NCLEX-RN: Psychiatric Nursing

Psychiatric Nursing: Behavior Modification

Focus topic: Psychiatric Nursing

Definition: Behavior modification is a process for dealing with problematic, maladaptive human behavior through planned, systematic interventions. It is a threestage process involving behavior assessment, intervention, and evaluation.

A. Behavior modification assumes that maladaptive behaviors have been learned or acquired through life’s experiences.
B. The process draws on learning theory as an approach to the modification of behavior.

  •  It involves stimulus–response type learning.
  • Techniques are drawn from Pavlov, Skinner, or stimulus–response theory.
  •  It has been labeled behavior conditioning; the older term was operant conditioning.
  •  It assumes that learned behavior is specifically connected with environmental reinforcers (e.g., U.S. eating patterns).
  •  The appropriate location for behavioral intervention and change is the individual’s environment.

C. Behavior cannot be thoroughly understood independent of events that precede or follow it.
D. The concept of contingency relationships is basic.

  •  Relationships occur between behavior and reinforcing events.
  •  Positive reinforcer is a desirable reward produced by a specific behavior; for example, salary is contingent on work: no work, no salary.
  •  Negative reinforcer is a negative consequence of behavior; for example, a mother spanks a child for playing with matches.
  • Removal of a positive reinforcer; for example, a student is not allowed to watch TV until his or her homework is finished.
  •  Removal of a negative reinforcer; for example, a mother threatens a child until the child cleans up his room. Removal produces avoidance behaviors.
  •  Principle of extinction.
    a. Reduces the frequency of a behavior by disrupting its contingency with the reinforcement.
    b. Arranges conditions so that the reinforcing event, which has been maintaining the behavior, no longer occurs.

E. Goal is to arrange and manage reinforcement contingencies so that desired behaviors are increased in frequency and undesirable behaviors are decreased in frequency or removed.
F. Specific terminology.

  •  Behavior problem: condemned, excessive, or deficient behavior.
  •  Operant behavior: voluntary activities that are strongly influenced by events that follow them.
  •  Reinforcer: a reward that positively or negatively influences and strengthens desired behavior.
    a. A primary reinforcer is inborn.
    b. An acquired reinforcer is not inborn.
  •  Stimulus: any event impinging on, or affecting, an individual.
  •  Accelerating behavior: increase in frequency of a desired behavior.
  •  Decelerating behavior: decrease in frequency of an undesirable behavior.
  • Target behavior: particular activities that the nurse wants to accelerate.

Principles of Implementation
A. The nurse can be the major treatment agent because he or she has the most significant number of contacts with the client and his or her environment.
B. The nurse may be in charge of designing and implementing the program.
C. The nurse may be in charge of supervising a program that another staff member is putting into effect.
D. Proximity to the client enables the nurse to identify any specifically maladaptive behavior.

Psychiatric Nursing

Psychiatric Nursing: Domestic Violence

Focus topic: Psychiatric Nursing

Definition: In a domestic or family setting, the abuser becomes destructive and abusive; threatens or attacks the victim.

A. The abuser (the majority are males) makes demands and threats against the victim who attempts to appease the abuser.
B. The abuser loses control and hurts the victim and then tries to make up for this behavior by becoming loving and apologetic (cycle of violence).
C. Most often other family members or outsiders do not know what is happening inside the family.
D. Often the victim hides the abuse and will not seek help from their family or the outside.
E. Abusers evidence certain characteristics similar to sociopathic personalities.

  • Poor self-esteem.
  •  Suspicious and dependent.
  •  History of sexual abuse or violent abuse during childhood.

F. Victims also have low self-esteem, are dependent and often depressed; they feel helpless and without power to change the situation.

A. Recognize and assess for abuse in the victim (bruises, cuts, broken bones, etc.).
B. Assess the family situation.
C. Report suspected cases of domestic abuse.

A. Assure privacy for the victim during examination; remind victim that information is confidential to allay fears.
B. If indicated, report to appropriate agency as a mandatory reporter.
C. Establish a nurse–client relationship to provide climate for the victim to feel safe in discussing family situation.
D. Encourage therapy for both victim and abuser; suggest group therapy, family counseling, and support groups.
E. Suggest therapy for the victim that focuses on building self-esteem, self-protective abilities, and problem-solving ability.

Psychiatric Nursing: Crisis Intervention

Focus topic: Psychiatric Nursing

Definition: Crisis intervention is a form of therapy aimed at immediate intervention in an acute episode or crisis in which the individual is unable to cope alone.

Crisis Situation
A. An individual is typically in a state of equilibrium or homeostatic balance.
B. This state is maintained by behavioral patterns involving interchange between the person and his or her environment.
C. When problems arise, the individual uses learned coping mechanisms to deal with them.
D. When a problem becomes too great to be handled by previously learned coping techniques, a crisis situation develops.

  •  Result is major disorganization in functioning.
  •  In circumstances of inability to resolve crisis, the individual is more amenable to intervention, and the potential for growth increases.

E. Precipitant factors in a crisis.

  • Threat to individual security, which may be loss or threat of loss.
    a. Situational crisis: actual or potential loss (job, friend, mate, etc.).

b. Developmental or maturational crisis: any change (e.g., marriage, new baby).
c. Adventitious crisis: crisis of disaster.
d. Two or more severe problems arising concurrently.

  • Precipitants typically occur within 2 weeks of onset of disorganization.

Stages of Crisis Development
A. Initial perception of problem occurs first.
B. Tension and anxiety rises; usual coping mechanisms are tried.
C. Usual situational supports are consulted.
D. Known methods prove unsuccessful and tension increases.
E. If new problem-solving methods are unsuccessful, the problem remains and cannot be avoided.

  •  Person’s functioning becomes disorganized.
  • Extreme anxiety is likely to be experienced.
  •  Perception is narrowed.
  •  Coping ability is further reduced.

F. Resolution usually occurs within 6 weeks with or without intervention.

A. Crisis is self-limiting, acute, and lasts 1–6 weeks.
B. Crisis is initiated by a triggering event (death, loss, etc.); usual coping mechanisms are inadequate for the situation.
C. Situation is dangerous to the person; he or she may harm self or others.
D. Individual will return to a state that is better, worse, or the same as before the crisis; therefore, intervention by the therapist is important.
E. Person is totally involved—hurts all over.
F. At this time the individual is most open for intervention; therefore, major changes can take place and the crisis can be the turning point for the person.

A. Examine period of disorganization.

  •  Assess degree of disorganization.
  •  Assess length of time situation has existed.
  •  Determine level of functioning.

B. Determine precipitant event.

  • Determine problem that triggered crisis.
  •  Evaluate significance of the event to the individual.

C. Assess past coping mechanisms.

  •  Check history of occurrence of similar situations in past.
  •  Assess past history of coping with similar situations.

D. Evaluate situational supports.

  • Ask about significant others in individual’s life.
  •  Check available agencies and resources.

E. Determine alternative coping mechanisms.

  • Assess new coping alternatives.
  •  Assess uses of situational supports.

A. Focus on immediate problem.
B. Use reality-oriented approach.
C. Stay with “here and now” focus.
D. Set limits.
E. Stay with client or have significant persons available if necessary.
F. Explore available coping mechanisms.

  •  Develop strengths and capitalize on them.
  • Do not focus on weakness or pathology.
  •  Help explore the available situational supports.

G. Clarify the problem and help the individual understand the problem and integrate the events in his life.
H. When the above steps are completed, some plans for future support should be established between nurse or crisis worker/therapist and the client.

Psychiatric Nursing: Rape Trauma Syndrome

Focus topic: Psychiatric Nursing

Definition: Rape is a non consensual sexual assault on a person (vast majority of victims are female and most perpetrators are male) that is basically an act of violence; only secondarily considered a sex act.

A. Before assessment, inform victim of his or her rights.

  •  Use of a rape crisis advocate.
  •  Notify victim’s personal physician.
  •  Privacy rights during assessment.
  •  Confidentiality is maintained by staff.
  •  Client gives consent for all tests and procedures.

B. Physical data gathered.

  •  Assist with a complete physical examination.
  •  Carefully assess and document all physical damage.
    a. Injuries.
    b. Signs of physical entry.

C. Emotional data.

  • Degree of emotional trauma.
  • Presence of symptoms.

D. Crisis response phases.

  •  Impact or acute phase: shock, crying, high anxiety, hysterical, incoherent, agitated, fearful, volatile, poor problem-solving ability.
  • Reconstitution phase: denial, appears calm and controlled, withdrawn, fearful, begins to talk about feelings, expresses anger, makes decisions.
  •  Resolution phase: realistic attitudes, able to express feelings, controlled anger, acceptance of facts.

A. Treatment focus for rape trauma syndrome.

  •  Emotional: crisis counseling and contact Women Against Rape; rape advocate.
  •  Medical: immediate medical care; assess assault and degree of trauma.
  •  Legal: do not bathe, douche, or change clothes; gather evidence, taking pictures may be part of protocol. Notify law enforcement.

B. Guidelines for care.

  •  Recognize that the assault of rape is a humiliating and violent experience and that the victim is experiencing severe psychological trauma.
  •  Accept the fact that the victim was indeed raped and that the victim is to be supported, not treated as the “accused.”
  •  Understand that the victim’s behavior might vary from hysterical crying and/or laughing to very calm and controlled.
  •  Victims may need encouragement and support to report rape to the authorities.

C. Interventions.

  •  Provide immediate privacy for examination.
  • Choose a staff member of the same sex to be with the victim.
  •  Remain with the victim.
  •  Administer physical care.
    a. Do not allow client to wash genital area or void before examination; these actions will remove any existing evidence such as semen.
    b. Keep client warm.
    c. Prepare client for complete physical examination to be completed by physician (same sex as client if possible).
    d. Physical exam includes
    (1) Head-to-toe exam.
    (2) Pap smear.
    (3) Saline suspension to test for presence of sperm.
    (4) Acid-phosphatase to determine how recently the attack occurred.
    e. Physical treatment may include
    (1) Prophylactic antibiotics.
    (2) Tranquilizers.
  •  Provide emotional support.
    a. Demonstrate a nonjudgmental and supportive attitude.
    b. Express warmth, support, and empathy in relating to the victim.
    c. Listen to what the victim says and document all information.
    d. Encourage the victim to relate what happened, having client tell you in his or her own words if it appears that client would like to talk about the experience.
    e. Do not insist if client chooses not to talk; allow the victim to cope in his or her own way.
    f. During the interview, continue to be sensitive to the victim’s feelings and degree of control. If in relating the attack client becomes hysterical, do not continue questioning at this time.
  • Provide beginning follow-up care.
    a. Assess ability to cope when client leaves hospital (suicide potential).
    b. Explore support system and resources.
    c. Encourage victim to arrange follow-up visits with a counselor.
    d. Involve in planning and support decisions.
  • Termination of crisis relationship.
    a. Counsel client to receive repeat test for sexually transmitted diseases in 3 weeks and HIV in several months, or sooner if symptoms appear.
    b. Help reestablish contact with significant people.
    c. Refer to appropriate community resource for follow-up care.
    (1) Sexual assault can have a long-term impact on the victim.
    (2) Many communities have a “ hotline” that offers crisis counseling to victims.
    d. Keep accurate records, as they may be important in future legal proceedings.

Psychiatric Nursing: Environmental Therapy

Focus topic: Psychiatric Nursing

Definition: Environmental therapy is a broad term that encompasses several forms and mechanisms for treating the mentally ill.

Community Mental Health Act
A. The Community Mental Health Act of 1964 provides for the establishment of mental health centers to serve communities across the country.
B. Each community must provide full service for its population.
C. Services include in- and outpatient treatment services, long-term hospitalization if necessary, emergency services, and consultation and educational services.

A. Hospitalization may be provided by private or public psychiatric hospitals or in psychiatric units of general hospitals.

B. Day–night hospitals provide structured treatment programs for a specified part of each day, after which the client returns to his or her family.
C. Residential treatment facilities provide live-in accommodations with guidance and treatment available for clients who are not quite ready to return to the community and function independently.
D. Therapeutic communities provide milieu therapy, a therapy involving the total community (or unit). The staff formulates and, together with the clients, implements the treatment program. Emphasis is often on group therapies and group techniques.
E. Partial hospitalization offers organized, structured therapeutic activities to prevent hospitalization or as a transitional treatment option when discharged from a mental health day–night facility.
F. Intensive outpatient programs are similar to partial hospitalization programs, but typically have fewer hours/day.


Psychiatric Nursing: Group Therapy

Focus topic: Psychiatric Nursing

Definition: Group therapy refers to the psycho therapeutic processes that occur in formally organized groups designed to improve symptoms or change behavior through group interactions.

Types of Groups
A. Structured group: Group has predetermined goals and leader retains control. Group has directed focus, factual material is presented, and format is clear and specific.
B. Unstructured group: Responsibility for goals is shared by group and leader; leader is non directive. Topics are not pres elected, and discussion flows according to concerns of group members. Often, emphasis is more on feelings than facts, and decision making is part of the group process.

Phases of Group Therapy
A. Initial phase: Group is formed; goals are clarified, and expectations expressed; members become acquainted; superficial interactions take place.
B. Working phase: Problems are identified; confrontation between members occurs; problem-solving process begins; group cohesiveness emerges.
C. Termination phase: Evaluation occurs; fulfillment of goals is explored; support for leave-taking is undertaken.

 Principles Underlying Group Work
A. Support: Members gain support from others in group via sharing and interaction.
B. Verbalization: Members express feelings, and group reinforces appropriate (versus inappropriate) communication.
C. Activity: Verbalization and expression of feelings and problems are stimulated by activity.
D. Change: Members have opportunity to try out new, more adaptive behaviors in group setting.

Methods of Focusing Group Therapy
A. Focus on here and now versus there and then. Group members are helped to express inner experiences occurring in the present rather than in the past. The past cannot be altered; the person can only report on it.
B. Focus on feelings versus ideas. Abstract or cognitive focus directs group away from dealing with here-and-now feelings and experiences and allows no opportunity for exploring and coping with feelings.
C. Focus on telling versus questioning. Focus on the individual’s reporting about self rather than on questioning of others, which is artificial and a defensive posture.
D. Focus on experience versus “ought” or “should.” Avoid “should” systems, which focus on judgmental and critical content rather than on supportiveness.

Leader Functions and Roles
A. Determine structure and format of group sessions.
B. Determine goals and work toward helping group achieve these goals.
C. Establish the psychological climate of group (e.g., acceptance, sharing, and non punitive interactions).
D. Set limits for the group and interpret group rules.
E. Facilitate group process to promote flow of clear communication.
F. Encourage participation from silent members and limit participation of monopolizers.
G. Exert leadership when group flounders; always maintain a degree of control.
H. Act as resource person and role model.

Advantages of Group Therapy
A. Economy in use of staff is possible.
B. Increased socialization potential in group setting leads to increased interaction between clients.
C. Feedback from group members occurs.

  •  Increases reality-testing mechanisms.
  • Builds self-confidence and self-image.
  • Can correct distortions of problem, situation, or feelings by group pressure.
  •  Gives information about how one’s personality and actions appear to others.

D. Reduction in feelings of being alone with problem and being the only one experiencing despair—universality.
E. Opportunity for practicing new alternative methods for coping with feelings such as anger and anxiety.

F. Increased feelings of closeness with others, thus reducing loneliness.
G. Potential development of insight into one’s problems by expressing own experiences and listening to others in group.
H. Therapeutic effect from attention to reality, from focus on the here and now rather than on own inner world.

Psychiatric Nursing: Family Therapy

Focus topic: Psychiatric Nursing

Definition: Family therapy is a form of group therapy

Basic Assumptions
A. An identified client is not ill; rather, the total family is in need of and will benefit from treatment.
B. An identified client reflects disequilibrium in the family structure.
C. Family therapy focuses on exploration of patterns of interaction within the family rather than on individual pathology.
D. Conjoint family therapy treats the family as a group. Method was originally developed by Virginia Satir for treatment for schizophrenics.based on the premise that it is the total family, rather than the identified client, that is dysfunctional.

Therapist Behaviors
A. Models role of clear communicator.

  •  Clarifies and validates communication.
  • Points out dysfunctional communication.
  •  Sets limits for inappropriate behavior.

B. Acts as resource person.
C. Observes and reports on congruent and in congruent communications and behaviors.
D. Supports entire family as members attempt to change inappropriate patterns of relating and communicating with one another.
E. In general, follows the same therapeutic approaches as in nurse–client relationship therapy.





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