophrenic patient may not realize how much

embarrassment he has caused by his disturbed behavior andalso in case of alcoholics, they may know their problems butmay not wish to reveal them.

History should always be recorded systematically and in thesame order to ensure that the interviewer does not forget

important themes or events. Given below a standard schemeof history taking in the form of list of topics to be covered. Thetrainee must learn by experience how to adjust his questioning

to problems that emerge as the interview proceeds. This isdone by keeping in mind the decisions about diagnosis andmanagement that will have to be made at the end of theinterview.

1. SOCIO DEMOGRAPHIC DATA

1. Name :

2. Father's / spouse name:

3. Address :

4. Phone number :

5. Age :

6. Sex :

7. Languages known :

Can speak Can write Can read

Mother tongue :

Other languages :

8. Marital status :

single /married /separated /divorced / widow /widower /other

9. Education :

10. Occupation :

UNIT-2 PSYCHIATRIC HISTORY-TAKING

11. Income (annual) : Self - Family -

12. Religion : Hindu / Muslim /Christian / others

13. Reasons for consultation/admission:

14. Source of referral and reasons for referral:

Source of Information gathered from: adequate/ reliable

2. PRESENTING COMPLAINTS (chronological):

The duration of each presenting complaints should be

mentioned in chronological order

3. HISTORY OF PRESENT ILLNESS:

Duration

Current episode /exacerbation:

Mode of onset : Abrupt <48 hrs Acute <1wk Insidious 1-2Sub acute few weeks - months

Course : Continuous /Episodic /Unclear (Fluctuating /Deteriorating /Improving)

Precipitating factors : (Describe) this can be physical (e.g

febrile illness) or psychological in nature (death/loss).

Description :

Chronological account, describe major abnormal behavior,

associated problems like homicide/ suicide/ disruptivebehavior/ thought content as expressed in speech/ writing,major mood states, abnormal perceptions and experiences,

biological functioning, occupational functioning, effects onwork, social functioning, changes in daily life etc. Descriptionof the time relations between symptoms and social

psychological and physical disorder needs to be mentioned.Associated disturbances in sleep, appetite, and sexual drivehave to be mentioned. Any treatment received, improvement

and deterioration has to be noted down.

Scheme for substance abuse/ dependence cases:

Mode of initiation, duration, quantity of consumption, earlypattern of intake, progression, salience, tolerance, craving,physical withdrawal features, pattern of use in recent and past,

medical complications (including accidents) neuropsychiatric

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problems, interpersonal problems, socioeconomic problems

(including debts if any) occupational problems, problems withlaw, earlier attempts to abstain, reason for consultation,motivation for abstinence etc.

In cases of multi substance use describe separately for eachsubstance.

Treatment history

Note the details regarding treatment received. For e.g.:

Magic-religious/ other systems like Homeopathy/ Ayurveda/Allopathic

Psychiatric pharmacotherapy- name of the drug; duration;dosage; side effects; compliance; others.

ECTs- No. of ECT's. Reason

Psychotherapy

Family interventions

Rehabilitative measures

Negative history

Major features that are usually present in the givensyndrome

History of trauma, fever, headache, vomiting, confusion,

memory disturbances,

Physical illnesses like, hypertension, diabetes, etc.

Other major psychiatric illnesses

Organic causes

Substance abuse

4. PAST HISTORY:

Chronological account since childhood has to be noted down.If possible draw an life chart. Describe each episode briefly

with onset, events, major features, course and duration,treatment taken, level of recovery.

Psychiatric illness:

Medical illness:

5. FAMILY HISTORY:

Genogram - Family of origin

Draw the tree for three generations on both sides in cases ofgenetic importance

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Describe each family member briefly: age, death, mode ofdeath, education, occupation, health status - physical andpsychological illnesses, major personality traits, relationship

with client, include other significant members.

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Details of family functioning

1. Type of family : (Nuclear / Joint / Others)

2. SES : (Upper / Middle / Lower)

3. Leadership pattern:

4. Role functions :

5. Communication with in the family and others:

6. Child rearing practices:

7. Interpersonal relationships:

8. Social position :

6. PERSONAL HISTORY:

Birth and development :

Antenatal period : Uneventful / Eventful (specify)

Birth history : Full term /Premature / Post mature, Normal /Forceps/ Caesarean/ Delayed birth cry / any other

complications.

Post natal history : Uneventful / Eventful (specify)

Physical health during infancy: Good / poor (specify)

Immunization schedule : Completed / not completed

Developmental milestones : Normal / Delayed

Motor :

Adoptive :

Speech :

Social :

Childhood health : Normal/ Abnormal/ Trauma/ Fever/ Convulsions/ Any other illness

Behavioral and emotionalproblems : (Nail biting, thumb sucking, sleep disturbances, tics, mannerisms, Enuresis, Sleep walking,

Temper tantrums, stammering. Look for conduct disturbances like frequent fights, truancy,

stealing, gang activities and relationship with parents, siblings and peers)

Home atmosphere duringchildhood : Satisfactory / Unsatisfactory

Emotional problems inadolescence : running away / delinquency/ smoking/ drug taking/ over weight/ identity problems

Home atmosphere duringadolescence : Satisfactory / Unsatisfactory

Parental lack : Yes / No (Dead/ separated fro more than one year/ habitually absent from home)

Anomalous family situation : Yes / No (Step parent, adoption status)

Comments :

Educational history :

9. Social support system:

10. Other :

History of illness in family:

Psychiatric: similar illness, other illness, other majorbehavioural problems like delinquency, personality problems,

suicide, substance use, epilepsy, mental retardation.

Medical: (Especially hereditary)

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Age of beginning :

Age of finishing :

Relationship with teachers :

Relationship with schoolmates(include nick names, bully orbutt of jokes :

Position in class : (Top / Middle / Low)

Special abilities :

Active participation in games:

Other extracurricular activities :

Occupational history :

Work record : Satisfactory / Unsatisfactory

Frequent changes of jobs : Yes / No

Work position : Raising / Falling / Stationary

Age at the time of starting towork :

Jobs held in the past (in chronological order, with wages, dates, reasons for change)

Present job : Duration:

Satisfied with work : Yes / No (Reasons for dissatisfaction)

Sexual history:

Information about sex : (How acquired, of what kind, how received, adequacy of knowledge, attitude towards oppositesex)

Masturbation : Age of starting : Frequency: (Guilt/ attitude if any,)

Sexual experience : (Homo/ Hetero/ Pre and extra marital / preferences)Any complaints includingDhat syndrome :

Menstrual history :

(Age at menarche / how regarded / regularity / duration / cycle / amount / physical / emotional problems)

Menopause : (Age / climacteric symptoms)

Marital history:

Genogram - family of procreation

Date / year of marriage (Arranged / affair)

Spouse : (Age, education, occupation, personality)

Marital relationship : Satisfactory / Unsatisfactory

Sexual relationship : Satisfactory / Unsatisfactory

Contraceptive practices :

Children: (Chronological list of children, miscarriage and still births (age, education, occupation, personality for each child,

relationship with client)

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7. PREMORBID PERSONALITY:

(Give details and cite examples from patients past life)

i. Social relations

ii. Intellectual activities : Hobbies and interests

iii. Mood (cheerful, strung up, optimistic, pessimistic, stable,fluctuating etc.)

iv. Character

a. Attitude to work and responsibility

b. Interpersonal relationships

c. Standards in moral, religious, social and health matters.

d. Energy and initiative

v. Fantasy life

8. Habits:

Eating fads / patterns

Sleeping patterns

Excretory functions

Alcohol consumption

Tobacco consumption

Self-medication with drugs

Conclusion:

History taking is the first for managing a patient in the psychiatricset up. A well taken history in itself is enough to diagnose aswell as management the patient. Therefore the art of taking

history should be essentially inculcated in all psychiatricnurses.

Reference:

1. Booklet on clinical skills in psychiatric nursing.Department of nursing. National Institute of Mental

Health and Neuro Sciences Bangalore-560 029. India/2009.

2. Kathy Neeb. Fundamentals of mental health nursing.

3rd ed. Jaypee. New Delhi. 2008

3. Sreevani R. a guide to mental health and psychiatricnursing. 3rd ed. Jaypee. New Delhi.2010.

4. Vracarolis EM, Halter MJ. Foundations of psychiatricmental health nursing- A clinical approach. 6th ed.

Saunders. St. Louis . 2010.

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UNIT-3 SYMPTOMATOLOGY IN MENTAL DISORDERS

Dr. RamachandraAssociate professor

Dept of nursing, NIMHANS, Bangalore-29

The systematic study of cognition and behavior is called'psychopathology'. Symptoms are the result of many forces.Their origin is usually within the patient. The symptoms maybe very bizarre but have a cause and meaning. Varioussymptoms observed in mental illness are addressed underthe following headings.

1. Disorders of motor aspects of behavior

2. Disorders of perception

3. Disorders of thinking

4. Disturbances of affect

5. Disturbances of attention

6. Disorders of consciousness

7. Disorders of orientation

8. Disorders of memory

1. DISORDERS OF MOTOR ASPECTS OF BEHAVIOR

Motor disturbance are related to action or impulse towardaction. It is called conation. These activities are relatedto attitude and feeling.

1.1. Increased activity (over activity)

Increased activity may be goal directed. But sometimesthe goal of the activity is constantly changing so noobjective is achieved. Ex: Mania. Even the stream of thethought is characterized by flight of ideas.

1.2. Decreased activity

Patient takes long time to start the activity when it getsstarted they do it very slowly. They have to make lots ofeffort to do it. In extreme form, the patients are mute andmotion less. Ex: severe depression.

1.3 Repetitious activities

The patient repeats the activity in the same manner foran indefinite period.

1.4 Stereotypy

Persistent and constant repetition of certain activitiesand may be of position, movement of body or speech.Stereotypy is seen in the following forms.

a) Stereotypy position

Catalepsy: A constantly maintained immobility of positionis known as catalepsy. It is frequently seen inSchizophrenia.

Waxy -flexibility: Here patient flex his extremities like waxin awkward position and remains in that position forlong time.

b) Stereotype Movement

Mannerisms: These are stereotyped movementscommonly seen in Schizophrenia. Ex: grimacesrepeated gestures and peculiarities of gait etc.

c) Stereotype Speech

Verbigeration: Repetation of words phrase or sentenceis called verbigeration.

1.5 Automatic Behaviour

In this patient follows compulsively and automaticallysuggestions and requests. This is seen in two forms:

Echolalia: patient repeats the words or phrases whichare spoken in his presence.

Echopraxia: patient imitates the action of others.

1.6. Negativism

It is a psychological defense reaction manifested byopposition and resistance to what is suggested. Thiscan be exhibited in different forms such as mutism,refusal of food and noncompliance with requests etc.Negativism provides gratification by the acting out ofhostile, revengeful feelings towards significant persons.

1.7. Compulsions

A morbid and often an irresistible urge to performpurposeless act repetiously is known as compulsion.Ex: touching an object twice or may take form of ritual.

1.8. Violence

Violence is an expression of aggressiveness in the formof murders, assaults, rape damaging self and othersand suicide.

1.9. Suicide

It means self-destruction. People with suicidal ideationhave sense of lack of love and affection and deep senseof personal rejection. They also suffer from self-derogatory attitude, profound feelings of hopelessnessand helplessness. The suicidal attempt is motivated bythe wish for revenge or by wish-fulfilling fantasies ofreunion in death.

DISORDERS OF PERCEPTION

Disorders of perceptions are classified as illusions andhallucinations.

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Illusions

Illusions are mistaken or misinterpretations of senseimpressions. Ex: patient perceives rope as a snake. Illusionsoccur due to individual emotional state, needs and fears.

Hallucinations

Hallucination is a perception without object. Hallucinationsshould be looked upon as mental products which, arisingfrom within and not related to any external stimulus. Theyrepresent a breakthrough of preconscious orunconsciousness in the form of sensory images in responseto psychological situations and needs.

Types of Hallucinations

1. Auditory Hallucinations : These are most common formof perceptual disturbances. These are sometimes in theform of noises but commonly in clear words or completesentences addressed to him.

2. Visual Hallucinations : These are not common as auditoryhallucinations. These occur most commonly in deliriumtremens in which patient sees terrifying images andcauses fear to the patient.

3. Olfactory Hallucinations: These are hallucination of smell,commonly seen in Schizophrenic states and with lesionsof the temporal lobe. They are unpleasant and representfeelings of guilt.

4. Gustatory Hallucinations: these are hallucinations of taste.They rarely occur alone but are associated with olfactoryhallucinations.

5. Tactile Hallucinations: these are the hallucinations of thetouch. They occur principally in toxic states. Ex: deliriumtremens, in cocaine addiction and in Scxhizophrenia also.

6. Kinesthetic Hallucinations: The phantom phenomenon.Ex: to feel pain in the amputated part of limb. This is themost common form of kinesthetic hallucinatory experience.

DISORDERS OF THINKING

Thought is the most highly organized psychobiologicalintegration and a form of implicit or internal behavior.

1. Disorders in the form of thought

Thinking is the product of stimulus and response. Stimuli forthought come from various sources. In day dreaming thinkingis directed by egocentric wishes and instinctual needs. In caseof Schizophrenia, thinking is directed by unconscious factors.Ex: autistic thinking or drastic thinking.

2. Disorders of progression of thought (Stream of thought)

The following are the disorders of the thought.

A. Flight of ideas: This is the disturbance of the streamof thought in which thinking process appear to runtoo quickly yet no idea is completed is known as flightof ideas. This happens because of increased innerdrive and distractibility. Sometimes a word similar insound but not in meaning calls up the new thoughtand may lead to senseless rhyme, e.g. Sit, sob, sigh,sorrow. This is called clang- association.

B. Retardation: In this initiation and thought are slow;patient will speak slowly and usually in low tone.Patient will complain that he has difficulty in thinking.It usually occurs in depressive phase of affectivepsychoses and may be in schizophrenia.

C. Perseveration: In this abnormal, persistent repetitionor continuance is seen in expression of an idea. Itoccurs in aphasia, catatonia and in senile dementia.

D. Circumstantiality: This is also disturbance of flow ofthought in which patient includes many unnecessarydetails before the goal is finally reached. This is seenin feeble-minded, epileptics and in advanced senilemental disorders.

E. Incoherence: This is characterized by confusion dueto repressed material highly charged affectively. Inthis one idea runs in to another with logical sequence.It occurs in schizophrenia.

F. Tangentiality: In this disorder of progression of thoughtpatient begins to respond, follows a series of relatedtopics but never reaches the goal finally. It is commonin Schizophrenics.

G. Blocking: When patient is talking and suddenly hestops talking. It means sudden interruption in train ofthought. It occurs when one feels strong affect. Eganger or terror and Schizophrenics.

3. Disorders of content of thought

A. Overvalued or over determined ideas: When an ideahas strongest feeling tones it tends to dominate andwe call it over valued idea. Overvalued idea becomesmost important determinant of behavior. This is howdelusion occurs.

B. Delusions: The delusion is defined as common falsebeliefs, which are irrational, not shared by persons ofsame race, age and standard of education, which isheld by conviction and which cannot be altered bylogical arguments and which are persistent.

Types of Delusions

I. Delusions of grandeur: Delusional beliefs of greatpower, wealth and influence. Ex: he may say he isgod. This delusion arises from feelings of insecurityor inferiority.

II. Delusions of Self-accusation: it arises when super-ego becomes critical became repression getsweakened and patient has vague feeling of guilt. Thissense of guilt takes the form of self-accusation.

III. Delusions of persecution: Delusional beliefs of anindividual that he is being deliberately interfered with,discriminated against, threatened or otherwisemistreated. He feels others are planning to harm him.These delusions permit a shifting of responsibilityand otherwise serve to relieve anxiety arising fromguilt. It occurs in chronic psychotic disorders.

IV. Ideas of reference: Delusional beliefs that otherpeople are talking about him referring to him or that

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the remarks or actions of people he meets areintended to have some special significance for him.In paranoid states ideas of reference represent aprojection of the patients own self-criticism on to theworld. In depression, feeling of guilt may stimulateideas of reference.

V. Delusion of guilt : Impoverishment and illness Theseoccur mostly in depressive cases. In thisunconscious hostile tendency may be projectedoutward giving rise to fear of punishment.

C. Hypochondria: In this patient shows exaggerated concernover physical health. In this anxiety is displaced fromunconscious mental sources to organs. It occurs in peoplewho have shown previous tendency to evade theresponsibilities of life through illness.

D. Obsessions: Thoughts that persistently push themselvesin to consciousness against the desire of the patient areknown as obsessions. Obsession thoughts are stronglycharged with the emotions of guilt or depression. Ex:patient keeps on asking why he was born. Obsessionthoughts are closely related to compulsive acts.

E. Phobias: Allied to obsessive thoughts the patient has fearsof dirt, bacteria,cancer or of crowds.

DISTURBANCES OF AFFECT

Affect is related to feeling which currently the person is havingwhereas mood is sustained feeling state of considerableduration. Affect serves as warning signal to refrain from aforbidden act. Affect influence our thoughts and ideas.

1. Pleasurable affects

A. Euphoria: It is the feeling of emotional and physicalwellbeing. In this patient has optimistic mental 'set' andis confident and assured in attitude. It is present inhypomanic states and in certain organic state. Ex:general paresis, multiple sclerosis and in frontal lobetumor.

B. Elation: patient feels overjoyed. Self-confidenceradiates from him. Elation is often labile and readilyshifts to irritability. It is accompanied with increasedactivity.

C. Exhalation: there is an intense elation accompanied byan attitude of grandeur.

D. Ecstasy: It's a feeling of extreme joy and tranquil senseof power. It can occurs in dissociative epileptic,Schizophrenic and affective reactions.

2. Depression

It is an effective feeling tone of sadness. It is the commonesttype of complaint in psychiatric patient. It can vary from milderdepressive syndrome to deeper depression. In milderdepressive syndrome the patient is quiet, restrained, inhibited,unhappy, pessimistic has feeling of inadequacy andhopelessness and the same feelings are in extreme form indeeper depression.

Grief: it is an effect of sadness due to loss of a close relation,may be death of a person.

3. Anxiety

It is a persistent feeling of dread, apprehension andimpending disaster. The patient is ignorant of its source.Following are the different states of anxiety.

A. Free-Floating anxiety: It means anxiety is not attachedto any ideational content but is felt as a morbid fearwithout apparent source.

B. Agitation: when anxiety is severe and over flows inthis way in to the muscular system, producing grossmotor restlessness, the reaction of the patient iscalled agitation.

C. Tension: In this patient feel restlessness,dissatisfaction, dread and discomfort. Tension isaccompanied by neuromuscular setting.

D. Panic: It is a pronounced state of anxiety whichproduces disorganization of ego functions. It occursin some long standing insecurity of the personalitywhich creates tension in threatening form the patientmay show aggressiveness and about, pupils getdilated and has difficulty in thinking, appearance ofbewilderment. Suicide may occur.

4. In adequate Affect

This is emotional dulling or detachment in the form ofindifference, also called apathy. Patient does not feel pleasureor pain or any other sentiments. This absence of emotionalresponsiveness may cause out of touch with reality. It mayappear as a protective, defensive reaction against painfulperceptions.

5. Inappropriateness of affect

It is a disharmony of affect. It is common emotionaldisturbance, seen in Schizophrenia.

6. Ambivalence

It means existence of contradictory feeling, attitudes towardthe same object or person. Both of these conflicting attitudesare faces of the same coin, while only one may be visible, theother is nevertheless present. Ex: feeling of love and hatetowards the parents.

7. Depersonalization

It is an affective disorder in which feelings of unreality and aloss of one's own identity are experienced. The unrealitysymptoms are of two kinds; a) feeling of changed personalityb) a feeling that the outside world is unreal. Patient feels thathe is no longer himself but he does not feel that he has becomesomeone else.it occurs in hypochondria, obsessional statesand hysteria

DISTURBANCES OF ATTENTION

Organism examines the external world for useful data is knownas attention.

1. Disordered attention

Fatigue toxic states and organic lesions interfere and lowerattention.

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2. Distractibility

The inability to hold attention for a sufficient length of timeis called distractibility. In Schizophrenia the degree ofattention is greatly diminished.

DISORDERS OF CONSCIOUSNESS

Impairments in consciousness from least to the greatest arestates of confusion, clouding of consciousness, delirium,dream and fugue states to complete stupor.

1. Confusion: It is a disturbance of consciousnesscharacterized by bewilderment, perplexity, disorientation,disturbance of associative functions and poverty of ideas.It occurs in diffuse impairment of brain tissue functionsassociated with toxic, infections or traumatic agents.

2. Clouding of consciousness: It is a disturbance in whichclear mindedness is not complete because of physical orchemical disturbances producing functional impairmentof the associative apparatus of cerebrum.

3. Delirium: It is also designated as the acute brainsyndrome. It consists of much more than clouding ofconsciousness. Delirious reactions occur in infectivestates, puerperial psychoses.

4. Dream state: This is also called twilight state. There isconsciousness disturbance and patient is not aware ofhis surroundings.

5. Stupor: In this patient is motionless and mute but withrelative preservations of conscious. Movement of eyes andrespiration occur. It can occur in toxic-organic braindisease, intense apathy, profound depression blocking,epilepsy and dissociative reaction to overpowering fear.

DISORDERS OF ORIENTATION

The process by which one understands his surroundings andlocates himself in relation to it is known as orientation. If aperson knows his position in reference to time, place andperson, he is said to be oriented. Disorientation may occur inorganic brain syndromes and in acute conflicts.

DISORDERS OF MEMORY

The function by which information is acquired and presentedto consciousness and attention is stored, later same isrecalled to consciousness is known as memory. It has threeprocesses.

a) Registration: it means reception of the mentalimpression

b) Retention: it means preservation of the previous byacquired impression.

c) Recall: It means reproduction of the impression.

The following are the disorders of memory are

1. Hypermnesia: It's an exaggerated degree of retentionand recall. It occurs in mild manic states, paranoia andcatatonia impressions with which strong emotions areattached.

2. Amnesia: It means loss of memory or inability to recallpast experience. It can occur in physiologicaldisturbances of neurons through chemical alterationsor trauma. In psychogenic amnesia, recall is not presentfor psychogenic reasons.

The types of amnesia are

A. Anterograde amnesia: confined to recent events and isprogressive.

B. Retrograde amnesia: involves the past events and is notprogressive.

3. Paramnesia: It is a falsification of memory as well asdistortions of memory also serves as protection againstintolerable anxiety. There are various types as follows:

A. Confabulation: the patient fills the gaps in his memoryby fabrications which are without any basis of fact. This isseen in senile psychoses and particularly in Korsakoff'ssyndrome.

B. Retrospect falsifications: These are illusions of memory,created in response to affective needs. It meansunconsciously selecting the memories which suit ourinterests.

4. "Déjà vu": This is an experience of seeing with the feelingthat one has seen it before but does not know when andwhere. This is seen in Schizophrenia, Psychoneuroses,lesions of the temporal lobe including epilepsy and statesof fatigue or intoxication.

Conclusion:

Psychiatric symptoms are difficult to identify yet once identifiedit forms as the basis of the patient's treatment. Therefore, it iscrucial on the part of the nurse to know about it.

Reference :

1. Gail W. Stuvart and Michele T. Laria. Principles andPractice of Psychiatric Nursing, 8th Edn. Elfvier NewDelhi, 2005, 35-38.

2. Lalitha K. Mental Health and Psychiatric Nursing -An Indian Perspective, 1st Edn. VMG Book House,147-149.

13


Dr. Sailaxmi GandhiAssistant Professor,

Department of Nursing, NIMHANS, Bangalore - 29

UNIT-4 MENTAL STATUS EXAMINATION

The mental status examination (MSE) is a standardizedprocedure where the primary purpose is to gather moreobjective data to be used in determining etiology, diagnosis,

prognosis, and treatment, and to deal immediately with anyrisk of violence or harm (Kneisl, Wilson & Trigoboff, 2004).

Definition: The MSE is the part of the clinical assessment that

describes the sum total of the examiner's observations andimpressions of the psychiatric patient at the time of the interview(Kaplan & Sadock, 1998).

Uses: The MSE is very useful to the psychiatric nurse. Someof these uses are:

1) It helps formulate the nursing diagnosis after identifyingthe clients problems

2) It helps the nurse teacher to teach nursing students

about the psychiatric client's symptoms of illness

3) It can be used to test effectiveness of various nursinginterventions on the psychiatric client.

4) It helps to assess changes in the psychiatric clientduring various stages of nursing interventions

5) It helps the nurse to assess when the client is fit for

discharge and to prepare the client for community life

A The format for writing up the MSE may vary slightly depending

on the organization. However, the format must contain certaincategories of information, which is included as follows:

1 GENERAL BEHAVIOR:

1.1 Appearance: This is a complete and accurate descriptionof the client's physical characteristics, apparent age, mannerof dress, use of cosmetics, personal hygiene, and responses

to the examiner. One has to include posture, gait, gestures,facial expression, tics, mannerisms, poise, etc. (A tic is aninvoluntary, spasmodic motor movement. A mannerism is an

ingrained, habitual, involuntary movement.). Signs of anxietyto be noted are tense posture, increased sweating, wide eyes,moist hands, etc.

1.2 Attitude towards examiner: The client's attitude towardsthe examiner may be described as co-operative, friendly,attentive, interested, seductive, defensive, perplexed, apathetic,

hostile, playful, ingratiating, evasive or guarded. Check if

rapport can be established and does the client maintainadequate eye contact.

1.3 Overt behaviour and Psychomotor activity (PMA):Psychomotor activity (PMA) can be simply termed as goaldirected activity. PMA can be increased, decreased or normal.There can be psychomotor retardation; aimless, purposeless

activity; restlessness, wringing of hands, pacing; gestures,twitches, stereotyped behaviour (repetitive, fixed pattern ofphysical action). Catatonic phenomena such as excitement,

stupor, rigidity, posturing, mutism, etc. should be noted andrecorded.

2.SPEECH:

Speech can be described in terms of quantity, rate of productionand quality. One has to note whether the client speaks

spontaneously, amount of speech, tone, tempo, reaction time,prosody and whether the speech is relevant and coherent.

3. THOUGHT:

Thought can be assessed under the following componentssuch as -

3.1 Form: This is the way a person puts together ideas and

associations, i.e. the form in which a person thinks. Theremay be rapid thinking, which, when carried to the extreme, iscalled as "flight of ideas". There may be incoherent

connections of thoughts (word salad), association by rhyming(clang associations), etc.

3.2 Stream: This is best described as flow of thought, train of

thought or continuity of thought. E.g. Loosening of association,blocking, circumstantiality, tangentiality, perseveration, etc.

3.2 Possessions: These could be thought alienation - thoughtinsertion (the client describes insertion of strange thoughtswhich do not belong to him), thought withdrawal (the client

describes a feeling of emptiness in the head as he feelsthoughts being removed), and thought broadcast (clientdescribes a strange situation where all his thoughts are

broadcast in the TV, radio, etc.). Obsessions may be elicitedwhich are pathological persistence of an irresistible thoughtor feeling that cannot be eliminated from consciousness by

logical effort. When these are present, clarify the nature ofcompulsive acts - checking, counting or washing and whether

14


they are "controlling" or "yielding". Phobias may also be present.

These are persistent, irrational, and usually pathological dreadof a specific stimulus resulting in a compelling desire to avoidthe stimulus.

3.3 Content: Disturbances here include preoccupations(which may involve the client's illness), antisocial urges,hypochondriacal and somatic symptoms, and depressive

ideation (ideas of worthlessness, guilt, hopelessness andsuicidal ideas and delusions. Delusions are firm, fixed andfalse beliefs out of keeping with the client's cultural background.

Some common delusions are delusion of poverty i.e.a person'sfalse belief that he or she will be deprived of all wealth, delusionof persecution i.e. a false belief that he or she is being harmed

or persecuted, delusion of grandeur i.e. a person'sexaggerated conception of his or her importance, power oridentity, etc.

4. MOOD:

Mood is defined as a pervasive and sustained emotion that

colours the person's perception of the world (Kaplan & Sadock,1998). Mood should be assessed by both subjective reportand objective evaluation. Various components should be

described such as quality of emotion e.g. Happiness,sadness, anxiety, anger, fear, etc., range of mood which canbe broad where the person is able to experience all mood

states or blunted, constricted and flat (with gradual decreasein emotional expression with absolutely no expression in flataffect), lability of mood i.e. rapid and sudden shifts in emotion

from one emotional state to the other, reactivity i.e. changes inemotion in relation to environmental factors, congruity i.e.emotional expression in relation to thought processes (e.g.

Smiles while talking about success in exams) andappropriateness i.e. emotional expression in relation tosituations (E.g. Laughing during a funeral is inappropriate

while crying during a funeral is appropriate).

5. PERCEPTION:

The client may experience perceptual disturbances, such as

hallucinations, illusions, depersonalization and derealization.Hallucinations are false sensory perceptions occurring in theabsence of a real stimulus. One should always specify the

sensory modality involved (auditory, visual, olfactory, tactile,gustatory) when hallucinations are experienced and alsodescribe the content of the hallucinations. With respect to

auditory hallucinations, always enquire whether thehallucinations are verbal/non-verbal, continuous/intermittent,single voice/multiple voices, familiar/unfamiliar, pleasant/

unpleasant, whether commanding, abusive or threatening,mood congruent/mood incongruent and first person/secondperson or third person.

Assessment is done by asking the following questions:

a) Have you ever heard voices when no one was aroundor sounds that no one else could hear?

b) Have you experienced any strange sensations in yourbody that others do not seem to experience?

c) Have you seen things that others do not seem to see?

5.2 Types of Hallucinations: Command hallucinations: Falseperception of orders that a client may feel obliged to obey, Firstperson hallucination: False perception of hearing an echo of

one's own thoughts, Second person hallucinations: Falseperception of hearing two voices talking to the client, Thirdperson hallucinations: False perception of hearing many

voices discussing about the client or in the form of a runningcommentary, De- personalization: A person's subjective senseof being unreal, strange or unfamiliar, De-realization: A

subjective sense that the environment is strange or unreal.

6. COGNITIVE FUNCTIONS:

Here clinical assessment includes the areas of -

6.1 Orientation

6.2 Attention & Concentration

6.3 Memory

6.4 Intelligence

6.5 Abstraction

6.6 Judgement

6.7 Insight

6.1 Orientation: Orientation is tested with respect to time,place and person

6.2 Attention & Concentration: One has to test whether

attention can be aroused and sustained.

Tests used in the clinical situation include:

6.2.1 The digit span test

6.2.2. Serial subtraction

6.2.3 Days or months forward to backward

6.2.1 Digit span test:

a) Forward: The client is given the following instructions: "Iwill be saying some digits, listen to me carefully. When I finishsaying them, you will have to repeat them in the same order.

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The examiner after instructing the clients, gives an example

for digit forward (e.g. If I say 3,7; you say 3,7) and for digitbackward ( e.g. if I say 2, 5; you should say 5, 2) The digitsforward/backward score is the highest number of digits

correctly recalled forward/backward after a maximum of twotrials.

6.2.2 Serial Subtractions: Increasingly difficult tests are

presented. The examiner

1. Instructs the client

2. Gives an example of how to perform the task

3. Notes the responses verbatim

4. Notes the time taken in seconds

Task Correct response Time limit

20-1 20 to 0 15 secs

40-3 40,37,31, etc 60 secs.

100-7 100,93,86,79, etc. 120 secs.

6.2.3 Days or months may be asked for in backward or forward

order.

The inference is recorded as attention can be aroused and

sustained. Concentration is good, average or poor

6.3 Memory: Memory functions are divided into immediate,

recent and remote. Memory impairment can occur in differenttypes of schizophrenia, psychosis, depression, dementia, etc.Assessment includes immediate, recent and remote memory

6.3.1 Immediate memory - Tested by the digit span test

6.3.2 Recent memory - Is tested by enquiring about what theclient had for breakfast, events of the day and what he ate the

previous night, etc.

6.3.3 Remote memory - Test by asking for information on life

events

Inference may be noted as follows - eg. Recent memory is

intact or impaired

6.4 Intelligence:

6.4.1 General information: Question the client according to

the educational level and background of the client. Commonquestions can be- Name of the Prime Minister, major cities ofIndia, etc.

Inference may be noted as follows - General information isadequate or inadequate or average

6.4.2 Comprehension: Ask questions of increasing difficultyranging from Eg. What will you do when you feel cold? --------

------ to--- Why should we be away from bad company?

Inference is noted as comprehension is good or bad.

6.4.3 Arithmetic: Tested by asking the client to solve simpleto complex problems in addition, subtraction, division andmultiplication. Illiterate clients can be asked questions such

as - "How many tsp. of sugar and tea leaves are required tomake tea for 5 persons?

Inference is recorded as - arithmetic is good, average or bad.

6.5 Abstraction: Abstract thinking is the ability to deal withconcepts.

6.5.1 Can the client explain similarities between a dog and alion?

6.5.2 Can the client state the difference between cinema and

radio?

6.5.3 The client is asked if he knows what a proverb is and to

state one with the meaning. Then the examiner states aproverb and asks for the meaning.

The client's response is to be noted verbatim. Inference is

made as abstraction present at concrete level (when specificexplanation is given) or concrete and abstract level (when bothspecific and abstract explanations are given).

6.6 Judgement: Is assessed in the following areas

6.6.1 Personal: Enquire about the clients future plans

6.6.2 Social: Observe the clients behaviour in social situationsor ask how he would dress up for a funeral/wedding?

6.6.3 Test: Present the following two problems to the client ina manner in which he can comprehend:

a) Fire problem: What will you do if your house catches fire?

b) Letter problem: What will you do if you see an addressed,sealed and stamped envelope which someone had dropped

when you are walking on the roadside?

Inference may be - Personal/Social/Test judgement is intactor impaired.

6.7 Insight: Insight is the client's degree of awareness andunderstanding about being ill.

The level of insight with the inference is as given below:

a) Complete denial of illness (Insight is absent)

b) Recognizes the presence of illness but gives explanationin physical terms i.e. headache, fever, etc. (Insight is partial)

c) Fully realizes the emotional nature of his/her illness, causeof the symptoms and feels he/she requires treatment (Insightis present)

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B. MINI MENTAL STATUS EXAMINATION (MMSE)

MMSE is a bed-side screening test which is not timeconsuming and is a formal evaluation of cognitive impairmentin the client. It is also a practical clinical examination to track

the changes in the client's cognitive state. It is used as aclinical test in mental disorders occurring due to a generalmedical condition, such as delirium, dementia, amnestic

disorders, etc.

The MMSE Questionnaire (Folstein M.F., Folstein S, McHugh

P.R.; 1975) is as follows:

1. Orientation (Score 1 if correct) Total score = 10

1.1 Name this hospital or building

1.2 What city are you in now?

1.3 What year are you in now?

1.4 What month is it?

1.5 What is the date today?

1.6 What state are you in?

1.7 What country is this?

1.8 What floor of the building are you on?

1.9 What day of the week is it?

1.10 What season of the year is it?

2. Registration (Score 1 for each object correctly repeated)Total score = 3

2.1 Name 3 objects and have the client repeat them Score thenumber repeated by the client. Name the three objects several

more times if needed for the client to repeat correctly (recordthe number of trials----)

3 Attention & Calculation Total score = 5

3.1 Subtract 7 from 100 in serial fashion to 65. Maximumscore = 5

4.Recall Total score = 3

4.1 Do you recall the 3 objects named before?

(Score 1 for each object named correctly)

5. Language tests (Total score = 8)

5.1 Confrontation naming = watch, pen (2)

5.2 Repetition = "No ifs, ands, or buts" (1)

5.3 Comprehension = Pick up the paper in your right hand,fold it into half, and set it on the floor (3)

5.4 Read and perform the command "Close your eyes"

(1)

5.5 Write any sentence (check subject, verb, object)(1)

6. Construction Total score = 1

6.1 Copy the design below

Total MMSE score = 30

Inference of score:

25 - 30 = Suggests no impairment

20 - 25 = Suggests impairment

< 20 = Indicates definite impairment

C EXAMINATION OF NON-COOPERATIVE OR STUPOROUSCLIENTS (Kirby, 1921):

It may be difficult to get information from non-cooperative orstuporous clients. However, this can lead to delay in assessingthe client's problems, formulating nursing diagnosis and

planning nursing care. Hence, to avoid this, this format canbe followed to assess the mental state of such clients.

1. General reaction and posture:

1.1 Attitude is voluntary or passive

1.2 Voluntary posture is comfortable, natural, constrained

or awkward

1.3 What does the client do if placed in awkward oruncomfortable positions?

1.4 Behaviour toward physicians and nurses is resistive,evasive, irritable, apathetic or compliant

1.5 Spontaneous acts: any occasional show of playfulness,mischievousness or assaultiveness. Defencemovements when interfered with or when pricked with

pin. Eats and dresses self. Pays attention to boweland bladder.

1.6 To what extent does the attitude change?

II Facial Expression:

Alert, attentive, placid, sulky, scowling, perplexed, distressed,etc.

Any change of facial expression or signs of emotion - tears,smiles, flushing, perspiration? On what occasion does this

change occur?

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III Eyes:

Open or closed. If closed, does he resist having the lid raised?Movement of eyes absent or can be obtained on request?

Rolling of eyeballs upward. Blinking, flickering, or tremors oflids.

Reaction to sudden approach to threat to stick pin in eye.

Sensory of pupils (reacts equally)

IV Reaction to what is said or done:

Shows tongue when commanded to do so, moves limbs &grasps with hand when asked to do so.

Reaction to pin-pricks

V Muscular reactions:

Test for rigidity, muscles are relaxed or tense whenlimbs or body is moved.

Test for negativism shown by movements in oppositedirection or springy or cog-wheel resistance.

Test head and neck by movement forward and backwardas well as to side

Test also the jaw, shoulders, elbows, fingers and the

lower extremities

Does distraction or command influence the reactions?

Is there closing of mouth, protrusion of lips, holding of

saliva, drooling, etc.

VI Emotional responsiveness:

Is feeling shown when talked to about family or children?Or when sensitive points in history are mentioned orwhen visitors come?

Note whether or not acceleration of respiration or pulseoccurs. Also look for flushing, perspiration, tears ineyes, etc. Do jokes elicit any responses?

Effect of unexpected stimuli (clap hands, flash of electriclight)

VII Speech:

Any apparent effort to talk, lip-movements, whispers,movements of head?

Note exact utterances with accompanying emotionalreaction (may indicate hallucinations)

VIII Writing:

Offer paper and pencil. Unresponsive or partiallystuporous clients will often write when they fail to talk.

Conclusion: It is of paramount importance that all nurses

working with psychiatric patients should know, understandand be skilled in mental status examination. This tool is anasset to all nurses as it aids in diagnosing, formulating nursing

interventions, observing changes and evaluating care. Anursing teacher also is benefited in that mental statusexamination is not only a clinical tool but also a teaching tool.

It helps the teacher in demonstrating on the patient how toassess presence of psychiatric symptoms. GNM levelstudents gain expertise when they return demonstrate this

skill to the teacher. Proficiency in this area will further helpthem to identify and refer psychiatric problems in patients whenthey work in the general hospitals, the community, schools,

etc. Teachers teaching psychiatric nursing should definitelygain clinical skills which will help their teaching to be effective!

References:

1. Folstein MF, Folstein S, Mc Hugh PR, "Mini-Mental State:A Practical method for grading the cognitive state of

patients for the clinician", J.Psychiatr Res 12:189, 1975

2. Kaplan.I.Harold, Sadock. J. Benjamin, "Synopsis of

Psychiatry: Behavioural Sciences/Clinical Psychiatry",B.I.Waverly Pvt. Ltd. , New Delhi, VIIIth Edition, 1998

18


Introduction:

Assessment is an important component of nursing process.

A complete nursing assessment includes both the collectionof subjective data and objective data. The complete healthhistory is performed to collect as much subjective data about

a client as possible. Objective data include information aboutthe client that the nurse directly observes during interactionwith him and information elicited through physical assessment

techniques.

1. Physical Examination:

Four basic techniques must be mastered before professionalcan perform a thorough and complete assessment of theclient. By using a systematic approach, examiner will less

likely to forget an area.

Four techniques used are:

i) Inspection.

ii) Palpation.

iii) Percussion.

iv) Auscultation.

i) Inspection:

Inspection involves vision, smell and hearing to observenormal conditions and deviations. Performed correctly,

inspection can reveal more than other techniques.

Inspection begins from first meeting with the patient and

continues throughout the health history and physicalexamination. As the examiner assess each body system,observe for color, size, location movement, texture, symmetry,

odor, and sounds.

ii)Palpation

Palpation required examiner to touch the patient with different

parts, using varying degrees of pressure. To do this, examinerneed short fingernails and warm hands. Always palpate tenderareas last. Information about the purpose of touch to different

parts is essential.

Evaluation of the following features are required:

Texture-rough or smooth?

Temperature-warm, hot or cold?

UNIT - 5 PHYSICAL & NEUROLOGICAL EXAMINATION

Dr. RamachandraAssociate Professor

Dept. of NursingNIMHANS , Bangalore-29

Moisture-dry, wet or moist?

Motion-still or vibrating?

Consistency of structures-solid or fluid filled?

iii) Percussion:

Percussion involves tapping fingers or hands quickly andsharply against parts of the patient's body, usually the chest or

abdomen. The technique helps to locate organ borders, identifyorgan shape and position and determine if an organ is solidor filled with fluid or gas.

Percussion requires a skilled touch and trained ear to detectslight variations in sound. Organs and tissues, depending on

their density, produce sounds of varying loudness, pitch andduration. For instance, air-filled cavities, such as the lungs,produce markedly different sounds than do the liver and other

dense tissues.

The examiner has to move gradually from areas of resonance

to those of dullness and them compare sounds. Also, comparesounds on one side of the body with those on the other side.

iv) Auscultation:

Auscultation, usually the last assessment step, involves

listening for various breath, heart and bowel sound with astethoscope. To prevent the spread of infection amongpatients, clean the hearts and end pieces of the stethoscope

with alcohol or a disinfectant after every use.

2. History

A thorough and accurate history of a neuro patient is often very

helpful in assessing their condition. The character ofsymptoms, distribution, temporal profile of symptoms,epidemiological associations are often needed in detail in

neurological patients in comparison to other general diseases.The fact that in neurological patients their cerebral dysfunctionmay limit or distort the account of history third party sources of

information are most often needed.

3. Neurologic Examination

Neurological assessment is one of the key components ofnursing practice. It plays a pivotal role in localization of the

problem. It encompasses history collection, and the physicalexamination. Observation is the most important key for

19


neurological assessment. The exam ination requires skill and

patience, from the examiner.

A thorough neurologic examination may take 1 to 3 hours;

however, routine screening tests are usually done first. If theresults of these tests raise questions, more extensiveevaluations are made. Three major considerations determine

the extent of a neurologic examination:

a. The client's chief complaints

b. The client's physical condition (i.e., level of

consciousness and ability to ambulate), as many partsof the examination require movement and coordinationof the extremities

c. The client's willingness to participate and cooperate.

3.1 Equipments required are

1. Reflex hammer

2. 128 and 512 hz tuning forks

3. Snellen Chart

4. Pen light

5. Ophthalmoscope

6. Sugar/salt

7. Coffee powder/any scented material

8. Disposable safety pin

9. Tongue depressors

10. Wisps of cotton to assess light- touch

11.T est tubes of hot and cold water for skin temperatureassessment

3.2 The components of neurological examination includes

assessment of:

1. Level of consciousness

2. Mini Mental Status Exam

3. Cranial nerves

4. Motor System

3.3 Assessment of Level of consciousness

General appearance:

Note the patient's personal hygiene and dress. Is it appropriate

for the environment situation or not

Make a note of the age, height, build and weight. Is the

patient obese or cachectic?

Check the vital signs including temperature, pulse,

respiratory rate and blood pressure.

Level of consciousness

Glasgow coma scale is an objective method to assess the

level of consciousness in the patients with neurologicaldisorders. This scale describes conscious level in terms ofeye opening, verbal response and motor response. These

are having 4, 5, 6 scores each respectively. On examination,observer has to assign score to the observed category to eachparameter. The minimum score is 3 and maximum is 15.

For children under 5, the verbal response criteria are adjustedas follow

Children with a Glasgow Coma Scale of 3-8 are consideredcomatose

3.4 Mental Status Examination

Evaluation of mental status is a part of the neurologicalexamination. The appearance, behaviour, level of

consciousness, attention, concentration, memory, orientation,abstraction, judgement, language and speech are assessedas discussed in earlier chapter

4. Examination of the Cranial Nerves

The following is a summary of the cranial nerves and theirrespective functioning.

5.Sensory System.

6. Deep tendon reflexes

7.Coordination and balance

8. Brain stem reflexes

Eye Opening (E) Verbal Response (V) Motor Response (M)

4= spontaneous 3= to voice 2= to pain 1= no response

5= oriented 4= disoriented conversation 3= non comprehensible words, 2= incoherent sounds 1= no response

6= obeys commands 5= localizes pain 4= withdrawal flexion 3= abnormal flexion decorticate posture 2= abnormal extension decerebrate posture 1= no response

Score 2 to 5 yrs 0 to 23 months

5 appropriate words or phrases

smiles or coos appropriately

4 inappropriate words cries and consolable

3 persistent cries and/or screams

persistent inappropriate crying &/or screaming

2 grunts grunts or is agitated or restless

1 no response no response

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I. Olfactory- Smell

II. Optic-Visual acuity, visual fields and ocular fundi

III, IV, VI. Oculo motor, Trochlear & Abducens- extra-ocularmovements, pupillary reactions including opening of

the eyes

V. Trigeminal- Facial sensation, movements of the jaw,

and corneal reflexes

VII. Facial-Facial movements

VIII. Vestibulo cochlear -Hearing and balance

IX, X. Glassopharngeal, Vagus-Swallowing, elevation of thepalate, gag reflex and gustation

XI. Spinal accessory,- shrugging the shoulders and turningthe head.

XII. Hypoglossal-Movement and protrusion of tongue

4.1 Cranial Nerve I (olfactory)

Evaluate the patency of the nasal passages bilaterally. Ask thepatient to close their eyes, occlude one nostril, and place any

familiar scented substance near the patent nostril and askthe patient to report what it is. Switch nostrils and repeat.

4.2 Cranial Nerve II (optic)

The components of testing include visual acuity, visual field,optic fundus and pupillary reaction.

Visual acuity:

Severe deficit can be assessed testing whether patient cansee light or movements, or can the patient count fingers. Patientmay also be assessed to read newspaper or book having

bigger letter size. To examine mild deficit, examiner recordreading activity with Snellen's chart or hand chart.

Perform this part of the examination in a well-lit room andmake certain that if the patient wears glasses, during the exam.

Hold the chart 14 inches from the patient's face, and ask thepatient to cover one of their eyes completely with their handand read the lowest line on the chart possible. Have them

repeat the test covering the opposite eye. For Snellen's chart,6 meters distance is expected to read letters. Test each eyeseparately.

Assessing visual fields by confrontation test

1. Stand two feet in front of the patient and have them lookinto your eyes.

2. Hold your hands about one foot away from the patient'sears, and wiggle a finger on one hand.

3. Ask the patient to indicate which side they see the fingermove.

4. Repeat two or three times to test both temporal fields.

5. If an abnormality is suspected, test the four quadrantsof each eye while asking the patient to cover the opposite

eye with a card.

Using an ophthalmoscope, observe the optic disc,physiological cup, retinal vessels. Note the pulsations of theoptic vessels, check for a blurring of the optic disc margin and

a change in the optic disc's colour form its normal yellowishorange. The initial change in the ophthalmoscopicexamination in a patient with increased intracranial pressure

is the loss of pulsations of the retinal vessels.

In the assessment of pupils note:

Size (small- miosis/ large-mydriasis)

Shape

Equality

Reaction to light: Both pupil constrict when light is

shown in either eye.

Reaction to accommodation and convergence.

4.3 Cranial Nerves III, IV and VI (Oculomotor, trochlear,abducens)

Observe for Ptosis

Test Extra ocular Movements

1. Stand or sit 3 to 6 feet in front of the patient.

2. Steady the patients head and ask him to follow your

finger with their eyes without moving their head.

3. Check gaze in the six cardinal directions

4. Check for nystagmus.

5. Question the patient about diplopia.

4.4 Cranial Nerve V (Trigeminal)

Assess for pain, temperature and touch. Palpate the masseter

muscles while you instruct the patient to bite down hard. Also

21


note masseter wasting on observation. Next, ask the patient

to open their mouth against resistance applied by the instructorat the base of the patient's chin

Test the three divisions (maxillary, mandibular &ophthalmic) for temperature sensation, pain & touch.

Test the Corneal Reflex

1. Ask the patient to look up and away.

2. From the other side, touch the cornea lightly with a fine

wisp of wet cottonwool.

3. Look for the normal blink reaction of both eyes.

4. Repeat on the other side

4.5 Cranial Nerve VII (Facial)

Observe for any facial droop or asymmetry or eyeclosure.

Ask Patient to do the following, note any lag, weakness,or asymmetry

1. Raise eyebrows(to wrinkle forehead)

2. Close both eyes to resistance

3. Smile

4. Frown

5. Show teeth

6.Puff out cheeks

4.6 Cranial Nerve VIII (Vestibulocochlear)

Assess hearing by instructing the patient to close their eyesand to say "left" or "right" when a sound is heard in the respective

ear. Vigorously rub your fingers together very near to, yet nottouching, each ear and wait for the patient to respond. Afterthis test, ask the patient if the sound was the same in both

ears, or louder in a specific ear

Test for lateralization (Waber)

1. Use a 512 Hz or 1024 Hz tuning fork.

2. Start the fork vibrating by tapping it on your oppositehand.

3. Place the base of the tuning fork firmly on top of thepatient's head.

4. Ask the patient where the sound appears to be comingfrom (normally in the midline).

Compare air and bone Conduction (Rinne)

1. Use a 512 Hz or 1024 Hz tuning fork.

2. Start vibrating the tuning fork by tapping it on youropposite hand.

3. Place the base of the tuning fork against the mastoid

bone behind the ear.

4. When the patient no longer hears the sound, hold theend of the fork near the patient's ear (air conduction is

normally greater than bone conduction).

4.7 Cranial Nerves IX and X (glossopharyngeal and vagus)

Listen to the patient's voice. If there is vocal cord

paresis(X nerve palsy)voice may be high pitched.

Ask Patient to swallow, to note swallowing difficulty.

Watch the movements of the soft palate and the pharynxby asking the patient to Say "Ah"

Test Gag Reflex Unconscious/Uncooperative Patient

Stimulate the back of the throat on each side. It is normalto gag after each stimulus

4.8 Cranial Nerve XI (spinal accessory)

Look for atrophy or asymmetry of the trapezius muscles.

Ask patient to shrug shoulders against resistance.

Ask patient to turn their head against resistance. Watch

and palpate the sternocleidomastoid muscle on theopposite side.

Repeat this manoeuvre on the opposite side. Thepatient should normally overcome the resistanceapplied by the examiner. Note any asymmetry.

4.9 Cranial Nerve XII (hypoglossal)

The hypoglossal nerve controls the intrinsic musculature ofthe tongue and is evaluated by having the patient stick outtheir tongue and move it side to side. Normally, the tongue will

be protruded from the mouth and remain midline. Notedeviations of the tongue from midline, a complete lack of abilityto protrude the tongue, tongue atrophy and fasciculations on

the tongue.

4.10 sensory assessment

The sensory modalities tested include pain,

temperature, vibration, joint position and touch.

Pain: Break off the wooden part of a cotton swab to

make a sharp object or use a disposable, sterilizedsafety pin. Ask the patient with eyes closed to distinguishsharp end of the pin from dull.

Temperature: Test coldness with metal tuning fork. Thepatient should be able to identify cool vs. warmer objects

or take two test tubes filled with hot water and coldwater separately. Surface on the body at different timesand observe reaction.

Vibration: Test with low-frequency (128) tuning fork. Thepatient should be able to sense the vibration of the

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tuning fork

Joint position or Proprioception: With eyes closed,

patient distinguishes whether finger and toe are movedup or down.

Touch: Test light touch with a cotton swab. The patient

distinguishes touch vs. no touch.

Special tests of sensory function

Stereognosis: With eyes closed, patient identifies pen,paper clip or coin placed in hand. This tests the parietalsensory cortex and posterior columns

Graphesthesia: With eyes closed, patient identifies

numbers or figures or shapes written on palm. Thistests the sensory cortex and integration.

Two-point discrimination: Patients should be able to

distinguish two simultaneous points of differentintensity 2 to 10 mm apart on fingers and hands.Compare patient's two sides.

4.11 Assesement of Motor System

The motor system evaluation is divided into the following:

Muscle bulk, muscle tone, involuntary movements and musclestrength.

Systematically examine all of the major muscle groups of thebody.

1. Note the muscle bulk (atrophy, hypertrophy, normal).

2. Feel the tone of the muscle (flaccid, clonic, normal).

3. Presence of any abnormal movements like tremor,fasciculation's, tics.

4. Test the strength of the muscle group.

Muscle strength grading: If pyramidal weakness is

suspect test the power of muscle with reference topressure and gravitation. Assign scores as follows:

0-No muscle contraction is detected

1-A flicker or trace contraction is noted in the muscle

while the patient attempts to contract it.

2-The patient is able to actively move the muscle withgravity eliminated.

3-The patient may move the muscle against gravity but

not against resistance from the examiner

4-The patient may move the muscle group againstsome resistance from the examiner.

5-The patient moves the muscle group and overcomes

the resistance of the examiner. This is normal musclestrength.

4.12 Deep Tendon Reflexes

Observing reflexes is the most objective part of the neurologicalexam, since the reflexes are not under voluntary control and

testing does not depend on the patient's cooperation, attitude,or awareness.

Biceps reflex tests C5-6: The biceps reflex is elicited by

placing your thumb on the biceps tendon and strikingyour thumb with the reflex hammer and observing thearm movement.

Brachioradialis reflex also tests C5-6. The

Brachioradialis reflex is observed by striking theBrachioradialis tendon directly with the hammer whenthe patient's arm is resting. Strike the tendon roughly 3

inches above the wrist. Note the reflex supination.

Triceps: tests C7-8. The triceps reflex is measured bystriking the triceps tendon directly with the hammerwhile holding the patient's arm with your other hand

Quadriceps (knee jerk): tests L2-L4 With the lower leg

hanging freely off the edge of the bench, the knee jerkis tested by striking the quadriceps tendon directly withthe reflex hammer.

Achilles (ankle jerk): tests L5-S2 The ankle reflex iselicited by holding the relaxed foot with one hand andstriking the Achilles tendon with the hammer and notingplantar flexion.

Deep tendon reflex grading

4+ very brisk, hyper reflexive, with clonus

3+brisker or more reflexive than normally

2+normal

1+ normal, diminished

0 no response

4.12 Co-ordination and Balance

The stance (attitude of standing) and the gait of the patient

have to be observed for irregularities. The tests of co-ordinationinclude Finger -nose test, heel -shin test, rapid alternatingmovements. Balance is tested using the Romberg's sign test.

Finger -nose test: Ask the patient to extend their index fingerand touch their nose, and then touch the examiner's

outstretched finger with the same finger. Ask the patient to goback and forth between touching their nose and examiner'sfinger. This tests the upper extremity co-ordination.

Heel- shin test: ask the patient to place the heel on the oppositeshin and run up to the knee and back to ankle. The patient

should be able to perform it quickly and without side-to-sidewavering.

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Rapid Alternating Movement

Ask the patient to place their hands on their thighs and thenrapidly turn their hands over and lift them off their thighs. Ask

the patient to repeat it rapidly for 10 seconds. Normally this ispossible without difficulty. Dysdiadochokinesia is the clinicalterm for an inability to perform rapidly alternating movements.

Romberg's test

Ask the patient to stand still with their heels together, arms onthe side and close their eyes. If the patient loses their balance,

the test is positive.

4.13 Assessment of brain stem reflexes

Pupillary response to light: The response to bright lightshould be absent in both eyes. The pupil should be

observed closely for one minute to allow time for a slowresponse to become evident. Widely dilated pupils arenot a necessary criterion for brain death but fixed pupils

with no response to light are mandatory.

Oculo cephalic reflex (Doll's eye phenomenon): This

test must not be performed in patients with an unstablecervical spine. The head is turned from starting positionto a new steady position and briskly to the opposite

side. The eyes move denoting the integrity of the mediallongitudinal fasciculus in the brain stem.

Gag reflexes: A tongue depressor is used to stimulateeach side of the oropharynx and the patient observedfor any pharyngeal or palatal movement.

Cough reflex: A suction catheter is introduced into theendotracheal or tracheostomy tube to deliberately

stimulate the carina. The patient is closely observedfor any cough response or movement of the chest ordiaphragm.

Oculovestibular reflex: Slow irrigation with at least 5-mlof ice-cold water is performed into the external auditory

canal while, the eyes are held open by an assistant.

The eyes should be observed for one minute afterirrigation is completed before repeating the test on theother side. An intact Oculovestibular reflex causes tonic

deviation of the eyes towards the irrigated ear. Anymovement of one or both eyes, whether conjugate ornot, excludes the diagnosis of brain death. In a brain

dead patient the eyes remain fixed. Combined ice-coldwater caloric stimulation and head rotation has beensuggested as the most pro-found stimulation for deeply

unconscious patients.

Conclusion

A thorough physical examination including history with focuson neurological examination helps the nurse in nursing

assessment and formulation of diagnosis. An accurate andtimely neurological examination performed by a nurse canpick up the subtle changes in patients, which often prove crucial

in areas like emergency department and critical care units.Practicing the examination and examining the practice makesone confident and skilled in the neurological examination.

References:

1. Kozier & Erbs, Fundamentals of Nursing, Concepts,

process, and practice: Pearson education, 8th edition,2007.

2. Potter and Perry, Fundamentals of Nursing, Mosbypublications, second edition, 2005.

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UNIT-6 INTERPERSONAL RELATIONSHIP AND COMMUNICATION SKILLSIN PSYCHIATRIC NURSING

Dr. Nagarajaiah,Associate Professor,

Dept. of Nursing,NIMHANS, Bangalore

INTRODUCTION

The concept of therapeutic relationship is the corner stone of

mental health - psychiatric nursing practice. The therapeuticnurse - patient relationship is complex. It has a positive effecton patient's outcomes.The relationship between the nurse

and the client is voluntary based on principles of agreement ina concept of negotiation through the years it leads to a taskcalled contracting. Secondly, the goal directed characteristic

of the one to one relationship, the focused effort or theexpectations. The clients expectations arrives from a broadrange of life experiences, desires and levels of personal

believes the nurses expectations arise from what sheconsiders to be helpful. Therapeutic goals aimed at client'sgrowth and developments through elements of relationship

itself. Thirdly, the concepts of mutual collaboration, the basicto this concept are issues of responsibility and accountability.Both the nurses and client bring personal abilities and

capacities to the relationships.

MEANING

Communication stems from the Latin word, "to impart,

participate, convey, and share information about" Webster'sNew Collegiate Dictionary, (1974).

Commnuication- Communication refers to the reciprocal

exchange of information, ideas, beliefs, feelings and attitudesbetween persons or among a group of persons. It is a goal-directed process in which people use asystem of symbols

and signs to convey a message

Interpersonal relationship-The nurse-client relationshipis adynamic partnership that defines, directs, and evaluates

treatment outcomes.(Antai-Otong and Wasserman 2003)

Therapeutic Relationship- An interaction between two people(usually a caregiver and a care receiver) in which input from

both participants contributes to a climate of healing, growthpromotion, and/or illness prevention.

Nurse-patient relationship-it is an interpersonal process

between a professional nurse and a client that helps the clientto foster and promote growth of personality, to help the clientimprove in construction and productive way of living.

DEFINITIONS

Communication- It is the act or reciprocal process of imparting

or interchanging thoughts, attitudes, emotions, opinions, orinformation by speech, writing, or signs. Nurses can use this

dynamic and interactive process to motivate, influence,educate, facilitate mutualsupport, and acquire essentialinformation necessary for survival, growth, and an overallsense

of well-being (Howells, 1975; Kleinman, 2004)

Communication- communication as a process by whichinformation is exchanged between individuals through a

common systems, signs or behavior.- Webster's Dictionary

Therapeutic communication- it is a process in which the nurseconsciously influences a client or helps the client to a better

understanding through verbal or nonverbal communication.Therapeutic communication involves the use of specificstrategies that encourage the patient to express feelings and

ideas and that convey acceptance and respect. - Mosby'sMedical Dictionary (2009).

Interpersonal relationships refer to reciprocal social and

emotional interactions between the patient and other personsin the environment.

Nurse- patient relationship- it is a mutual learning experience

and a corrective emotional experience for the patient. the nurseuses personal attributes and specified clinical techniques inworking with the patient to bring about behavioral change.

JOHARI WINDOW

A Johari window is a cognitive psychological tool created byJoseph Luft and Harry Inghamin 1955 in the United States,

used to help people better understands their interpersonalcommunication and relationships.

The Johari Window is a communication model that can be

used to improve understanding between individuals andincrease self-awareness.

Two key ideas behind the tool:

• Individuals can build trust between themselves bydisclosing information about themselves.

• They can learn about themselves and come to terms

with personal issues with the help of feedback fromothers.

Using the Johari model, each person is represented by their

own four-quadrant, or four-pane, window. Each of these

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contains and represents personal information - feelings,

motivation - about the person, and shows whether theinformation is known or not known by themselves or otherpeople.

The four quadrants are:

Quadrant 1: Open Area

What is known by the person about him/herself and is also

known by others.

Quadrant 2: Blind Area, or "Blind Spot"

What is unknown by the person about him/herself but which

others know. This can be simple information, or can involvedeep issues (for example, feelings of inadequacy,incompetence, unworthiness, rejection) which are difficult for

individuals to face directly, and yet can be seen by others.

Quadrant 3: Hidden or Avoided Area

What the person knows about him/herself that others do not.

Quadrant 4: Unknown Area

What is unknown by the person about him/herself and is alsounknown by others.

Key Points:

• In most cases, the aim in groups should be to developthe Open Area for every person.

• Working in this area with others usually allows for

enhanced individual and team effectiveness andproductivity. The Open Area is the 'space' where goodcommunications and cooperation occur, free from

confusion, conflict and misunderstanding.

• Self-disclosure is the process by which people expandthe Open Area vertically. Feedback is the process by which

people expand this area horizontally.

• By encouraging healthy self-disclosure and sensitivefeedback, you can build a stronger and more effective

team.

THERAPEUTIC COMMUNICATION IN PSYCHIATRIC NURSING

The nurse-client relationship is the foundation on which

psychiatric nursing is established.The therapeuticinterpersonal relationship is the process by which nursesprovide care for clients in need of psychosocial intervention.

Mental health providers need to know how to gain trust andgather information from the patient, the patient's family, friendsand relevant social relations, and to involve them in an effective

treatment plan. Therapeutic use of self is the instrument fordelivery of care to clients in need of psychosocial intervention.Interpersonal communication techniques are the "tools" of

psychosocial intervention.

THERAPEUTIC NURSE-CLIENT RELATIONSHIP- Therapeuticrelationships are goal- oriented and directed at learning and

growth promotion.

Components of Therapeutic Relationship

• Rapport- It's a relationship or communication especially

when useful and harmonious

It's a willingness to become involved with anotherperson

Its growth towards mutual acceptance andunderstanding of individuality

It promotes self-disclose

• Trust- To trust another, one must feel confidence in thatperson's presence, reliability, integrity, veracity, andsincere desire to provide assistance when requested.

It is imperative for the nurse to convey an aura oftrustworthiness, which requires that he or she possessa sense of self-confidence.

• Respect- Every client deserves the respect of nursesparticipating in the clients' care. Respect is a point ofview that says to another. It is also called non possessive

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warmth or unconditional positive regard. Client is

regarded as a person of worth and is respected assuch. Her attitude is non judgmental, it is with outcriticism, ridicule or reservation.

• Genuineness- it involves being ones own self. Thisimplies that the nurse is aware of her thoughts, feeling,values and their releveance in the immediate interaction

with a client.

• Empathy- it's an ability to feel with the patient whileretaining the ability to critically analyse the situation. It

is the abiltiy to put oneself in another person'circumstances and feelings.

• Concreteness- It involves using specific terminology

easy to understand, rather than abstraction, whendiscussing the client's feelings, experiences andbehavior. It avoids vagueness and ambiguity and is the

opposite of generalizing, labeling and makingassumptions about the client's experiences.

Phases of a Therapeutic Nurse-Client Relationship

• Pre-interaction phase- this phase begins when thenurse is assigned to initiate a therapeutic relationshipand this includes obtaining information about the

patient from charts, significant others or health teammembers. In this phase the nurse starts with initialassessment, she evaluate her own feeling, explore

fantasies, fears and ambivalence, strengths andlimitations and she plan her first meeting. In this phaseshe feels difficulty in self analysis, self acceptance,

anxiety, boredom, anger, indifference and depression.

• Orientation/Introductory Phase- Nurse and patientmeets for the first time. The task involves in this phase

are to establish trust and rapport, establish a contractfor intervention, assessment and examination of thepatientsproblems and needs, identifies the patients

strengths and limitations. Then she sets realistic goalsmutually agreeable by patient and the nurse. Developinga plan of action. Both explore the feelings of each other

• Working Phase- therapeutic work is carried out in thisphase. The nurse maintains the trust and rapport. Sheuses the problem solving approaches to over come

the resistances. She continuously evaluates andexplore for stressors. She promotes Insight andconstructive coping mechanism to overcome the

patients problems.

• Termination- it is a difficulty phase. The goal of thisphase is to bring an therapeutic end to the relationship.

The nurse should recognize that the patientsfunctioning has improved, relief from the problems, the

patient has increased self esteem and a strong sense

of identity and has achieved the planned treatmentoutcomes..

Nurse has to establish reality of separation, mutually explore

feeling of rejection, loss, sadness, anger and related behavior.She review the progress of therapy and attainment of goals.She have to formulate plans for meeting future therapy needs

and plan for continuing care.

INTERPERSONAL COMMUNICATION

• Interpersonal communication is a transaction between

the sender and the receiver. Both persons participatesimultaneously.

• In the transactional model, both participants perceive

each other, listen to each other, and simultaneouslyengage in the process of creating meaning in arelationship, focusing on the patients' issues and

assisting them learn new coping skills.

• Both sender and receiver bring certain preexistingconditions to the exchange that influence the intended

message and the way in which message is interpreted

THERAPEUTIC COMMUNICATION TECHNIQUES

1. Using silence - allows client to take control of thediscussion, if he or she so desires

2. Accepting - conveys positive regard

3. Giving recognition - acknowledging, indicatingawareness

4. Offering self - making oneself available

5. Giving broad openings - allows client to select the topic

6. Offering general leads - encourages client to continue

7. Placing the event in time or sequence - clarifies the

relationship of events in time

8. Making observations - verbalizing what is observed orperceived

9. Encouraging description of perceptions - asking clientto verbalize what is being perceived

10. Encouraging comparison - asking client to compare

similarities and differences in ideas, experiences, orinterpersonal relationships

11. Restating - lets client know whether an expressed

statement has or has not been understood

12. Reflecting - directs questions or feelings back to clientso that they may be recognized and accepted

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13. Focusing - taking notice of a single idea or even a single

word

14. Exploring - delving further into a subject, idea,experience, or relationship

15. Seeking clarification and validation - striving to explainwhat is vague and searching for mutual understanding

16. Presenting reality - clarifying misconceptions that client

may be expressing

17. Voicing doubt - expressing uncertainty as to the realityof client's perception

18. Verbalizing the implied - putting into words what clienthas only implied

19. Attempting to translate words into feelings - putting into

words the feelings the client has expressed onlyindirectly

20. Formulating plan of action - striving to prevent anger or

anxiety escalating to unmanageable level whenstressor recurs

Nontherapeutic Communication Techniques or barriers

Giving reassurance - may discourage client from furtherexpression of feelings if client believes the feelings will

only be downplayed or ridiculed

Rejecting - refusing to consider client's ideas orbehavior

Approving or disapproving - implies that the nurse hasthe right to pass judgment on the "goodness" or"badness" of client's behavior

Agreeing or disagreeing - implies that the nurse hasthe right to pass judgment on whether client's ideas oropinions are "right" or "wrong"

Giving advice - implies that the nurse knows what isbest for client and that client is incapable of any self-direction

Probing - pushing for answers to issues the client doesnot wish to discuss causes client to feel used andvalued only for what is shared with the nurse

Defending - to defend what client has criticized impliesthat client has no right to express ideas, opinions, orfeelings

Requesting an explanation - asking "why" implies thatclient must defend his or her behavior or feelings

Indicating the existence of an external source of power

- encourages client to project blame for his or her

thoughts or behaviors on others

Belittling feelings expressed - causes client to feelinsignificant or unimportant

Making stereotyped comments, clichés, and trite

expressions - these are meaningless in a nurse-clientrelationship

Using denial - blocks discussion with client and avoids

helping client identify and explore areas of difficulty

Interpreting - results in the therapist's telling client themeaning of his or her experience

Introducing an unrelated topic - causes the nurse totake over the direction of the discussion

THERAPEUTIC IMPASSES

Therapeutic impasses are blocks in the progress of the nurse-patient relationship. It proke intense feelings in both the nurseand the patientthat may range from anxiety and apprehension

to frustration, love, or intense anger. Five specific therapeuticimpasses and ways to overcome are to be learnt to developtherapeutic nurse-patient relationship.

1. Resistance.

2. Transference.

3. Counter transference.

4. Gift giving.

5. Boundary violations.

Resistance- it is the patients' attempts to remain unaware of

anxiety-producing aspects within him. It is natural or learnedreluctance to avoidance of verbalizing or even experiencingtroubled aspects of self. It is caused by the patients'

unwillingness to change when the need for change isrecognized or secondary gain.it ocurs in working phase andas this phase encompasses problem-solving process.

Resistance occurs due to over involvement of nurse, lack ofrespect, nurses' inappropriate role model behavior.

Transference- it is an unconscious response of the patient in

which he experience feelings and attitudes towards the nursethat were originally associated with significant figures, in hisearly life. It reduces the patient's self-awareness and the nurse

is viewed as an authority figure from the past, such as a parent,lost loved object, former spouse.it may be hostile anddependent reaction transference.

Interventions to resolve resistance and transference:

1. The nurse must be prepared to be exposed to powerfulnegative and positive emotional feelings coming from

the patient.

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2. Make therapeutic contracts, develop a mutually

acceptable goals or plan of action, defining the goals,purpose and roles of the nurse and patient in therelationship. Sometimes resistance occurs because

the nurse and patient have not arrived at mutuallyacceptable goals or plans of action. This may occur ifthe contract was not clearly defined in the orientation

stage of the relationship. The appropriate action thenis to return to clarifying the goals, purposes and rolesof the nurse and patient in the relationship.

3. Listen to patient's analysis of the resistance ortransference. Use clarification and reflection of feelings.

Clarification gives the nurse more focused idea of what

is happening. Reflection of the content may help thepatients become aware of what has been going on intheir own minds. Reflection of feelings acknowledges

the resistance and mirrors it to the patient. For examplethe nurse may say, "I sense that you are struggling withyourself. Part of you wants to explore the issue of your

marriage and another part says 'No- am not ready yet."

4. Explore the possible reasons for resistance and workthrough the transference reactions with the patient. The

depth of exploration and analysis engaged in by thenurse and the patient is related to the nurse'sexperience and knowledge basis.

Counter transference- Counter transference is a therapeuticimpasse created by the nurse. It refers to the specific emotionalresponse generated by the qualities of the patient. This

response is inappropriate to the content and context oftherapeutic relationship and inappropriate in the degree ofintensity of emotion. Counter transference is the transference

applied to the nurse. Inappropriateness is the importantelement of this impasse, just as it is with transference.

It is natural, for example, that the nurse will feel warmth toward

or liking for some patients more than others, and the nursewill be genuinely angry at times in regard to the actions ofcertain patients. But in the case of counter transference, the

nurse's responses are justified by reality. In this case thenurse identifies the patient with individuals from his or herpast, and the personal needs will interfere with therapeutic

effectiveness.

Types of counter transference

Counter transference reactions are usually of the following

three types:

1. Reactions of intense love or caring.

2. Reactions of intense hostility or hatred.

3. Reactions of intense anxiety often in response to

resistance by patient.

Through the use of immediacy, the nurse can identify countertransference in of its various forms.

Forms of Counter Transference Displayed by Nurses

1. Inability to empathize with the patient in certain problemareas.

2. Depressed feelings during or after the session.

3. Carelessness about implementing the contract bybeing late, running overtime etc.

4. Drowsiness during sessions.

5. Feeling of anger or impatience because of the patient'sunwillingness to change.

6. Encouragement of the patient's dependency, praise or

affection.

7. Arguing with the patient or a tendency to push the patientbefore he is ready.

8. Trying to help the patient in matters not related to theidentified nursing goals.

9. Involvement with the patient on a personal or social

level.

10. Dreaming about or preoccupation with the patient.

11. Sexual or aggressive fantasies towards the patient.

12. Recurrent anxiety, unease or guilt feelings about thepatient.

13. A tendency to focus repeatedly on only one aspect or

way of looking at the information presented by thepatient.

14. A need to defend nursing interventions used with the

patient to others.

Advantages of Counter Transference

Different forms off counter transference occur because the

nurse is involved with the patient as a participant observer,and not a detached bystander. They function as

1. Powerful tool in exploration and potent instruments in

uncovering inner states. They are destructive only if theyare brushed aside, ignored or not taken seriously.

2. Counter transference can lead to further information,

can bring to light new materials, and help in developinginsight.

3. Nurse understanding of counter transference and her

own feelings help to maintain a working relationshipwith the patient.

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Interventions to Counter Transference

1. Experience of working with psychiatric patients.

2. Constantly lookout for counter transference.

3. Hold counter transference in abeyance or utilize it for

promoting therapeutic goals.

4. Apply self-examination throughout the course ofrelationship, particularly when the patient attacks or

criticizes. Asking oneself the following questions maybe helpful:

How do I feel about the patient?

Do I look forward to seeing the patient?

Do I feel sorry for or sympathetic toward the patient?

Am I bored with the patient and believe that we are not

progressing?

Am I afraid of the patient?

Do I get extreme pleasure out of seeing the patient?

Do I want to protect, reject or punish the patient?

Do I dread meeting with the patient and feel nervousduring the sessions?

Am I impressed by or try to impress the patient?

Does the patient make me very angry or frustrated?

5. Pursue to find out the source of the problem.

6. Exercise control over counter transference.

7. Have individual or group supervision.

8. Weekly clinical seminars, peer consultation, and

professional meetings can also offer emotionalsupport.

GIFT GIVING

Receiving a gift from the patients make the nurse to inhibitindependent decision-making, create a feeling of anxiety orguilt. Gift is that of something of value is voluntarily offered to

another person, usually to convey a gratitude.

Gifts can be divided into following five types (Morse, 1991).

Gifts to reciprocate for care given.

Gifts intended to manipulate or change the quality ofcare given or the nature of nurse-patient relationship.

Gifts given as perceived obligation by the patient.

Serendipitous gifts or gifts received by chance.

Gifts given to organization to recognize excellence ofcare received.

Gifts can be tangible or intangible; Lasting or temporary.

Tangible gifts may include box of sweets, a bouquet of flowers

or hand painted picture. Intangible gifts can be expression ofthanks to a nurse by a patient who is about to be dischargedor a family members gratitude at being able to share an

emotional burden with another caring person.

Gift giving is a controversial issue in nursing. The taboo againstnurse accepting gifts from patients has been long accepted.

However, some have questioned the theoretical rationale forthis position and suggest that gift giving can sometimes servediscrete therapeutic goals. Whether gift giving is an impasse

depends upon the timing of the particular situation, the intentof the giver, and the contextual meaning of the giving of the gift.Occasionally it may be most appropriate and therapeutic for

the nurse to accept a patient's gift; on other occasions it maybe quite inappropriate and detrimental to the relationship. Inthe orientation phase of the relationship, gift giving can be

harmful if it meets personal needs rather than therapeuticgoals. By giving a gift, the patient may be trying to manipulatethe nurse and control the relationship. In contrast, by giving

gift to the patient, the nurse may be attempting to relate throughobjects instead of the therapeutic use of self and to avoidexploring feelings of inadequacy or frustration.

In the working phase gift giving may take on a differentsignificance. For example the patient offering a cup of coffeecan be a sign of respect for the nurse and in their work together.

As an isolated incident, the nurse's acceptance of it canenhance the patient's confidence, self esteem, and a senseof responsibility.

Gift giving most often arises in the termination phase ofrelationship, and in is in this phase that the meaning behind itcan be the most complex and difficult to determine. At this time

gifts can reflect a patient's need to make the nurse feel guilty,delay the termination process, compensate for feelings ofinadequacy or an attempt to transform the therapeutic nurse-

patient relationship in to social one that can go on indefinitely.The nurse can initiate gift giving for similar reasons. If feelingsare identified and clarified, then a small gift that reflects

gratitude and remembrance can be exchanged, accepted andvalued.

Boundary violations- A boundary indicates a border or a limit. It

determines the extent of acceptable limits. Many types ofboundaries exist. Examples include the following:

Material boundaries

Social boundaries

Personal

Professional boundaries (College and Association of

Registered Nurses of Alberta [CARNA], 2005).

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Concerns regarding professional boundaries are commonly

related to the following issues:

1. Self-disclosure. Self-disclosure on the part of the nursemay be appropriate when it is judged that the information may

therapeutically benefit the client. It should never be undertakenfor the purpose of meeting the nurse's needs.

2. Gift-giving. Individuals who are receiving care often feel

indebted toward health care providers. Indeed, gift-giving maybe part of the therapeutic process for people who receive care(CARNA, 2005). Accepting financial gifts is never appropriate,

but in some instances nurses may be permitted to suggestinstead a donation to a charity of the client's choice. Ifacceptance of a small gift of gratitude is deemed appropriate,

the nurse may choose to share it with other staff memberswho have been involved in the client's care. In all instances,nurses should exercise professional judgment when deciding

whether to accept a gift from aclient. Attention should be givento what the giftgiving means to the client, as well as toinstitutional policy, the ANA Code of Ethics for Nurses, and the

ANA Scope and Standards of Practice.

3. Touch. Nursing by its very nature involves touching clients.Touching is required to perform the many therapeutic

procedures involved in the physical care of clients. Caringtouch is the touching of clients when there is no physical need(Registered Nurses

Association of British Columbia [RNABC], 2003). Caring touchoften provides comfort or encouragement and, when it is usedappropriately, it can have a therapeutic effect on the client.

However, certain vulnerable clients may misinterpret themeaning of touch. Certain cultures, are often uncomfortablewith touch. The nurse must be sensitive to these cultural

nuances and aware when touch is crossing a personalboundary. In addition, clients who are experiencing high levelsof anxiety or suspicious or psychotic behaviors may interpret

touch as aggressive. These are times when touch should beavoided or considered with extreme caution.

4. Friendship or romantic association. When a nurse is

acquainted with a client, the relationship must move from oneof a personal nature to professional. If the nurse is unable toaccomplish this separation, he or she should withdraw from

the nurse-client relationship. Likewise, nurses must guardagainst personal relationships developing as a result of thenurse-client relationship. Romantic, sexual, or similar personal

relationships are never appropriate between nurse and client.

CONCLUSION

Effective communication is the core skill in mental health care

in primary care settings. Self-awareness and ability tocollaborate with other health care providers are also skillsthat will facilitate accurate inquiry into the patient's true

concerns and the context in which they occur.

REFERENCES

1. Lalitha, k. Mental health and psychiatric nursing: AnIndian perspective. Bangalore: V.M.G. book house;2010.161 - 165.

2. Stuart GW Principles and Practice of psychiatric nursing.7th edition, Mosby, Philadelphia, 2001:15-49

3. Epstein RM, Borrell F, Caterina M . Communication and

mental health in primary care. In New Oxford Textbookof Psychiatry (Edrs. Gelder MG, López-Ibor JJ,Andreasen NC), Oxford University Press, 2000.

4. Sreevani R, A guide to mental health and psychiatricnursing. 1st edition, New Delhi, Japee Brothers,2004:32-35

5. MARY C. Essentials of Psychiatric Mental HealthNursing, 4th edition. F. A. Davis Company,philadelphia,2008:96-108

31


INTRODUCTION

One of the best ways to increase communication and interview

skills is by reviewing the clinical interaction exactly as theyoccur between the nurse therapist and the patient. This processoffers the opportunity to identify themes and patterns in both

the nurse therapist and the patients' communications. Clinicalreviews also helps students learn to deal with the variety ofsituations that arise in clinical interview. As a nurse working

with mental illness is always a challenge. Conducting aprocess recording gives the opportunity to improve thecommunication skill, note taking, self-awareness,

assessments, learning to listen, observations, and role playing.A process recording provides with an additional opportunity topractice nursing values and ethics. The brief conversation

based on the therapeutic goals, symptoms of illness and theverbal and non verbal behavior of the patient also are exploredduring the process.

Process recording is written record of a segment of the nursepatient session that reflect as closely as possible the verbaland non-verbal behaviour of both patient and nurse.

DEFINITION

1. A process recording is a written record of a verbatim

conversation between a nurse and a client.

2. It is written account or verbatim recording of all thatconversed, during and immediately following the nursepatient interaction.

3. It is a systematic method of collecting, interpreting,analyzing and synthesizing data collected during a

nurse- patient interaction, by using variouscommunication techniques.

The verbal communication is written from the student'smemory. Both the verbal and non verbal cues are noted. Therecord includes noting therapeutic communication techniques

that are used. It also includes the student's analysis of thecommunication.

PURPOSE

1. To critically analyze communication and its effect onbehavior of the individual

2. To modify subsequent behavior resulting in improvedquality of therapeutic communication and nursing care.

UNIT-7 PROCESS RECORDING

Dr. RamachandraAssociate professor

Dept. of nursing NIMHANS Bangalore-29

3. Assists the nurse to plan, and evaluate the interactionon a conscious level rather than an intuitive level.

4. To gain the patients confidence and get his co-operation.

5. To establish rapport with the patient.

6. To know about the patients illness and to understandthe psychodynamics of illness.

7. To identify the role of the socio-cultural background of

the patients behavior.

8. To practice various communication interview

techniques to get information from the patient and tohelp him.

9. To increase the observational skills as there is aconscious process involved in thinking, sorting andclassifying the interaction under the various headings.

10. To increase the ability to identify problems and gainskills in solving them.

GUIDELINES FOR PROCESS RECORDING:

Process Recording includes a brief description about thepatient regarding his name, age, educational status,occupation, marital status, health problems, and the duration

of stay in the hospital.

Describe about the environment in which the interactionoccurred, date, time, place of interaction. This will provide cuesabout the patient's thoughts and feelings. Details such as

personal history, family, socio-economic condition of the family,medical problems, current issues and complaints, pastillnesses can be collected through systematically planned

process recording.

Setting the goals: set appropriate goals and time. It shouldfocus on correcting the altered psychodynamics, therapeutic,rehabilitative, continuation of the care.

Interaction: record the factual information collected. What the

nurse asked and did? What the patient said and did? Note thenon-verbal cues during the interaction. Nurse must aware ofher own non-verbal behavior and its effect on the interaction.

She can observe her own thoughts and feelings for self-evaluation. Use techniques like offering self, broad opening,reflection, clarifying, validating, focusing, silence, etc. during

the conversation.

32


Interpretation and analysis: interpret the verbal and non-verbal

behavior of the patient, along with the thoughts and feelings.Analyze the findings and come to inferential conclusion.

Advantages:

1. Useful tool for identifying communication patterns.

2. It is possible to take notes, verbatim or recording of theinterview or conversation in a private area immediately

after the interaction takes place.

3. Careful recording of Nurse Therapist words andpatient's words helps in identifying whether Nurse

Therapist responses are Nurse Therapist's or not, andrecall Nurse Therapist thinking and emotions at thetime.

Disadvantage:

1. Process recording relies on memory and so subject todistortions.

2. Taking notes or recording during the conversation may

be distracting for both the interviewer and the patient.

PROCESS RECORDING FORMAT

Date; time; duration.

Venue:

Diagnosis:

Setting and situation:

Appearance of the patient:

Therapeutic communication goals:

33


CLIENT (VERBAL AND NON VERBAL CONVERSATION)

NURSE(VERBAL AND NON VERBAL

CONVERSATION) TECHNIQUES USED

ANALYSIS (ANALYZE WHETHER EACH

TECHNIQUE WORKED AS YOU

PLANNED)

INFERENCE

Good morning again, Mrs. Laxmi, I am the student nurse who is going to spend some time talking with you.” (smiling)

Offering self

I am so nervous! I feel like I am impersonating a nurse! I hoped she would talk to me.

Good morning sister?” {looks down and no eye to eye contact maintained}

Patient appears not interested in talking

You appear sad today. Can you brief me about it?

Making observation Broad opening

I was hoping to start with a broad opening so she could take whatever direction she wanted.

Sister I have a feeling that my family is making plan to kill me. My husband is unfaithful to me so they are trying to poison my food. Hence I have not eaten my breakfast.

Appears to have delusion of persecution and jealously

Yes go no Offering general leads

I thought may be she would talk more about her feeling if I could keep her talking.

What else to say sister. I am scared that I am not safe even in the hospital

Continues to justify the delusion

.

It’s hard to believe that any one can harm you in the hospital. What makes you say so?

Clarifying Duh! This like a stupid question.

No you do not know sister. It is true I feel they have kept some spies around to check on me.

Systematizes the delusion

See Laxmi. We all are here. There are staff nurses, doctors, security everybody around you. So do not get scared that some one will harm you. When you tart getting these thoughts come and share it with a staff nurse so that she can help you. In the midst of so many people I find it hard that anyone can harm you. If you feel scared you can come and sit in the nurse’s station.

Planning for coping

I was trying to get her to find the way she could talk to the peoples.

Thank you sister. I will do as you say.

I was trying to do planning for coping.

I was glad she was talking to me. It seems like she lightened up, became calmer.

Smiles and appears relaxed

Thank you for talking to me Laxmi.{ I got up to leave and squeezed her hand}

Showing the end of the conversation and I wanted her to know I care about her.

Discuss the issues related to patients concern, fix nextappointment

Summary: While summarizing, list all the inferences drawn,any difficulties faced during the interaction by patient and thenurse and techniques used to overcome the difficulties,importance of care plan.

Termination : when patient is ready for discharge, inform himabout the need for termination, tell the patient he can contact ifneed arises.

Signature of the nurse:

Conclusion: Process recording is a method by which a nurseestablishes her rapport with the patient. by the use oftherapeutic communication the nurse can establish a helping

Yes, Go On

relationship with the patient. Therefore this art should beessentially inculcated in all psychiatric nurses.

Reference:1. Booklet on clinical skills in psychiatric nursing.

Department of nursing. National institute of mentalhealth and neuro sciences.bangalore-560 029.india/2009.

2. Kathy neeb. Fundamentals of mental health nursing.3rd ed. Jaypee. New Delhi. 2008

3. Sreevani R. A guide to mental health and psychiatricnursing. 3rd ed. Jaypee. New Delhi.2010.

4. Varcarolis EM, Halter MJ. Foundations of psychiatricmental health nursing- A clinical approach. 6th ed.Saunders. St. Louis . 2010.

See, Mrs. Laxmi

Thank You Mrs. Laxmi (I gotup to leave and shook herhand),

34


Nursing documentation is the maintenance of recordsregarding the nursing assessment, planning implementation

and evaluation of the patient's condition in relation to thenursing care provided. The nurse is responsible for datacollection and assessment of health status of the client;

determination of the nursing care plan directed towardsdesignated goals; evaluation of the effectiveness of nursingcare in achieving the goals of care; and subsequent

reassessment and revision of the nursing care plan. One ofthe most important professional functions of the psychiatricnurse is evaluation of the patient's responses to nursing care.

Psychiatric patient records are legal documents which maybe used in the courts of law and is the only written evidence ofthe patient's problems and the care provided.

Definition: It is defined as the collection and assessment ofhealth status; determination of the nursing care directed

towards designated goals and evaluation of the effectivenessof nursing care in achieving the goals of care (Corponito, 1983)

1. Purpose of Nursing Care Plans

They represent a priority set of diagnosis (collaborativeproblems or nursing diagnosis) for a client.

They provide a "blue print" to direct charting

They communicate to the nursing staff what to teach,what to observe, and what to implement.

They provide outcome criteria for reviewing andevaluating care.

They direct specific interventions for the client, familyand other nursing staff members to implement.

They provide legal protection

They are used for accreditation, licensure, andcertification

They help to comply with regulatory standards innursing

They help in auditing evidence based nursing care

4 Objectives of Formulating Nursing Care Plans

They help in auditing evidence based nursing care

To recognise and accept the client as an individual

UNIT- 8 NURSING CARE PLAN

Dr. Sailaxmi GandhiAssistant professor

Dept. of NursingNIMHANS, Bangalore

To accurately observe and document the client'sbehaviour

To protect the patient from self injury and injury to others

To help the patient to identify his own potentials

To develop a sense of well being to maintain personalhygiene and be self sufficient

To assess the patient, plan for comprehensive nursingcare and evaluate the outcome

To provide opportunities for the client to make decisionand assume responsibilities for his life.

To identify factors involved in relationship of the client tohis family situation

To recognise and involve family as a tool in promoting

and improving care of the patient.

3. Components of Nursing Care Plan

Diagnostic statements (collaborative problems ornursing diagnoses)

Outcome criteria or nursing goals

Nursing orders or interventions

Evaluation (status of diagnosis and client's progress)

Each nursing care plan should project individually the problems

that the patient presents on priority basis and should be writtenin nursing diagnostic statements. For a psychiatric patient, ifthe physical problem is more severe (e.g. in catatonia if the

patient refuses to eat), then the physical problem becomes apriority. The nursing objectives or the nursing goals shouldbe planned accordingly. Having set the nursing goals, the

interventions are implemented based on scientific principlesto achieve the nursing goals. Status of the diagnosis/problemand client progress is evaluated accordingly.

4. Model Nursing Care Plan

35


Conclusion: Formulating a comprehensive care-plan whichis individually tailored and prioritized based on the patient'sneeds is a very important function of the psychiatric nurse.

Care plans should be flexible and the nurse should be preparedto change the intervention and prioritization based on changesin the patient. The nurse should also remember to always

document the care plan.

References:

1. Folstein MF, Folstein S, Mc Hugh PR, "Mini-Mental State:

Sl No.

Nursing Problem

Nursing Diagnosis Nursing objectives

Nursing interventions Rationale or scientific principal

Evaluation

1. Subjective: Patient says, “I can hear several people scolding me and telling me to kill myself. And this happens when no one is with me” Objective: The patient is seen always talking to self although she is alone and appears frightened and distressed

Impaired sensory perception related to psychopathology As evidenced by inappropriate responses & disordered thought sequencing

Short term goal: The patient’s subjective distress reduces Long term goal: Sensory perception occurs only in the presence of real stimuli in the environment

1.Establish rapport with the patient 2.Assess the presence, content and severity of alteration in client’s perception 3. Take suitable precautionary measures depending on the content of the voice 4. Set limits on the patient’s impulsive behavior in response to altered perceptions 5.Encourage reality based conversation 6. Engage the patient in activities of his/her choice 7. Engage the patient in activities such as reading loudly, listening to music, etc. 8.Positively reinforce reduced incidents of hallucinatory behavior/reporting of the ‘voices’ 9. Administer prescribed antipsychotics, watch for, report & document the effect, side-effects

1.To improve the interpersonal relation and trust which helps in verbalization 2.Provides baseline information about the patient’s behavior, potential for violence, observe changes in response to interventions, etc. 3. To avoid incidents of violence/self-harm/suicide, etc. 4. Helps the patient to differentiate between desirable & un-desirable behavior 5. Helps the patient to correctly interpret the stimuli within the milieu 6. Helps the patient in distracting from the ‘voices’ 7. Since the sensory perception impairment is in the auditory area, related activities will help blocking the ‘voices’ 8. This will increase repetition of desirable behaviors 9. Antipsychotics alter the biochemical mechanisms and help controlling the hallucinations

1. Patient’s hallucinatory behavior reduced 2. Reduced or no verbalization of auditory hallucination 3. Reduced or no verbalization of subjective distress

A Practical method for grading the cognitive state ofpatients for the clinician", J.Psychiatr Res 12:189, 1975

2. Lynda Juall Carpenito, "Nursing Care Plans andDocumentation", Third Edition, Lippincott, 1983

3. Kaplan.I.Harold, Sadock. J. Benjamin, "Synopsis of

Psychiatry: Behavioural Sciences/Clinical Psychiatry",B.I.Waverly Pvt. Ltd. , New Delhi, VIIIth Edition, 1998

36


Nursing practice is governed by laws that specify herresponsibilities towards patients, laws that affect the nurse

as an employee, laws that regulate her relationship withphysicians and laws that specify her duty to protect thepublic and laws that specify her duties for record keeping and

reporting.

Legal aspects of psychiatric nursing relates to the treatmentand care of persons with mental illness in least restricted

environment, to make better provision to respect, to protectand to fulfill the human rights of persons with mental illnessbased on the guidelines given by Mental Health Act (1987),

National Mental Health Policy (1982 and 2003), Standards ofpsychiatric nursing and Consumer Protection Act (1986).

(1) Introduction: Safe nursing practice includes an

understanding of the legal boundaries in which nurses mustfunction. An understanding of the implication of the lawsupports critical thinking on the nurses part. Laws are

changing constantly to reflect changes in society, changes inthe delivery of health care and advancement in medicaltechnology. The legal aspects of psychiatric nursing in India

is based upon NMHP (1982& 2003), MHA (1987), CPA(1986)and psychiatric nursing standards.

(2) Mental Health Act, 1987 (MHA), notified in 1993. It is not

fully implemented in many states. It has 98 sections. MHA,1987 also contains 10 chapters. Contents of MHA largelywritten with an administrative purpose. Details are,

Chapter I : Preliminary (and definitions): This chapterconsists of definition of terms Mentally ill person,Mentally ill prisoner, cost of maintenance, District

Court, Inspecting Officer, License, Licensee,licensed psychiatric hospital (or nursing home),licensing authority, medical officer, Medical

Officer In-Charge, Medical Practitioner, Minor,Psychiatric Hospital or psychiatric nursinghome, psychiatrist, Reception order, and

Temporary treatment order.

Chapter II: Mental Health Authority: This chapter describesthe roles and responsibilities of authorities to

regulate, to develop, to direct and coordinate themental health services in the country.

Chapter III: Psychiatric hospitals & psychiatric nursing

UNIT-9 LEGAL ASPECTS OF PSYCHIATRIC NURSING

Dr. K. Lalitha,Professor and Head,

Dept. of Nursing, NIMHANS, Bangalore 560 029.

home: This chapter deals with terms andconditions related to establishment of

psychiatric hospitals and p s y c h i a t r i cnursing home.

Chapter IV: Admission and Detention in psychiatric hospital

or psychiatric nursing home. This chapterexplains the procedures to be followed whileadmitting psychiatric patients and detaining

them in psychiatric hospitals. It classifies (I)Admission on voluntary basis (Major, Minor), (II)Admission under special circumstances, (iii)

Temporary treatment order (iv) Reception Order- on application, on production before theMagistrate; (v) Admission in emergencies and

(vi) Miscellaneous admission.

Chapter V: Inspection, Discharge, Leave or Absence, andremoval of mentally ill person; This chapter

explains the composition of Board of Visitors,their responsibilities, dischargeprocedure to be followed by for the voluntary

admission patients and for other than a voluntarypatient in psychiatric hospital.

Chapter VI: Judicial Inquisition: This chapter gives

guidelines about judicial inquisition regardingalleged mentally ill person possessing property.

Chapter VII: Liability to meet cost of maintenance of mentally

ill persons: This chapter provides guidelines tomeet the cost of maintenance of mentally illpersons in the psychiatric hospital.

Chapter VIII: Protection of human rights of mentally ill person:This chapter confirms the human rights of thementally ill person.

Chapter IX: Penalties and procedures: This chapter dealswith nature of penalties and punishmentprocedures applicable for those who violate the

provisions given in Mental Health Act, 1987and much emphasis is given to the provision ofChapter III.

Chapter X: Miscellaneous : This chapter focuses on theduties and responsibilities of the medical officerin-charge of psychiatric hospital.

37


(3) Admission procedures to be used in psychiatric hospital.

(a) Admission on voluntary basis

Major: Application on prescribed form to be submitted to themedical officer in charge of psychiatric hospital for admission.

Minor: The nearest guardian of patient applies for admission

(b) Admission under certain special circumstances:

Relatives or friends can produce the patient to medical officer

to admit the patient along with two medical certificates (onefrom a Gazetted Medical Officer). Only for 90 days patient canbe admitted.

(c) Temporary treatment order

Medical officer obtains reception order from Magistrate bysubmitting one medical certificate and detains patients for 6

months (only).

(d) Reception order

(i) On application: Relative or a friend who has seen patient

within 14 days can apply for reception order with two supportingmedical certificate (one from a Gazetted Medical Officer).

Medical Officer of a psychiatric hospital writes to Magistrate

and gets reception order to detain patient for 6 months for inpatient treatment.

(ii) On production before the Magistrate: Police officers produce

patient to Magistrate within 24 hours, with 2 medical certificatesto get reception order. Relatives who willfully neglect the patientmay be punishable with fine upto Rs. 1,000/-.

(e) Admission in emergencies: Medical Officers admit thepatient first & applies for reception order within 72 hours.Magistrate has to personally see the patient.

(f) Miscellaneous: Any public can bring patient for admission.But the reception order should be arranged by Medical OfficerIn-Charge of psychiatric hospital.

(4) Discharge procedures:

Medical Officer in-charge of the hospital can discuss any patientexcept criminals or those admitted on voluntary basis. It

requires the consent of 2 Medical Officers of his team.

Voluntary admission patients (major) writes a request letterfor discharge and the medical officer discharges or gives leave

of absence for 60 days within24 hours of request.

Any mentally ill person (other than a voluntary patient) may betransferred to any other psychiatric hospital with the consent

of the Govt. of the state.

(5) Rights of mentally ill patients:

It is the responsibility of the nurses to ensure that their actions

promote the welfare of patients. Psychiatric patients are often

the least capable of protecting their own rights.

Psychiatric problems may cause patients to lack social skillsor may cause an inability to make a point clearly understoodbecause of difficulties in concentration. As a result, the rights

of psychiatric patients have been ignored and abused forcenturies.

When a psychiatric patient enters a hospital, he loses his

freedom to come and go, to schedule his days, to choose hisactivities, and to control his activities of daily living. If he is alsoadjudicated incompetent, he loses his freedom to manage

his financial and legal affairs and make many importantdecisions. Because of the loss of these important freedoms,the authorities of health care agencies closely guard and value

those rights that the psychiatric patient retains. Some of therights of the psychiatric patients are:

(i) The right to wear their own cloths

(ii) The right to keep and use their own personalpossessions, including toilet articles.

(iii) The right to keep and be allowed to spend a reasonable

sum of their money for canteen expenses and smallpurchases.

(iv) The right to have access to individual storage space for

their private use.

(v) The right to see visitors everyday

(vi) The right to have reasonable access to telephone both

to make and to receive calls

(vii) The right to have ready access to letter writing materials

(viii) The right to mail and receive unopened

correspondence

(ix) The right to refuse electro convulsive therapy

(x) The right to manage and dispose of property

(xi) The right to excuse wills

(xii) The right to hold civil service status

(xiii) The right to treatment in the least restrictive setting.

In Section 81 of MHA (1987) the following rights are explained.

81.1 Right to protection against inhuman, cruel anddegrading treatment: provision of a safe and hygienic

environment; adequate sanitary conditions in themental hospital facilities; facilities for leisure,recreation, education & religious practices; person's

privacy is protected; not forced to undertake work in amental health facility; adequate provision is made forpreparing the person for living in the community.

81.2 Non-discrimination: Treated equal to persons with

38


physical illness in the provision of health care and

health services: Right to obtain medical insurance fortreatment of mental illness; Right to emergency facilitieseg: Ambulance living conditions in hospitals same as

they are for patients with physical illness

81.3 Protection in research: Free & informed consent of theperson for participation in research;

When the person cannot consent, consent of

- SMHA who in turn to have consent of

- Nominated representative &

- Subject to certain specific conditions

81.4 Right to information: oPerson & Nominatedrepresentative have the same right to information;

Right to make application to MHRC to review admission;Nature of the illness for which they are being treated. In alanguage & manner, that the patients and family members

can understand.

Nurses have to closely guard and value these rights that thepsychiatric patients retain.

Legal responsibilities of a mentally ill person.

(i) Criminal responsibility: Mc Naughten Rule protectsthe psychiatric patient from punishment (IAC, 1957)

when he does an offensive act without knowing thenature and quality of act and when he cannotdiscriminate between right & wrong act.

(ii) Durham Rule (1954) The accused is not criminallyresponsible if his act was the "product of mentaldisease".

(iii) American Law Institutes (ALI) Test: says that "a personis not responsible for criminal conduct if at the time ofsuch conduct as a result of mental disease or defect

wherein he lacks adequate capacity either to appreciatethe criminality of his conduct to conform his conduct tothe requirement of the law.

(6) Civic responsibility

Mentally if patients are kept away from

(i) Management of property & affairs

(ii) Marriage

(iii) Testamentary

(7) The Narcotic Drugs and Psychotropic Substance Act

(1985)

The Act includes the nature of punishment and or fine when aperson produces, possesses, transports, imports, sells,

purchases or uses any narcotic drugs or psychotropicsubstances.

Legal role of the nurse

(i) Observing the legal aspects of admission, discharge&leave of absence procedure

(ii) Providing safe & secured environment in the ward

(iii) Following the principles of therapeutic community

(iv) Assisting for diagnostic & therapeutic procedures

(v) Protecting the rights of patients

(vi) Preventing nursing malpractice - negligence; care isto be taken in the areas of staffing, educationalqualifications, competencies and job descriptions.

(vii) Documentation

(viii) Informed/Substituted consent

(ix) Confidentiality

(x) Responsible record keeping

Conclusion: Rules and regulations framed by statutory bodiesmust be strictly followed at all levels. Nursing students must

be aware of legal aspects in nursing in general and inpsychiatric nursing in particular for improving patient safetyand professional development.

References:

1. Lalitha K, "Mental Health and Psychiatric Nursing -AnIndian Perspective", VMG Book House,Bangalore, 2007,

p. 610-634.

BOOKLETON

PSYCHIATRIC NURSING SKILLSTOTEACHERS OF

SCHOOL OF NURSING

EDITED BY:DR. K.LALITHA

DR. NAGARAJAIAHDR. RAMACHANDRA

DR. SAILAXMI GANDHI

DEPARTMENT OF NURSINGNATIONAL INSTITUTE OF MENTAL HEALTH AND NEUROSCIENCES

BANGALORE 560 029

2011

A C K N O W L E D G E M E N T

We feel extremely happy to express our heartfelt gratitude to

Prof. P. Satish Chandra, Director/Vice-Chancellor of NIMHANS

for permission, extending total support and encouragement

to research project on 'Effect of training programme on

Knowledge, Attitude and Clinical Skills of Nursing Teachers of

School of Nursing Towards Psychiatric Nursing' and ensuing

the booklet.

We sincerely thank Dr. V. Ravi, Registrar, for administrative

support in this academic venture.

Our sincere thanks to Prof. Shoba Srinath, Dean, Behavioural

Sciences, for support and guidance.

We sincerely thank the chair-person and members of ethical

committee for their valuable suggestions in this endeavour.

We are sincerely grateful to the President, Indian Nursing

Council, for financial assistance.

We extend our heart-felt thanks to Prof. K.Reddemma, Former

Dean, Behavioural Sciences and Professor of Nursing, for

her continuous encouragement and involvement.

Our sincere thanks to Dr.R.Parthasarathy, Professor,

Department of Psychiatric Social Work, for being a resource

person.

Our profound thanks to all our nursing colleagues in the

Department of Nursing at NIMHANS for their moral support

and encouragement throughout this endeavour.

This booklet would not have been possible without the

dedicated and conscientious effort of Mrs. Leelavathy. A. &

Mrs. Kalyani S. stenographers, at Department of Nursing,

NIMHANS.

We are grateful to the principals of the various Schools of

Nursing, who have permitted their faculty to participate in this

research project.

Last, but not the least, the authors owe their thanks M/s.

Manjushree Printers for quality printing of this booklet.

Dr. K. Lalitha

Dr. K.Thennarasu

Dr.Nagarajaiah

Dr. Ramachandra

Dr.Sailaxmi Gandhi

CO

NT

EN

TS

C O N T E N T S

PageAuthor NameArticles

1. PREFACE

2. ACKNOWLEDGEMENT

3. UNIT 1- PSYCHIATRIC INTERVIEW DR. R. PARTHASARATHY

& MS. SHOBITHA

4. UNIT 2- PSYCHIATRIC HISTORY TAKING DR.NAGARAJAIAH

5. UNIT 3- SYMPTOMATOLOGY IN MENTAL DISORDERS DR. RAMACHANDRA

6. UNIT 4- MENTAL STATUS EXAMINATION DR. SAILAXMI GANDHI

7. UNIT 5- PHYSICAL & NEUROLOGICAL EXAMINATION DR. RAMACHANDRA

8. UNIT 6- INTERPERSONALRELATIONS AND DR. NAGARAJAIAH

COMMUNICATION SKILLS

9. UNIT 7- PROCESS RECORDING DR.NAGARAJAIAH

10. UNIT 8- NURSING CARE PLAN DR. SAILAXMI GANDHI

11. UNIT 9- LEGAL ASPECTS OF

PSYCHIATRIC NURSING DR. K. LALITHA

Workshop on Clinical skills in Nursing for Staffs at Schools of Nursing

Health & Medicine

Transcript of Workshop on Clinical skills in Nursing for Staffs at Schools of Nursing