UPDATED 2024

A Psychiatric nurse faces various challenges because of changes in the inpatient care approach. Some of these changes that affect her role are as follows:

Trends in Health Care

• Increased mental health problems
• Provision for quality and comprehensive services
• Multidisciplinary team approach
• Providing continuity of care
• Care provided in alternative settings

Economic Issues

• Industrialization
• Urbanization
• Raised standard of living

Changes in Illness Orientation

• Shift from illness to prevention (modification of style), specific to holistic, quantity of care to quality of care

Changes in Care Delivery

• Care delivery is shifted from institutional services to community services, genetic services to counseling services, nurse patient relationship to nurse-patient partnership.

Information Technology

• Telenursing
• Telemedicine
• Mass media
• Electronic systems
• Nursing informatics

Consumer Empowerment

• Increased consumer awareness
• Awareness of the community in early detection and treatment of mental illness as well as proper utilization of available psychiatric hospitals
• Patients are health care consumers demanding quality health care services at affordable cost with less restrictive and more humane rates.

Deinstitutionalization

• Bringing mental health patients out of the hospital and shifting care to community.

Physician Shortage and Gaps in Service

• Physician shortage can provide the opportunity for new roles, for example, nurse practitioner. In respect to gaps in services, nurses always meet the needs of people for whom services are not available, for example, home visiting nurse.

Demographic Changes

• Increasing number of the elderly group
• Type of family (Increased number of nuclear families).

Change in Patient Needs

• Wanting a more holistic orientation in health care.

Challenges in Psychiatric Nursing

• Knowledge development, dissemination and application
• Overcoming stigma
• Health care delivery system issues
• Impact of technology

Educational Programs for the Psychiatric Nurse

• Diploma in Psychiatric Nursing (The first program was offered in 1956 at NIMHANS, Bengaluru)
• MSc in Psychiatric Nursing (The first program was offered in 1976 at Rajkumari Amrit Kaur College of Nursing, New Delhi)
• Mphil in Psychiatric Nursing (1990, MG University, Kottayam)
• Doctorate in Psychiatric Nursing (offered at MAHE, Manipal; RAK College of Nursing, Delhi; NIMHANS, Bengaluru, National Consortium for PhD in Nursing under RGUHS, Karnataka, etc)
• Short term training programs for both the degree and diploma holders in nursing

Standards of Mental Health Nursing

The development of standards for nursing practice is a beginning step towards the attainment of quality nursing care. The adoption of standards helps to clarify nurses areas of accountability, since the standards provide the nurse, the health agency, other professionals, patients, and the public, with a basis for evaluating practice. Standards also define the nursing profession’s accountability to the public. These standards are therefore a means for improving the quality of care for mentally ill people.

Development of Code of Ethics

This is very important for a psychiatric nurse as she takes up independent roles in Psychotherapy, behavior therapy, cognitive therapy, individual therapy, group therapy, maintains patient’s confidentiality, protects his rights and acts as patient’s advocate.

Legal Aspects in Psychiatric Nursing

Knowledge of the legal boundaries governing psychiatric nursing practice is necessary to protect the public, the patient, and the nurse. The practice of psychiatric nursing is influenced by law, particularly in its concern for the rights of patients and the quality of care they receive.

The patient’s right to refuse a particular treatment, protection from confinement, intentional torts, informed consent, confidentiality, and record keeping are a few legal issues in which the nurse has to participate and gain quality knowledge.

Promotion of Research in Mental Health Nursing

The nurse contributes to nursing and the mental health field through innovations in theory and practice and participation in research.

Cost-effective Nursing Care

Studies need to be conducted to find out the viability in terms of cost involved in training a nurse and the quality of output in terms of nursing care rendered by her.

Focus of Care

A psychiatric nurse has to focus care on certain target groups like the elderly, children, women, youth, mentally retarded and chronic mentally ill.

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UPDATED 2024

Therapeutic communication is an interpersonal interaction between the nurse and the patient during which the nurse focuses on the patient’s specific needs to promote an effective exchange of information. All nurses need skills in therapeutic communication to effectively apply the nursing process and to meet standards of care for their patients.

Therapeutic communication can help nurses to accomplish many goals:

• Establish a therapeutic nurse-patient relationship
• Identify the most important patient’s needs
• Assess the patient’s perception of the problem
• Facilitate the patient’s expression of emotions
• Implement interventions designed to address the patient’s needs

To have an effective therapeutic communication, the nurse must consider privacy and respect of boundaries, use of touch and active listening and observation.

Principles or Characteristics of Therapeutic Communication

• The patient should be the primary focus of interaction
• A professional attitude sets the tone of the therapeutic relationship
• Use self-disclosure cautiously and only when it has a therapeutic purpose
• Avoid social relationship with patients
• Maintain patient confidentiality
• Assess the patient’s intellectual competence to determine the level of understanding
• Implement interventions from a theoretic base
• Maintain a nonjudgmental attitude. Avoid making judgments about patient’s behavior
• Avoid giving advice
• Guide the patient to reinterpret his or her experiences rationally.

Therapeutic Communication Techniques

1. Listening: It is an active process of receiving information. Responses on the part of the nurse, such as maintaining eye-to-eye contact, nodding, gesturing and other forms of receptive nonverbal communication convey to the patient that he is being listened to and understood.

Therapeutic Value: Nonverbally communicates to the patient the nurse’s interest and acceptance.

• Broad Openings: Encouraging the patient to select topics for discussion. For example, “What are you thinking about?”

Therapeutic Value: Indicates acceptance by the nurse and the value of patient’s initiative.

• Restating: Repeating the main thought expressed by the patient. For example, “You say that your mother left you when you were 5-year-old”

Therapeutic Value: Indicated that the nurse is listening and validates, reinforces or calls attention to something important that has been said.

• Clarification: Attempting to put vague ideas or unclear thoughts of the patient into words to enhance the nurse’s understanding or asking the patient to explain what he means. For example, “I am not sure what you mean. Could you tell me about the again?”

Therapeutic Value: It helps to clarify feelings, ideas and perceptions of the patient and provides an explicit correlation between them and the patient’s actions.

• Reflection: Directing back the patient’s ideas, feelings, questions and content. For example, “You are feeling tense and anxious and it is related to a conversation you had with your husband last night”.

Therapeutic Value: Validates the nurse’s understanding of what the patient is saying and signifies empathy, interest and respect for the patient.

• Humor: The discharge of energy through comic enjoyment of the imperfect. For example, “That gives a whole new meaning to the word ‘nervous’”, said with shared kidding between the nurse and the patient.

Therapeutic Value: Can promote insight by making repressed material conscious, resolving paradoxes, tempering aggression and revealing new options, and is a socially acceptable for of sublimation.

• Informing: The skill of information giving. For example,” I think you need to know more about your medications.”

Therapeutic Value: Helpful in health teaching or patient education about relevant aspects of patient’s well-being and self-care.

• Focusing: Questions or statements that help the patient expand on a topic of importance. For example, “I think that we should talk more about your relationship with your father”.

Therapeutic Value: Allows the patient to discuss central issues and keeps the communication process goal-directed.

• Sharing Perceptions: Asking the patient to verify the nurses understanding of what the patient is thinking or feeling. For example, ”You are smiling, but I sense that you are really very angry with me”.

Therapeutic Value: Conveys the nurse understands to the patient and has the potential for clearing up confusing communication.

1. Theme Identification: This involves identification of underlying issues or problems experienced by the patient that emerge repeatedly during the course of the nurse-patient relationship. For example, “I noticed that you said, you have been hurt or rejected by the man. Do you think this is an underlying issue?”

Therapeutic Value: It allows the nurse to promote the patient’s exploration and understanding of important problems.

1. Silence: Lack of verbal communication for a therapeutic reason. For example, sitting with a patient and nonverbally communicating interest and involvement.

Therapeutic Value: Allows the patient time to think and gain insight, slows the pace of the interaction and encourages the patient to initiate conversation while enjoying the nurse’s support, understanding and acceptance.

1. Suggesting: Presentation of alternative ideas for the patient’s consideration relative to problem solving. For example, “Have you thought about responding to your boss in a different way when he raises that issue with you? You could ask him if a specific problem has occurred.”

Therapeutic Value: Increases the patient’s perceived notions or choices.

Ineffective/Non-therapeutic Communication

These include failure to listen, conflicting verbal or non-verbal messages, a judgmental attitude, false reassurance, giving of advice, the inability to receive information because of a preoccupation of impaired thought process and changing of the subject if one becomes uncomfortable with the topic being discussed.

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List of Psychiatry Nursing (Mental Health) Notes are given below. Click the respective Topic to Read the respective Nursing Procedures in detail

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DEFINITION

Nursing process is an orderly, systematic manner of determining the patient’s problems, making plans to solve them, initiating the plan or assigning others to implement it and evaluating the extent to which the plan was effective in resolving the problems identified.

The five steps in nursing process are as follows:

1. Assessment or gathering data
2. Diagnosis or identifying a problem
3. Planning or creating a plan to achieve desired outcomes
4. Implementation or enacting the plan
5. Evaluation or determining the effectiveness of the plan

NURSING ASSESSMENT

Assessment involves the collection, organization and analysis of information about the patient’s health. In psychiatric mental health nursing, this process is often referred to as a psychosocial assessment. The nurse obtains assessment data from several sources.

Components of Psychosocial Assessment

• Interview with the patient and his family
• History and physical examination
• Mental status examination
• Records from other healthcare facilities or prior treatment
• Laboratory and psychological tests
• Assessments by other professional and para-professionals

Clinical Interview

The interview allows the nurse to hear the patient’s perspective on the problem

• Conduct the interview in a quiet place, ensure privacy
• Be relaxed and maintain an unhurried posture
• Maintain eye contact with the patient
• Be interested and attentive to what he says
• Pick up verbal and non verbal cues of distress
• Allow the patient to talk freely without any interruption
• When the patient deviates from the theme or loses his tract, guide him to the main theme politely
• Use open-ended questions
• Use active listening
• Do not offer premature conclusions and assurance on the outcome of the treatment

History Taking

History taking proceeds through different headings as follows:

• Identification and demographical details
• Presenting complaints and duration
• History of present illness
• Past psychiatric history
• Family history
• Personal history
• Premorbid personality

Identification and Demographical Details

This includes the patient’s name, age, sex, religion, address, socioeconomic status, hospital number, marital status, occupation details of informant, and information relevant or not, adequate or not.

Presenting Complaints/Chief Complaints

Here symptoms are listed in a chronological order with their duration. Sometimes the patient may deny the existence of any symptoms and say that he was forcibly brought to the hospital by his relatives. In such cases, information is collected from his relatives. It is preferable to use the patient’s own words verbatim, without translating or interpreting their meaning. For example, sleeplessness – 3 weeks, loss of appetite and hearing voices – 2 weeks.

The mode of onset of the illness may be acute or insidious. The progress may be steady and progressive or diminishing and reappearing periodically or staying the same way throughout. These should also be enquired into. Sometimes the patient will be able to point out some antecedent stressful event alluded as precipitants. The temporal relation of the event with the illness, severity of the stress, the patient’s preoccupation with the events and the value attached to the event by him, may all give a clue to the presence and nature of the precipitant.

History of Present Illness

Under this are recorded the evolution of the patient’s symptoms from the time they were first noted till the time of consultation. Details of each symptom should be collected. The patient’s history may have to be supplemented with data available from other sources.

It is ideal to use the patient’s own words. Look for and also ask for any precipitating factors. An attempt should also be made to identify any possible secondary gain to the patient because of his symptoms.

Past Psychiatric History

Enquire whether the patient has any psychiatric illness in the past. If so its nature, duration, treatment and outcome should be noted down. If treatment was discontinued in the middle enquire the reason for this as well as the reason for switching over to other models of therapy.

Family History

Enquire about the type and size of family and the general family environment. The presence of psychiatric illness on the paternal or maternal side should be routinely asked. It would be useful to construct a family tree depicting the living members, their age, deceased members and their age at death. Mark whether any of them has or had a similar illness and if known the type of treatment they received and the outcome. Note specifically any history of suicide, mental retardation, epilepsy or any genetically transmittable disorders.

Personal History

The personal history includes the developmental, educational, occupational as well as the sexual history of the patient. Developmental history includes details of pregnancy and delivery, developmental milestones, health during childhood and adolescence, neurotic symptoms and occurrence of any significant event (for example, separation from parents, bereavements, etc are recorded).

The educational history relates to details regarding the level of performance in school, relationship with peers and teachers, academic achievements and extracurricular activities.

In occupational history, enquiry should be made about the types of work, job satisfaction, whether jobs were changed frequently and if so, the reasons for this, work skills and relationship with colleagues.

Sexual history includes details about sexual development, practices and attitudes towards sex. In marital history, enquire about married life and details about spouse and children.

Premorbid Personality

Personality of a patient consists of those habitual attitudes and patterns of behavior which characterize an individual. Personality sometimes changes after the onset of an illness. The nurse has to get a description of the personality before the onset of the illness and aim to build up a picture of the individual not a type. Enquiry with respect to the following areas has to be made.

• Attitude to others in social, family and sexual relationship: Ability to trust others, make and sustain relationship, anxious or secure, leader or follower, participation, responsibility, capacity to make decision, dominant or submissive, friendly or emotionally cold, etc. Difficulty in role taking- gender, sexual and familial.
• Attitude to self: Egocentric, selfish, indulgent, dramatizing, critical, depreciatory, over concerned, self-conscious, satisfaction or dissatisfaction with work. Attitude towards health and bodily functions. Attitude to past achievements and failure, and to the future.
• Moral and religious attitudes and standards: Evidence of rigidity or compliance, permissiveness or over conscientiousness, conformity, or rebellion. Enquire specifically about religious beliefs. Excessive religiosity
• Mood: Enquire about stability of mood, mood swings, whether anxious, irritable, worrying or tense. Whether lively or gloomy. Ability to express and control feelings of anger, anxiety or depression.
• Leisure activities and hobbies: Interest in reading, playing, music, movies, etc., Enquire about creative ability. Whether leisure time is spent alone or with friends. Is the circle of friends large or small?
• Fantasy life: Enquire about content of day dreams and dreams, amount of time spent in day dreaming
• Reaction pattern to stress: ability to tolerate frustrations, losses, disappointments, and circumstances arousing anger, anxiety or depression. Evidence for the excessive use of particular defense mechanisms, such as denial, rationalization, projection, etc.,

Mental Status Examination

The mental status examination (MSE) is used to determine whether a patient is experiencing abnormalities in thinking and reasoning ability, feelings or behavior. The MSE includes observations and questions in the following categories:

• General appearance and behavior
• Speech
• Thought
• Mood and affect
• Perception
• Cognitive functions

General Appearance and Behavior

Describe patient’s appearance and behavior. Is he dressed properly? Assess the patient’s sensorium. Is he alert? Drowsy? Stuporous? Comatose? Is he cooperative for the examination? Does he make eye contact with the examiner? What is his level of activity? Is he excited? Retarded? Hyperactive? Restless?  Does he have any mannerisms? Gestures? Tics? Involuntary movements?

Speech

The manner of speaking and its defects are recorded under speech, whereas the content and form of speech are recorded under thought disorders. Does he speak spontaneously or only responding to questions posed to him? Assess the rate, quantity and flow of speech. It is worthwhile to record a sample of speech for later analysis.

Thought

Inference about the thought process and its disorders are made from the speech sample or the writing sample of the patient. Disorders of form, progression, content and possession may be present. Does the patient have delusions, obsessive ruminations and thought alienation? How does the delusion affect his behavior?

Mood and Affect

The patient should be asked about his affective state. Compare the subjective report with what is objectively observed. Is his mood appropriate or not? Congruent or incongruent? Labile? Is the emotional expression blunt? Is the emotional expression blunt? Is the affective expression adequate and appropriate?

Perception

Has the patient any perceptual abnormalities like illusions and hallucinations? If hallucinating, what is the type of hallucination and what is his reaction?

Cognitive Function

Is the patient attentive? Can his attention be easily aroused and sustained? How is his concentration? To assess cognitive function some simple tests can be administered. The patient is asked to name the days of the week or names of the months forwards and backwards. He may be asked to serially subtract 7 or 3 from 100 and tell the numbers.

Is the patient oriented to time, place and other persons? Orientation to time involves ability to tell correctly the time of the day, date, week, month, year and other related data. Orientation to a place includes correct information of his whereabouts, how he came to be there and other details. Correct identification of people around him ensures orientation to other persons.

Patient’s intelligence can be inferred from his conversation and behavior, educational level vocabulary, ability for abstract thinking and reasoning, general information, etc., Specific tests are used when a more accurate measurement of intelligence is needed. The patient’s awareness of his disabilities and readiness for treatment are reflected in insight. Judgment may be inferred from his plans for the future.

Physical Examination

A thorough physical examination should be carried out in all cases. The physical examination should include body system review, neurological status and laboratory tests.

Particular attention is paid to recent head trauma, episodes of hypertension, and changes in personality, speech, or ability to handle activities of daily living. Also note for any movement disorders. Available laboratory data are reviewed for any abnormalities and documented. Particular attention is paid to any abnormalities of hepatic or renal function because these systems metabolize or excrete many psychiatric medications. In addition, abnormal white blood cell and electrolyte levels should be noted.

Psychological Tests

Psychological tests are another source of data for the nurse to use in planning care for the patient. Commonly used psychological tests are instruments for assessing symptoms.

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Nursing diagnosis is defined as clinical judgments about individual, family or community responses to actual and potential health problems. Nursing diagnoses are used to describe nursing interventions, and to delineate the parameters for developing outcome criteria.

A nursing diagnosis statement consists of the problem of patient response and one or more related factors that influence or contributes to the patient’s problem or response; signs and symptoms or deficiency characteristics or subjective and objective assessment data that support the nursing diagnosis.

The basic level psychiatric nurse identifies nursing problems by using the nomenclature specified by the North American Nursing Diagnoses Association (NANDA).

A nursing diagnosis describes an existing or high-risk problem and requires a three-part statement.

1. The health problem (Problem, ‘P’)
2. The etiological or contributing factors (Etiology, ‘E’)
3. The defining characteristics (Signs and symptoms, ‘S’)

For example:

• High-risk for self-directed violence related to depressed mood, feeling of worthlessness, anger turned inward on the self
• Powerlessness related to dysfunctional grieving  process, lifestyle of helplessness, evidenced by feelings of lack of control over life situations, over dependence on others to fulfill needs.

Planning

Planning involves setting and prioritizing goals, formulating nursing interventions and developing a care plan in conjunction with the patient based on the nursing diagnoses chosen.

• Specific patient needs
• Consideration of the patient’s strengths and weaknesses
• Encouragement of the patient to help set achievable goals and participate in his own care
• Feasible interventions

Nursing interventions with rationale are selected in the planning phase based on the patient’s identified risk-factors and defining characteristics. The process of planning includes:

• Collaboration by the nurse with patients, significant others, and treatment team members
• Identification of priorities of care
• Critical decisions regarding the use of psycho therapeutic principles and practices (identify the most appropriate nursing intervention)
• Coordination and delegation of responsibilities

In this, the nurse will choose nursing interventions appropriate to an individual’s identified problem with specific expected outcomes.

Once the nursing diagnoses are identified, the next step is the prioritization of the problems in order of importance. Highest priority is given to those problems that is life threatening. Next in the priority are those issues that are related to normative or developmental experiences. Psychiatric nurses often use Maslow’s hierarchy of needs to prioritize nursing diagnosis.

Outcome Identification

Outcomes can be defined as a patient’s response to the care received. Outcomes are the end result of the process. Measuring outcomes not only demonstrates clinical effectiveness, but also helps to promote rational clinical decision making on the part of the nurse. Each outcome must follow certain criteria.

• Relate directly to the nursing diagnosis
• Be measurable, time limited, and realistic
• Be stated as a desired patient outcome of nursing care
• Reflect the desires of the patient and his family
• Be stated in a way that the patient and his family can understand

Diagnosis: Impaired social interaction (isolates self from others)

Outcome: Patient will attend group sessions everyday

Intervention: Using a contract format explain the role and responsibility of patients

Correct and Incorrect Outcome Statements

Nursing Diagnosis – Anxiety

Correct Outcome- Verbalizes feeling, calm, relaxed, with absence of muscle tension and diaphoresis; practices deep breathing

Incorrect Outcome- Exhibits decreased anxiety, engages in stress reduction

Nursing Diagnosis- Ineffective Coping

Correct Outcome- Makes own decisions to attend groups; seeks staff for interaction

Incorrect Outcome- Demonstrates effective coping abilities

Implementation

In the implementation phase nurse sets interventions prescribed in the planning phase.

Nursing interventions (also known as nursing orders or nursing prescriptions) are the most powerful pieces of the nursing process. Interventions are selected to achieve patient outcome and to prevent or reduce problems. Implementation serves as a blueprint of plan.

Nursing interventions are classified as independent, interdependent and dependent.

Nursing Intervention in Psychiatric Nursing

Interventions for biological dimension:

• Self-care activities
• Activity and exercise
• Nutritional interventions
• Hydration interventions
• Thermoregulation intervention
• Pain management
• Medication management

Interventions for Psychological Dimension:

• Counseling interventions
• Conflict resolutions
• Bibliotherapy
• Reminiscence therapy
• Relaxation interventions
• Behavior therapy
• Cognitive therapy
• Psychoeducation
• Spiritual interventions

Interventions for social dimensions:

• Group interventions
• Family intervention
• Milieu therapy

Evaluation

Evaluation is the process of determining the value of an intervention. Nurses determine the effectiveness of interventions with particular patients. Nurses evaluate selected interventions by judging the patient’s progress towards the outcome set down in the nursing care plan.

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Psychological testing of patients is ideally conducted by a clinical psychologist who has been trained in the administration, scoring and interpretation of these procedures.

Instruments for Assessment of Symptoms

• Brief psychiatric rating scale
• Psychiatric symptom checklist
• Clinical global impression
• Anxiety self-rating scale
• Hamilton anxiety scale
• Beck’s anxiety scale
• Beck’s depression scale
• Hamilton depression scale
• Maniac state rating scale
• Yale brown obsessive compulsive scale
• Suicide intent scale
• Nurses observation scale for inpatient evaluation (NOSIE)
• Positive and negative symptom scale (PANSS) for schizophrenia
• Extrapyramidal symptom rating scale
• Global assessment of functioning (GAF) scale
• Insight and treatment attitude questionnaire (ITAQ)
• The CAGE questionnaire
• Mini mental status examination (MMSE)
• Child behavior checklist (CBCL)

Instruments for Assessment of Personality Traits and Disorders

• Minnesota multiphasic personality inventory
• Cattel’s 16 factor personality inventory
• Eysenck personality inventory

Instruments for Assessment of Cognitive Functioning

• Wechsler adult intelligence scale (WAIS)
• Wechsler intelligence scale for children
• Binetkamatch rest of intelligence
• Bhatia battery test of intelligence
• NIMHANS neuropsychological battery of lobe dysfunction.

Instruments for Assessment of Psychodynamics

• Rorschach inkblot test
• Thematic apperception test

Instruments for Assessment of Environmental Stressors

• Social adjustment scale
• Marital satisfaction inventory

Role of a Nurse in Psychological Assessment

Psychological tests have been designed to help clinicians. They help in:

• Measuring the extent of the patient’s problems
• Making an accurate diagnosis
• Tracking patient progress over time
• Documenting the efficacy of treatment

Nurses should become familiar with the many standardized psychological tests that are available to enhance each stage of the nursing process. These tests help in providing care and measurable indicators for treatment outcome. For example, if the nurse is caring for a patient with depression. It would be helpful to use one of the depression rating scales with the patient at the beginning of care/treatment to establish a baseline profile of the patient’s symptoms and help confirm the diagnosis. The nurse might open administer the same scale at various times during the course of treatment to measure the patient’s progress.

A nurse should have knowledge about all the psychological tests, which will enable her to clarify the patient’s and relative’s doubts regarding the psychological tests they have to undergo.

The nurse should reassure the patient about the safety of the tests and confidentiality of the observations of the psychologist. Psychological tests are another source of data for the nurse to use in planning care for the patient.

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Nursing focuses on the individual’s response to potential or actual health problems. Under the nursing model, human behavior is viewed from a holistic perspective.

Nursing View of Behavioral Deviations

• Behavior is viewed on a continuum from healthy adaptive responses to maladaptive responses that indicate illness.
• Each individual is predisposed to respond to life events in unique ways. These predispositions are biological, psychological, socio cultural, and the sum of the person’s heritage and past experiences.
• Behavior is the result of combining the predisposing factors with precipitating stressors. Stressors are life events that the individual perceives as challenging, threatening or demanding. The nature of the behavioral response depends on the person’s primary appraisal of the stressor and his secondary appraisal of the coping resources available to him.
• A stressor that has primary impact on physiological functioning also affects the person’s psychological and socio-cultural behavior. For instance, a man who has a myocardial infarction may also become severely depressed, because he fears he will lose his ability to work. On the other hand, the patient who enters the psychiatric inpatient unit with major depression may be suffering from malnutrition and dehydration because of his refusal to eat or drink. The holistic nature of nursing encompasses all of these facets of behavior and incorporated them into patient care planning.

Nursing Process

Nursing intervention may take place at any point on the continuum. Nursing diagnosis may focus on behavior associated with a medical diagnosis or other health behavior that the patient wishes to change.

A nurse may practice primary prevention by intervening in a potential health problem, secondary prevention by intervening in an actual acute health problem or tertiary prevention by intervening to limit the disability caused by actual chronic health problem. The nursing assessment of the patient includes presenting complaints, past history, family history, personal history, occupational history, sexual history, physical examination and mental status examination. Additional data may be collected for significant others and by reviewing the systems. A nursing diagnosis is then formulated and based on this diagnosis; planning and interventions are carried out. Finally, evaluation will be done to find out the effectiveness of nursing interventions.

Providing nursing care is a collaborative effort, with both the nurse and the patient contributing ideas and energy to the therapeutic process.

Summary of Selected Nursing Theories

Peplau’s Theory

Peplau proposed an interpersonal theory applicable to nursing practice in general and to psychiatric-mental health nursing in particular. It focuses primarily on the nurse-patient relationship. Peplau’s theory describes, explains, predicts and to some extent, permits control of the sequence of events occurring in the nurse-patient relationship.

Peplau describes the interpersonal aspects of nursing as a process consisting of four phases. These are orientation, identification, exploitation and resolution phases.

While working with the patient through these phases, the nurse assumes six roles: resource person, technical expert, teacher, leader, surrogate parent and a counselor.

Peplau’s theory continues to apply to today’s nursing scene, especially with respect to long-term psychiatric care in outpatient and home health settings.

Orem’s Theory

Dorothea E Orem’s theory is based on the premise that people need a composite of self-care actions to survive. Self-care actions consist of all behaviors performed by people to maintain life and health. The capacity of the patient and the patient’s family to perform self-care is called self-care agency. Orem states that a need for nursing care exists if the patient’s self –care demand exceeds the patient’s self-care agency. Thus, the goal of nursing is to meet the patient’s self-care demands until the patient and his family are able to do so.

Orem’s theory describes three types of self-care:

• Universal self-care behaviors, required to meet physiological and psychosocial needs.
• Developmental self-care behaviors, required to undergo normal human development.
• Health deviation self-care behaviors, required to meet patient’s needs during health deviations.

The classification of self-care behaviors in this manner helps to ensure complete assessment of the patient’s self-care agency.

Assessment focuses on the patient’s self-care demand, self-care agency and self-care deficits. A plan is formulated from the information obtained in the assessment that indicates the nursing approach needed to meet the patient’s needs. It can be categorized as follows:

• Wholly compensatory, in which the patient does not participate behaviorally in self- care.
• Partially compensatory, in which the patient and nurse participate behaviorally in meeting the patient’s self-care needs.
• Educative-developmental, in which the patient meets self-care needs with minimal nursing assistance.

To implement the required nursing approach, the nurse uses one of the five behaviors: acting or doing for the patient, guiding, supporting, providing and teaching.

Roger’s Theory

Roger’s model focuses on the individual as a unified whole in constant interaction with the environment. The unitary person is viewed as an energy field that is more than as well as different from the sum of the biological, physical, social and psychological parts. In Roger’s model, nursing is concerned with the unitary person as a synergistic phenomenon.

Nursing science is devoted to the study of nature and direction of unitary human development. Nursing practice helps individuals achieve maximum well-being within their potential.

Roy’s Theory

According to Callista Roy’s theory, the goal of nursing is to promote the patient’s adaptation in health and illness. This goal is achieved through the nurse’s efforts to change, manipulate or block stress-producing stimuli that may impinge on the patient. The theory assumes that this kind of nursing intervention assists the patient to cope more effectively through reducing stress.

Roy’s theory assumes that all human beings have adaptive systems and change in response to stimuli. If the change does not promote the person’s integrity then the change can be considered maladaptive.

The nursing process used in Roy’s theory involves two levels of assessment. The first level includes observation of behavior related to the four adaptive modes: Physiologic, self-concept, role function and interdependence. These four modes represent methods used by the patient to adapt. The second level of assessment consists of identifying focal, contextual and residual stimuli. The focal stimulus represents the immediate dominant stimulus affecting the patient, such as injury, stress or illness. Contextual stimuli include the environment, the patient’s family and all other background factors related to the focal stimulus. Residual stimuli consist of the patient’s previous background, beliefs, attitudes and traits.

According to Roy’s theory, a person’s adaptation level is a function of focal, contextual and residual stimuli. When a person encounters stresses form these stimuli that surpassinnate and acquired mechanisms to cope effectively, the person behaves ineffectively as demonstrated by one or more of the adaptive modes. At this point, nursing intervention is required. This emphasizes on the patient’s behavior, stimuli determining the patient’s behavior, stimuli determining the patient’s behavior, and the nurse intervening in some way to interfere with the stimuli.

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Investigations are useful to detect alteration in biologic function and to screen for medical disorders causing psychiatric symptoms.

Routine Investigations

• A complete hemogram (total and differential blood count, hemoglobin, ESR) and urinalysis are the basic routine tests. Leucopenia and agranulocytosis are associated with certain medications (Clozapine). Treatment with lithium and neuroleptic malignant syndrome are often associated with leukocytosis.
• Renal function tests: Treatment with lithium
• Liver function tests: For all alcoholic patients treatment with carbamazepine, valproate and benzodiazepines
• Serum electrolytes: Dehydration, treatment with carbamazepine,  antipsychotics, lithium
• Blood glucose: Routine screen above 35 years age
• Thyroid function test: Depression, treatment with lithium and carbamazepine
• Electrocardiogram (ECG): Above 35 years of age, treatment with lithium, antidepressants, ECT, antipsychotics
• HIV testing: IV drug users suggestive sexual history, AIDS, dementia
• VDRL: Suggestive sexual history
• Serum CPK: Neuroleptic malignant syndrome (markedly increased levels)
• Chest X-ray: Before treatment with ECT
• Drug level estimation: Drug levels are indicated to test for therapeutic blood levels, for toxic blood levels and for testing drug compliance. Examples are lithium (0.6 – 1.6 mEq/L), carbamazepine (6-12 mg/mL), valproate (50-100 mg/mL), haloperidol (8-18 ng/mL), tricyclic antidepressants (Imipramine 200-250 ng/mL, nortriptyline 50-150 ng/mL), benzodiazepines, barbiturates.

Electrophysiological Tests

Electroencephalogram (EEG): Measures brain electrical activity, identifies dysrhythmias and asymmetries, used in the diagnosis of seizures, dementia, neoplasm, stroke, metabolic or degenerative disease.

        Polysomnography/sleep studies: Used in the diagnosis of sleep disorders and seizures.

Brain Imaging Tests (Cranial)

• Computed tomography (CT) scan: Measures accuracy of brain structure to detect possible lesions, abscesses, areas of infarction or aneurysm. CT scan also identifies various anatomic differences in patients with schizophrenia, organic mental disorder and bipolar disorder.
• Magnetic resonance imaging (MRI) scan: Measures the anatomic and biochemical status of various segments of the brain; detects brain edema, ischemia, infection, neoplasm, trauma and other changes such as demyelination used in the diagnosis of dementia, to detect morphological changes in schizophrenia patients.
• Other tests are positron emission tomography (PET).

Neuroendocrine Tests

Commonly used neuroendocrine tests are dexamethasone suppression test, TRH stimulation test, serum prolactin levels, serum 17-hydroxycorticosteriod, serum melatonin levels.

Genetic tests

Cytogenetic work-up is advised in some cases of mental retardation.

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The holistic view of the patient, with the body and soul seen as inseparable, and the patient viewed as a member of a family and community was central to Nightingale’s view of nursing. The primary goal of nursing is to help patients develop strategies to achieve harmony within themselves and with others, nature and the world. Integrative functioning of the patient is physical, emotional, intellectual, social and spiritual dimensions are emphasized. Each person is considered as a whole, with many factors contributing to health and illness.

Major Concepts

Five major concepts are generally accepted as premises of holistic health care philosophy:

• First, each person is multidimensional; one’s physical, emotional, intellectual, social and spiritual dimensions are in constant interaction with each other:
• The physical dimension involves everything associated with one’s body, both internal and external.
• The emotional dimension consists of affective states and feelings, including motor behavior associated with emotion, the experienced aspect of emotion, and the physiological mechanisms that underlie emotion
• The intellectual dimension includes receptive functions, memory and learning, cognition and expressive functions.
• The social dimension is based on social intersection and relationships, more so the global concept of culture.
• The spiritual dimension is that aspect of a person from which meaning in life is determined; through which transcendence over the ordinary is possible.
• The second premise of holistic care philosophy is that the environment makes significant contributions to the nature of one’s existence. Each person’s environment consists of many factors that are influential in that person’s quality of life. Consequently, people cannot be fully understood without consideration of environmental factors such as family relationships, culture, and physical surroundings.  Individuals interact with their unique environments through all dimensions, based on subjective experience as well as external stimuli.
• The third premise is that each person experiences development across his life cycle; in each stage of life, the individual experiences and confronts different issues or similar issues in different ways. One’s experience of each stage of life, forms the basis for further development as one moves through the life cycle.
• Fourth, the holistic healthcare model maintains that stress is a primary factor in health and illness. Any event or circumstance can act as a stressor. Regardless of the source, stress has an impact on the whole person. Examples of stressors directly affecting the physical dimension include stressors associated with genetic factors, physiological processes, and body image. Emotional stress may result from any experience or situation. Examples include poor physical conditions, perceived social inequities, a significant loss, intellectual incompetence, and a sense of meaninglessness. Stressors affecting the intellectual dimension may include factors that interfere with receptive functions, memory and learning, cognitive functions, and expressive functions. Social stressors may arise from interactions and relationships with other people, as well as from more general societal and cultural factors. Stressors affecting the spiritual dimension include all such factors that interfere with one’s ability to meet spiritual needs.
• Fifth, people are ultimately responsible for the directions their lives take and the lifestyles they choose. Within a holistic framework, people are viewed as active participants in and contributors to their health status; they are willing to learn from illness and strive towards healthier choices.

Recognizing all human dimensions encourages a balanced and whole view of a person. Each facet of an individual is important and contributes to the quality of life experience. All dimensions are intricately interwoven, and the person as a whole functioning organism is more than the simple combination of dimensions. The holistic model emphasizes that all the dimensions of the individual should be considered when planning and instituting care.

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