Psychiatric & Mental Health Nursing

Psychiatric & Mental Health Nursing

Psychiatric-mental health nursing is a core component of the DHA Registered Nurse licensing assessment, testing the nurse's ability to provide safe, therapeutic, and evidence-based care to clients experiencing acute and chronic psychiatric disorders. This section focuses on anxiety, depressive disorders, schizophrenia, and the clinical application of therapeutic communication.

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Therapeutic Communication in Nursing Practice

Therapeutic communication is a foundational skill in psychiatric nursing. It is a goal-directed process that helps build trust, promote client self-disclosure, and facilitate positive behavioral change. The DHA exam frequently requires candidates to identify the most therapeutic response in a given clinical scenario.

Core Techniques of Therapeutic Communication

• Active Listening: Demonstrating attentiveness using non-verbal cues (e.g., eye contact, nodding, and open posture).
• Open-Ended Questions: Encouraging the client to express thoughts and feelings without limiting their response (e.g., "What is on your mind today?").
• Reflection: Directing back the client's feelings or ideas so they can explore them further (e.g., "It sounds like you are feeling overwhelmed by your diagnosis.").
• Paraphrasing/Restating: Repeating the main idea of what the client said in different words to verify understanding and show active engagement.
• Offering Self: Making oneself available to show interest and support (e.g., "I will sit here with you for a while.").
• Presenting Reality: Describing what is real without arguing or challenging the client's perception (e.g., "I know you hear voices, but I do not hear anyone speaking.").

Non-Therapeutic Communication Traps

Non-therapeutic techniques block communication, cause defensiveness, and damage the nurse-client relationship. The following communication traps should be avoided:

• Asking "Why" Questions: Demands an explanation, making the client feel accused or defensive (e.g., "Why did you stop taking your medication?").
• Giving Advice: Implies the nurse knows best and takes away the client's decision-making power (e.g., "If I were you, I would take the medicine.").
• False Reassurance: Minimizing the client's feelings and offering empty promises (e.g., "Don't worry, everything will be fine.").
• Defending: Protecting a person or institution from criticism, which invalidates the client's concerns.
• Changing the Subject: Directing the conversation away from a difficult topic because of the nurse's own discomfort.

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Anxiety Disorders and Levels of Anxiety

Anxiety is a subjective state of apprehension, tension, or dread resulting from real or perceived threats. The nurse must recognize the level of anxiety a client is experiencing to implement the correct clinical interventions.

The Four Levels of Anxiety

1. Mild Anxiety: Broad perceptual field. Enhanced learning and problem-solving. Sharpens focus and increases motivation. Restlessness, irritability, or mild butterflies in the stomach may be present. Nursing Intervention: Provide information, encourage problem-solving, and allow verbalization.
2. Moderate Anxiety: Narrowed perceptual field. The client can focus on central concerns but misses details unless redirected. Physical symptoms include muscle tension, increased heart rate/respirations, perspiration, and shakiness. Nursing Intervention: Use short, simple sentences, validate feelings, and redirect the client to a calm activity.
3. Severe Anxiety: Perceptual field is greatly reduced. The client focuses only on one specific detail and cannot learn or problem-solve. Somatic complaints like headache, nausea, hyperventilation, tachycardia, and a sense of dread are common. Nursing Intervention: Stay with the client. Do not leave them alone. Speak in a calm, low-pitched voice. Give clear, one-step directions. Decrease environmental stimuli.
4. Panic Anxiety: Disorganized behavior. Loss of touch with reality (hallucinations/delusions may occur). Terror, dilated pupils, severe trembling, chest pain, palpitations, immobility or hyperactivity. Nursing Intervention: Ensure safety. Speak in short, simple phrases. Place the client in a quiet, low-stimulus environment. Maintain the physical safety of the client and others.

Obsessive-Compulsive Disorder (OCD)

OCD is characterized by obsessions (persistent, intrusive thoughts) and compulsions (repetitive behaviors performed to reduce anxiety).

• Nursing Consideration: In the acute phase, allow the client to perform their ritualistic behavior, as stopping it will cause panic-level anxiety. Gradually, help the client set limits on the rituals and teach alternative coping mechanisms.

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Depressive Disorders & Suicide Risk Assessment

Major Depressive Disorder (MDD) is characterized by a persistent depressed mood, loss of interest in activities (anhedonia), changes in sleep and appetite, psychomotor agitation or retardation, fatigue, feelings of worthlessness, and suicidal ideation.

Suicide Risk Assessment & Safety Interventions

The nurse must prioritize patient safety by performing a direct suicide risk assessment whenever depression is suspected:

1. Ask Directly: Use clear, unambiguous language (e.g., "Are you having thoughts of suicide?" or "Do you have a plan to end your life?").
2. Evaluate the Plan: Assess the lethality of the method, availability of means, and specificity of the plan. Higher lethality (e.g., firearms, hanging) indicates higher risk.
3. Safety Precautions:
   • Initiate one-to-one (1:1) constant observation (within arm's reach at all times) for high-risk clients.
   • Search the client's room and belongings; remove all hazardous objects (e.g., belts, shoelaces, glass, plastic bags, razors, medications).
   • Ensure the client swallows all medications ("cheeking" checks) to prevent hoarding.

Pharmacological Care and Safety

• Selective Serotonin Reuptake Inhibitors (SSRIs): (e.g., Fluoxetine, Sertraline, Escitalopram) are first-line antidepressants.
  • Lag Time: Educate the client that SSRIs take 2 to 4 weeks to produce a therapeutic effect.
  • Suicide Risk Warning: As antidepressants begin to take effect, the client's physical energy improves before their mood does. This gives them the energy to carry out suicide. Monitor closely for sudden improvements in mood or energy.
• Tricyclic Antidepressants (TCAs): (e.g., Amitriptyline, Imipramine) are associated with anticholinergic side effects (dry mouth, blurred vision, urinary retention, constipation) and are highly cardiotoxic in overdose (causing lethal arrhythmias).

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Schizophrenia & Psychotic Disorders

Schizophrenia is a chronic brain disorder characterized by disturbances in thought, perception, affect, and behavior. Symptoms are divided into positive and negative categories.

Positive vs. Negative Symptoms

• Positive Symptoms (Exaggeration of normal function): Hallucinations (perceptions without external stimuli, most commonly auditory), delusions (fixed, false beliefs), disorganized speech (e.g., loose associations, word salad), and bizarre behavior.
• Negative Symptoms (Deficit of normal function): Flat or blunted affect, avolition (lack of motivation), anhedonia (inability to experience pleasure), alogia (poverty of speech), and social withdrawal.

Nursing Interventions for Acute Psychosis

When caring for a client experiencing hallucinations or delusions, the nurse must maintain a therapeutic and safe environment:

• Do NOT argue or challenge: Do not try to prove a delusion wrong or debate the logic of a hallucination. This increases anxiety and breaks trust.
• Acknowledge and Validate Feelings, State Reality: Focus on the emotion the client is feeling and gently present reality (e.g., "I understand you hear a voice warning you, but I do not hear any voice. You are safe here.").
• Do NOT reinforce hallucinations: Avoid statements like "What is the voice saying to you?" as if the voice is real. Instead, ask, "What are you experiencing right now?"
• Assess for Command Hallucinations: Determine if the voices are instructing the client to harm themselves or others. This is a psychiatric emergency requiring immediate safety measures.

Antipsychotic Medications & Side Effects

Antipsychotics (neuroleptics) are used to manage positive symptoms but carry significant side-effects:

• Extrapyramidal Symptoms (EPS): Primarily caused by first-generation antipsychotics (e.g., Haloperidol, Chlorpromazine):
  • Acute Dystonia: Severe muscle spasms of the tongue, face, neck, or back. (Emergency treatment: IV or IM Benztropine or Diphenhydramine).
  • Akathisia: Intense motor restlessness (inability to sit still).
  • Pseudoparkinsonism: Bradykinesia, tremors, shuffling gait, drooling.
  • Tardive Dyskinesia (TD): Involuntary movements of the tongue, face, and jaw (e.g., lip-smacking, tongue protrusion). Can be irreversible. Standard screening is the AIMS scale.
• Neuroleptic Malignant Syndrome (NMS): A rare, life-threatening reaction to antipsychotics.
  • Clinical Manifestations: High fever (hyperthermia), lead-pipe muscle rigidity, autonomic instability (tachycardia, labile blood pressure, tachypnea, diaphoresis), and altered mental status.
  • Nursing Interventions: Discontinue the antipsychotic immediately, initiate cooling measures, administer IV fluids, and notify the physician. Medications like dantrolene or bromocriptine may be prescribed.