Determinants of mental patient | CHAPTER 1 | Psychiatric nursing

Determinants of mental patient – This book covers the entire syllabus of “Psychiatric Nursing” prescribed by the Universities of Bangladesh- for Basic and diploma nursing students. We tried to accommodate the latest information and topics. This book is an examination-friendly setup according to the teachers’ lectures and examination questions.

At the end of the book previous university questions are given. We hope in touch with the book students’ knowledge will be upgraded and flourish. The unique way of presentation may make your reading of the book a pleasurable experience.

Determinants of mental patient

Anatomical & Physiological Aspect of Psychiatry

Neurotransmitter:

Neurotransmitters are chemical substances that are secreted when the axon terminal of a presynaptic neuron is excited and transmit nerve impulse across the synapse (from neuron to neuron and from neuron to effector cells) either to excite or inhibit the target cells.

[ Ref: Katzung/13/ ]

Or,

The small space or cleft between two neurons is known as synapse. When a message reaches the end of the nerve cell, it stimulates pockets of a chemical substance and releases it into the synapse. This chemical substance is called neurotransmitter. It acts as a bridge and helps the message to reach the other cell.

[Ref-S Nambi/24]

Characteristics of neurotransmitter:

To be considered as a post-junctionally acting neuro-humoral transmitter a substance must fulfill the following criteria:

1. It should be present in the presynaptic neuron (usually along with enzymes synthesizing it).

2. It should be released in the medium following nerve stimulation.

3. Its application should produce responses identical to those produced by nerve stimulation.

4. Its effects should be antagonized or potentiated by other substances which similarly alter effects of nerve stimulation.

Or,

• It must be manufactured in the pre-synaptic terminal of a neuron.
• It should be released when a nerve impulse reaches the terminal.
• Its presence in the synaptic gap must generate a biological response in the next neuron.
• If its release is blocked, there must be no subsequent response.

[Ref-S Nambl/2]

Name some neurotransmitter

Classification of neurotransmitter:

1. Excitatory neurotransmitter:

• Acetylcholine.
• Nor-adrenaline
• Glutamate.

2. Inhibitory neurotransmitter:

• GABA (Gamma amino-butyric acid)
• Dopamine
• Glycine
• Serotonin

3. Mixed neurotransmitter:

• Enkephalins
• 5-HT

Other types of neurotransmitters

1. Centrally acting:

• Acetylcholine
• Dopamine
• Serotonin
• Histamine

2. Peripherally acting:

• Acetylcholine
• Nor-epinephrine

According to chemical nature:

A. “Classical” neurotransmitters

1. Acetylcholine (Ach)

2. Amines:

• Catecholamines:

➤ Epinephrine (E),

➤ Nor epinephrine (NE) and

➤ Dopamine (DA)

• Histamine (H)
• Serotonin (5-HT)

3. Amino acids (in CNS):

• Aspartate (aspartic acid)
• Glutamate (glutamic acid)
• Gamma-aminobutyric acid (GABA) and
• Glycine

B. Peptide Neurotransmitters:

• Substance P, Beta endorphin, Enkephalin,
• Somatostatin, Vasopressin, Angiotensin II,
• Gastrin, Cholecystokinin,
• Oxytocin, Neuropeptide Y, etc.

C. Certain soluble gases also act as neurotransmitters:

• The most important member of this category is nitric oxide (NO).

Functions of cerebellum:

1. Control of voluntary activity (via pyramidal system).

2. Control tone, posture & equilibrium (via extra pyramidal system).

3. Maintains the motor activity of the distal part of limbs. E.g.- hand, fingers, feet, toes etc.

4. Concerned with overall planning & time of the sequential moto activity.

Functions of neocerebellum: 1

The lateral portions of cerebellar hemispheres are called neocerebellum.

The functions of neocerebellum are:

1. Planning & programming of movements by interacting with the motor cortex.

2. Helps in muscular co-ordination.

3. Responds to proprioceptive, tectile, visual & auditory stimulation.

Cerebellar function tests:

1. Finger-nose test:

The patient attempts to place the tip of the finger of the outstretched hand on the tip of the nose

2. Gait:

The patient tends to deviate to the affected side and brings himself back to the original line-a zigzag path result.

Basal ganglia:

The basal ganglia, an accessory motor system (like the cerebellum) that functions usually not by itself but in close association with the cerebral cortex. The basal ganglia by itself receive most of their input signals from the cerebral cortex and return almost all their output signals back to the cortex.

[The term ‘basal ganglia (or basal nuclei) is applied to five interactive structures on each side of the brain. These are –

i. Caudate nucleus.

ii. Putamen.

iii. Globus pallidus.

iv. Subthalamic nucleus &

v. Substantia nigra.

Functions of basal ganglia:

1. Control of voluntary motor activity.

2. Control of muscle tone.

3. Control of reflex muscular activity.

4. Control of automatic associated movements.

[Ref: Guyton and Hall 17/689/]

Hypothalamus:

The hypothalamus is a very small, but extremely important part of the diencephalon that is involved in the mediation of endocrine, autonomic and behavioral functions.

Or,

Hypothalamus liberates hormones (or factors) which enter the adenohypophysis via the portal system of blood supply and strongly influences the secretions of the aderiohypophysis.

(Ref: Dr. Ranzu/15/)

Functions of hypothalamus:

1. Thermoregulation:

there is cold environment in the outside

⇓

There is cautaneous vasoconstriction, standing up of the fur (horripilation) and shivering occurs.

⇓

Temperatute loss is decreased as well as gaining of temp occur.

Or (Another answer)

When there is hot environment

⇓

There is sweating, cautaneous vasodilatation and relaxation of muscle tone occurs.

⇓

Normal temperature is maintained.

These functions are maintained by hypothalamus. Thus, hypothalamus acts as a thermostat.

2. Behavior & emotions:

This includes-

1. Hunger & satiety.

2. Sex & mating.

3. Thirst & drinking.

4. Defense reactions.

5. Emotions like rage and panic.

3. Control of endocrine gland:

Various releasing hormones (CRH/GnRH/ TRH/ GHRH etc) of hypothalamus control the anterior pituitary. The anterior pituitary, in turn, control many different endocrine glands.

4. Control of autonomic nervous system.

5. Acts as a biological clock.

[Ref: Guyton/12]

In Short:

Functions of hypothalamus:

1. Endocrine control: With the help of releasing or inhibitory factors, it regulates the secretion of different endocrine gland.

2. Neurosecretion: Supraoptic and paraventicular nucleus secrete ADH and Oxytocin.

3. General autonomic effect: Anterior hypothalamus mediates the parasympathetic
activity and the posterior part mediates the sympathetic activity. Thus it regulates the CVS, respiratory and alimentary functions.

4. Temperature regulation: Cold sensative area exists in anterior part and heat sensative area exists in posterior part-by which it regulates body temperature.

5. Regulation of food and water intake: Hunger centre is placed laterally, the satiety center is medially by which it regulates food and water intake.

6. Sexual behaviour and reproduction: It controls sexual function and reproductive cycle through gonadotropin production.

[Ref-Dr. Ranzu/15/10.23]

Short Note:

Major Neurotransmitters:

Ref: Psychiatric-Mental Health Nursing-Sheila. L/9/211

Psychiatric patient

Psychiatric patient:

Psychiatric patient is a patient suffering from mental illness.

People with mental illness ere entitled to fair treatment, and they should:

• Be treated with respect and dignity
• Have their privacy protected
• Receive services appropriate for their age and culture
• Understand treatment options and alternatives
• Get care that doesn’t discriminate on the basis of age, race, or type of illness

Rights of a psychiatric patient:

1. The right to wear their own cloths.

2. The right to keep and use their own personal possessions, including-toilet articles.

3. The right to keep and be allowed to spend a reasonable sum of their money for canteen expenses and small purchases.

4. The right to have access to individual storage space for their private use.”

5. The right to see visitors every day.

6. The right to have reasonable access to telephones, both to make and to receive calls.

7. The right to have ready access to letter-writing materials. 8. The right to mail and receive unopened correspondence.

9. The right to refuse electroconvulsive therapy.

10. The right to manage and dispose of property.

11. The right to execute wills.

12. The right to hold civil service status.

13. The right to treatment in the least restrictive setting

[Ref: K. Lalitha/1/198/]

Defense mechanisms:

When an individual is faced with problems, difficulties or failures, he employs certain ways or devices to achieve health, happiness or success. These are called defense mechanisms. Psychologist have identified a number of such defense mechanisms, which include the following:

1. Rationalization: Instead of accepting failure and correcting himself, the individual tries to make excuses and justifies his behaviour. It is like the proverbial fox declaring that the grapes were sour, when it could not reach them. This is called rationalization. It is a face- saving device.

2. Projection: Sometimes the individual blames others for his mistakes or failures. It is just like the student saying that he could not score good marks the examination because, his teacher did not like him.

3. Compensation: Many people make use of compensation to enhance their self-esteem and prestige. The familiar example is that the student who is not good – Ills studies may distinguish himself in sports or dramatics, music or other activities.

4. Escape mechanism: Some individuals adopt what is known as an “escape mechanism” to overcome failure or defeat. Some students pretend illness and do not appear for examinations. This is an escape phenomenon.

5. Displacement: An office clerk badly snubbed by his superior takes it out on His wife and children on reaching home. This is like a rebound phenomenon. It is trying to escape from one situation and fixing blame on another situation.

6. Regression: Some people resort to childhood practices (e.g., weeping when something goes wrong) as a mode of adjustment.

[Ref: K. Park/241]

Assessment of a Psychiatric Patient

Basic techniques of psychiatric nursing assessment:

The basic techniques included in psychiatric nursing assessment are:

1. History taking

2. Mental status Examination (MSE)

3. Psychological tests.

[Ref: KP Neeraja/I/Vol-1/801]

Objectives of history taking:

1. To provide insight into the nature of relationships with closest people

2. To allow the client and his relative to express their feelings freely in their own words

3. To identify the predisposing factors and causes of Mental Illness

4. To note the client’s condition by identifying manifestations of illness

5. To formulate nursing diagnosis (actual and potential psychosocial health problems)

6. To identify psychiatric emergencies

7. To Plan and implement nursing interventions.

[Ref: KP Neeraja/F/Vol-1/811]

Steps of taking psychiatric history:

1. Informant: Client/relative/friend

➤ Reliability of informant (Relative or friend, who is giving information about the client)

➤ Name of informant: Relationship with the client and duration of relationship.

➤ Intimacy with the client: Living along with the client and any bias associated.

➤ His/Her interest towards client’s property or money.

2. Identifying data:

Important client’s characteristics that may alter diagnosis, treatment and compliance.

➤ Ward

➤ I.P.No.

➤ Bed No.

➤ Name of the patient

➤ Age

➤ Sex

➤ Religion

➤ Education

➤ Marital Status

➤ Occupation

➤ Monthly family income

➤ Languages known

➤ Ethnic background

➤ Nationality

➤ Identification Marks

➤ Date of Admission

➤ Nativity

➤ Address of the client

➤ Diagnosis of client

3. Presenting chief complaints or problems:

➤ Record chief complaint and its duration in verbatim (word to word what the client says) of client and his relative. Try to write the information related to complaint in chronological order.

4. History of present illness: It helps identify the client’s problems/illnesses and making diagnosis as it provides in detail the chronological events upto the present situation in client’s life.

• Mode of onset: acute (within 2 weeks)/sub-acute (more than 2 weeks)/abrupt (sudden)/ insidious (more than 4 weeks).
• Duration of illness: Continuous/episodic/ fluctuating/associated with other symptoms
• Deteriorating/improving/unclear/abrupt or sudden (within 24 hours).
• [Mode of onset and duration gives clue to the cause and its implications on prognosis.]
• Precipitating factors: Events that occur shortly before the onset of illness or appear to induce illness
• Description of present illness in chronological order
• Associated problems, e.g. depression, suicidal tendency
• Changes in ADL activities
• Functioning pattern:

➤ Social functioning, e.g. managing day activities, hobbies, leisure time activities.

➤ Biological functioning, e.g. Sleep, appetite, bowel, bladder and sexual functions.

➤ Occupational functioning, e.g. ability to work; alteration in work pattern.

➤ Mental functioning: Concentration, thinking, recall mood pattern, interest. attitude, etc.

• Alteration in speech pattern
• Interpersonal relations: Quality of relationship with families
• Legal association: any legal problems
• Losses: Beloved persons, property, financial matters

5. Past medical history (PMH):

The interviewer should explore the PMH to look for surgical or medical diseases or medications that cause, contribute to, or mimic psychiatric disease. Past psychiatric history: explore previous diagnoses, treatments, and outcomes.

6. Family history (FH): Explore familial psychiatric disorders or medical conditions as a cause of or contributing factors to psychiatric disorders.

7. Social history (SH): Document the social circumstances of the patient, such as finances, housing, relationships, drug and alcohol use, and problems with the law, as these can contribute to the cause of psychiatric disease.

8. Development history: past, present, family, social, and cultural.

9. Review of systems (ROS): explore pertinent systems associated with the onset of psychiatric disease.

[Ref: KP Neeraju/I/Vol-1/81 + Clinical Consult to Psychiatric Nursing/1/6-7/]

Mental status examination (MSE):

1. Appearance: physique, grooming, dress, habits, nutritional status, posture, nervousness, and eye contact.

2. Attitude/rapport: attitude toward the examiner. For example, is the patient friendly, cooperative, bored, or defensive?

3. Mood: the patient’s emotions. Elicit by asking the patient questions such as, “How have you been feeling on most days?” List the mood in the patient’s own words.
Moods include being depressed, angry, anxious, stressed, or elevated.

4. Affect: defined by the interviewer. Observable emotion: euthymic (normal), neutral, euphoric, dysphoric, or flat (no variation in emotion); the range: full, constricted, or blunted; appropriateness: appropriate or labile.

5. Speech: quality, quantity, rate, and volume

6. Thought process: the organization of the patient’s thoughts.

➤ Loose associations: the patient slips off the track from one idea to an unrelated one.

➤ Flight of ideas: verbally skipping from one idea to another before the previous one has been concluded

➤ Tangentiality: the responses never approach the point of the questions.

➤ Thought blocking: patient stops abruptly in the middle of a thought.

➤ Circumstantiality: delay in getting to the point because of unnecessary details and irrelevant remarks

➤ Neologism: patient creates new words.

7. Thought content:

➤ Suicidal ideation: assess plan and previous attempts

➤ Homicidal ideation: assess plan and previous attempts a

➤ Obsessions and compulsions

➤ Phobias

➤ Paranoia

8. Perceptual disturbances

9. Hallucinations: perception of a stimulus in the absence of a stimulus; auditory (hearing things), visual (seeing things), olfactory (smelling things), tactile (feeling things), and gustatory (tasting things)

10. Delusions: grandiosity, religious delusion, persecution, jealousy, thought insertion (belief that someone is putting ideas or thoughts into his or her mind), ideas of reference (belief that irrelevant, unrelated phenomena in the world refer to him or her directly or have special personal significance)

11. Illusions: erroneous interpretation of a present stimulus

12. Insight: the patient’s understanding of his or her illness

13. Judgment: estimate the patient’s judgment on the basis of the history or on an imaginary scenario. Ask the following question: “What would you do if you smelled smoke in a crowded theater?” (Adequate response is, “Get help”; poor response is, “Do nothing” or “Watch the smoke rise”).

14. Impulsivity: the degree of the patient’s impulse control

15. Reliability: determine whether the patient seems reliable, unreliable, or if it is difficult to determine.

[Ref: Clinical Consult to Psychiatric Nursing/1/7-8]

Define psychological testing

Psychological testing: Psychological testing offers objective data about mental functioning. It involves administration, scoring, and interpretation of specific tasks in a controlled fashion.

[Ref: Clinical Consult to Psychiatric Nursing/1/13]

Aims of psychological test:

To determine individual’s –

1. Intellectual capacity

2. Motive pattern

3. Self-concept

4. Perception of environment

5. Roles to be taken

6. Coping pattern and

7. Personality integration

[Psychological tests will be carried out by the clinical psychologist or Nurse.]

[Ref: KP Neeraja/I/Vol-1/90]

Information provided by psychological testing:

Psychological testing has the ability to provide useful diagnostic information regarding level of intellectual functioning, identify and describe the nature of a mental health disorder, and indicate underlying motivation, personality attributes, and other variables.

1. The patient must be able to participate in the assessment. Grossly confused or psychotic patients are not good candidates for psychological testing.

2. Psychological testing is useful in treatment planning and outcome evaluation.

3. Psychological testing is useful when objective data are required to establish a suspected diagnosis (sanity boards, interdiction).

[Ref: Clinical Consult to Psychiatric Nursing/1/14]

Types of psychological test:

Many types of psychological tests are available to qualified users, which include the following:

1. Measures of intellectual functioning

2. Personality questionnaires

3. Projective techniques

4. Neuropsychological tests

5. Measures of cognitive impairment

Associated tests include the following:

1. Psychodiagnostic screening tests

2. Educational diagnostic tests

3. Aptitude tests

4. Interest inventories

[Ref: Clinical Consult to Psychiatric Nursing/1/14]

Important issues in psychological testing:

1. Reliability

2. Validity

3. Cultural bias

4. Confidentiality

5. Qualified examiners and assistants

6. Explaining test results to referral sources

[Ref: Clinical Consult to Psychiatric Nursing/1/14]

Determination of appropriate patients for psychological testing:

1. Almost anyone who possesses a reasonable reality orientation and is nonpsychotic is an appropriate candidate for psychological testing.

2. Individuals with better mental statuses are capable of participating in more complex psychological testing procedures.

3. Not all patients are capable of participating in all psychological tests. Physical handicaps, language barriers, and illiteracy may limit the available testing procedures.

4. The willingness of the patient has an influence on the procedure. Angry or deceptive individuals may distort the outcome data. There are specific psychological tests to detect malingering and deception.

5. Very specific referral questions allow for the selection of instruments (measures) to specifically address the reason for referral for testing.

[Ref: Clinical Consult to Psychiatric Nursing/1/14]

Mental Health Promotion

Health promotion:

Health promotion is “any planned combination of educational, political, environmental, regulatory, or organizational mechanisms that support actions and conditions of living conducive to the health of individuals, groups, and communities”

Or,

Health promotion is the process of enabling people to increase control over, and to improve, their health. It moves beyond a focus on individual behaviour towards a wide range of social and environmental interventions.

(Ref: WHO)

Mental health promotion:

Mental health promotion is a “state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.

[Ref: Lecture, Mohakhali Nursing College]

Or,

“A state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.”

Approach for mental health promotion:

1. Identifies risks that may contribute to illness or disability

2. Recognizes the interrelatedness of mental health and physical health

3. Communities can often reduce the severity of mental illness and promote recovery through early identification of individuals who may need assistance or support.

4. Focuses on prevention and promotes mental health across the lifespan.

5. Public health also plays an important role in early intervention and recovery

6. Public health systems can also connect individuals with community resources and provide information on maintaining positive mental health across the lifespan to help support people living people living with mental illness.

[Ref: Lecture, Mohakhali Nursing College]

Rehabilitation in psychiatry

Psychiatric rehabilitation, also known as psychosocial rehabilitation, and sometimes simplified to psych rehab by providers, is the process of restoration of community functioning and well-being of an individual diagnosed in mental health or mental or emotional disorder and who may be considered to have a psychiatric disability.

Or,

Rehabilitation in psychiatry is that process which attempts to benefit a mentally ill person back, as near as possible, to his original state. It is the process designed to help the handicapped individuals to make maximum use of their residual capacities and to enable them to lead a beneficial and meaningful life in the community

[Ref-S Nambi/2nd]

The utilization of the existing capacities of the handicapped person by the combined and coordinated use of medical, social, educational and vocational measures to the optimum level of his functional ability’.

[Ref: KP Neeraja/I/Vol-1/295]

Indications for rehabilitation in psychiatry:

The following disorders are indicated j commonlyfor rehabilitation such as-

1. Chronic schizophrenia.

2. Chronic organic mental disorders.

3. Mental retardation

4. Alcohol and drug dependence

[Ref-S Nambi/2nd]

Aims of rehabilitation:

1. Prevents chronic disability

2. Acquire and maintain the life skills that are necessary to cope-up effectively

3. Helping the physically challenged person to attain their best level of social functioning

4, The client will lead fully independent life

5. Provides lifelong support

6. Alleviates manifestations of problems is secondary

7. Improves clients’ ego strengths, to have mental strength and ready to do any work independently

8. Cope-up with emotional and interpersonal factor which are involved in starting and continuation of work or job

Rehabilitation team:

The members of the rehabilitation team are –

1. Psychiatrist

2. Clinical psychologist

3. Medico-social worker

4. Psychiatric Nurse

5. Counsellor

6. Occupational therapist

7. Recreational therapist

8. Other mental health care professionals.

[Ref: KP Neeraja/P/Vol-1/296]

Seven strategic principles of psychiatric rehabilitation:

The mission of psychiatric rehabilitation is to enable with best practices of illness management, psychosocial functioning, and personal satisfaction. Treatments and practices towards this is guided by principles. There are seven strategic principles:

1. Enabling a normal life.

2. Advocating structural changes for improved accessibility to pharmacological services and availability of psycho-social services.

3. Person-centered treatment.

4. Actively involving support systems.

5. Coordination of efficient services.

6. Strength-based approach.

7. Rehabilitation isn’t time specific but goal specific in succeeding.

The peer-provider approach is among the psychosocial rehabilitation practices guided by these principles. Recovery through rehabilitation is defined possible without complete remission of their illness, it is geared towards aiding the individual in attaining optimum mental health and wellbeing.

Post-traumatic stress disorder

Symptoms of post-traumatic stress disorder:

1. Re-experiencing the traumatic event through intrusive memories, flashbacks, nightmares, or intense mental or physical reactions when reminded of the trauma.

2. Avoidance and numbing such as avoiding anything that reminds you of the trauma, being unable to remember aspects of the trauma, a loss of interest in activities and life in general, feeling emotionally numb and detached from others and feeling a sense of a limited future

3. Hyperarousal, including sleep problems, irritability, hypervigilance (on constant “red alert”), feeling jumpy or easily startled, angry outbursts, and aggressive, self-destructive, or reckless behavior.

4. Negative thought and mood changes like feeling alienated and alone, difficulty concentrating or remembering, depression and hopelessness, feeling mistrust and betrayal, and feeling guilt, shame, or self-blame.

PTSD symptoms in children:

In “children especially very young children the symptoms of PTSD can be different from adults and may include:

• Fear of being separated from parent.
• Losing previously-acquired skills (such as toilet training).
• Sleep problems and nightmares.
• Somber, compulsive play in which themes or aspects of the trauma are repeated.
• New phobias and anxieties that seem unrelated to the trauma (such as fear of monsters).
• Acting out the trauma through play, stories, or drawings.
• Aches and pains with no apparent cause.
• Irritability and aggression.

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• Psychiatric nursing | Diploma in Nursing Science and Midwifery