Monday, March 29, 2010

Nursing in mental Illness treatment and Prevention

Major objectives that serve as guidelines toward achieving a good mental health
1.    Promoting of mental health
2.    Prevention of mental health
3.    Treatment of client with mental disorders
4.    Restoration of health

1.   Promoting good mental health it is nurse responsibility to promote good mental health that contributes to the social, human and economic capital of society. Mental ill health can drastically reduce the quality of life of affected individuals and their families, in promoting mental health nurse does promoting campaign healthy life style, taking regular exercise, balance diet, good hygiene habit and good stress management and life pressure. Example nurse does a campaign to school and industry to give our society an awareness of stress sign and symptom.

2.   Prevention of mental illness is whereby a nurse does identify and advice Public who had or experiences the symptom will come and seek treatment and counseling to consult their problem. Nurse does prevent by advising the patient to continue the medication to prevent relapse cases and follow the physician advise  when to discontinue their medication or how to overcome burn out from stressful life and does community visit to see examined ex-patient will mental illness from relapse

Level of prevention consist of 3 level

1. Primary prevention-focus on reducing occurrence and incidence of mental disorder e.g. Meet the senior citizen to discuss strategies for linking with community resources, staying socially and intellectually active.

2. Secondary prevention- focus on reducing the prevalence of mental disorder. trough early identification  of symptom
E.g. treats patient with after making diagnoses of mental disorder, such as mental clinic, day treatment, home and school. Then referring patient to family therapy as additional treatment.

3. Tertiary prevention-focus on reducing residual effect of disorder and providing rehabilitation and restoration.
 E.g.; continue to meet the family who has a member with mental disorder assist and reinforce willingness to care for the member and help identify symptom that occur. And conduct seminar and workshop to teach patient job skill and match potential employer with potential patient employees,

3.   Treatment of client with mental disorders. Usually treatment will be eletroculvalsive ECT and therapy Medication using psychotic drug. That reduce psychosis symptom.

4.   Restoration of health. After patient under go their treatment and being trained in mental hospital they will be trained to do they activity daily living by themselves so that they will not depend on family and will be able to organize and manage they own life so that they serve in community and work as normal person after under go treatment and job skill.. Example:   Treatment And Job Skill In Occupational therapy and speech therapy.

2. The principle of nurse :patient  relationship

·       1.The relationship is therapeutic rather than social
A therapeutic relationship is formed to help patient to solve problem, make decision, achieve growth, learn coping strategies, let go unwanted behaviors, reinforce self worth and examine relationship example. Teach the patient what to do and method of solving problem such as how to work and get money to survive
·        2. The focus remains on the patient’s need and problem rather than the nurses or other issues.
Client focus patient redirect the focus away from self by changing the subject the nurse confront the diversion in matter of fact way  and refocus the topic example nurse control the conversation by asking patient what their problem. Because patient maybe fear or anxiety.
·        3. The relationship is purposeful and  goal directed
Goal direction the primary purpose of a therapeutic relationship is helping clients to meet adaptive goal. Nurse and patient together determining problem and issues and collaboratively decide what the client needs and able to achieve, the nurse and patient agree to work  toward those goal and put intention into action modifying strategies until they goal achieve. Example Patient taught to do his own activity daily living such bathing and self hygiene and planning patient into occupational therapy so that patient learn to work.

·       4.The relationship is objective rather than subjective in quality

Nurse remain therapeutic when they remain objective  mean remain free from bias, prejudice and personal identification in interaction with patient and able to process information based on facts. and subjective mean nurse should emphasis own feeling , attitude, and opinion when interacting with the patient.  Example : nurse who encounter  a patient who depressed  and grieving in the recent death of her mother. The nurse should seek supervision or therapy for the patient so that the patient will recover. Nurse do not enmeshed by sharing her experience.
·         5. The relationship is time limited rather than open ended

Nurse should set a time for her to see patient on specific time, and nurse should know when to end the time while meeting patient. Nurse should know when patient become irritable and she should discontinue them conversation. Example nurse should determine when to meet patient and do not continue asking patient to identify the patient problem because patient can be aggressive.

The factors that can influence and hinder the effectiveness of therapeutic Communication.
Communication consists of several structural components the stimulus, the sender, the massage, the medium, the receiver, and  feed back.

Sender/receiver, perception,value, culture, environment, relationship, content, contex, socioeconomic, knowledge, life/family experiance

Communication is learned process influence by several factors, including the environment, the relationship between the sender and the receiver, the content of the massage and the context in which the massage takes place other factor include attitude, values, ethic background, socioeconomic status, family dynamic, life experience, knowledge level and the ability to relate to others experience, knowledge level and the ability to relate to other.
Therapeutic communication is foundation of psychiatric nursing and the psychiatric nurse’s single most importance tool. It is an interactive process that occurs between the nurse and the patient.
 The art of interacting therapeutically is a learned skill involving non verbal and verbal communication. The purpose of therapeutic communication is to enhance patient growth and intervention to promoting health to patient.
The effectiveness of therapeutic communication can be influence by trait of genuineness, positive regard or respect, empathy, trustworthiness, clarity, responsibility and assertiveness. They incorporate verbal and nonverbal behavior as well attitudes, beliefs and feeling behind the communication all of this necessary for therapeutic communication to take place.
1.Genuineness. Is being consistent with both verbal and non verbal behavior. Consistent verbal and non verbal behavior shows that we are open, honest and sincere. Genuineness is importance to patient to develop trust in nurse.
2.Positive regard or respect and acceptance. Nurses should shows that they view their client as worthy. For example sitting and listening to patient expressing concern about event affecting the patient and validating the patient feeling nurse also should shows positive regard by being nonjudgmental. Avoid harsh judgment of patient behavior and feelings both are real and cannot be argued with, discounted or criticize.
3. Empathy is the foundation of all therapeutic nurse client relationship   and essential trait for nurses to have in order to meet their patient needs. It is difficult  for client to trust their nurse if they do not believe  the nurse has empathetic appreciation of them as individuals (McCabe, 2004: Reynolds,2000)
Therefore, empathy or understanding is the nurse ability to see thing from patient view point and to communicate the ability to be sensitive  and communicate understanding to the patient the ability to be sensitive to and communicate understanding of the patient feeling(May and Alligood,2000)  Empathy begins with awareness of another person's feelings. It would be easier to be aware of other people's emotions if they would simply tell us how they felt. But since most people do not, we must resort to asking questions, reading between the lines, guessing, and trying to interpret non-verbal cues. Emotionally expressive people are easiest to read because their eyes and faces are constantly letting us know how they are feeling.
Once we have figured out how another person feels, we show empathy by acknowledging the emotion. We may say, for example,
- I can see you are really uncomfortable about this.
- I can understand why you would be upset.
We can also show empathy through a simple sign of affection such as hug or a tender touch. Though empathy is usually used in reference to sensing someone else's painful feelings, it can also apply to someone's positive feelings of success, accomplishment, pride, achievement etc. In this case a "high five" would also be a sign of empathy.
Empathy poses 2 stages if patient an importance and uncomfortable emotions first be receptive to understand the patient by putting your self in the patient place. Then be able to communicate understanding.
4. Trustworthy
Trustworthy is another essential characteristic of an effective nurse being trustworthy nurse keep commitment and promise and consistent their approach and respond to patient the trustworthy nurse respect the patient privacy, dignity and need for confidentiality.

5. Clarity
Nurses need to communicated clearly to the patient who often have difficulty processing information or thinking clearly as a result as their mental disorder.
Problem will happen if instruction and information are given in highly technical manner. patient are embarrass to ask for clarification. Therefore   nurse should make an effort to speak at the patient
Hinder of effectiveness of therapeutic communication is resistance, transference, counters transference and boundary violations are obstacle to therapeutic communication.
1. Resistance, occur when patient who consciously or unconsciously maintain a lack of awareness of their problem in order to avoid anxiety. The nurse should assure the patient to overcome the patient fear.
 2. Transference,
 Is when patient unconsciously associates the nurse with someone significant in his life, the patient transfer they feeling and attitude about the other person to the nurse. Transference is a simple appearing idea that has to do with the way people understand one another and form relationships with one another. As its name suggests, it involves the idea of transferring something from one place to another.. example  a patient sees a nurse as some she don’t  like then she resist, nurse should listen to the patient and u used therapeutic  communication technique ,clarifying and reflecting to recognize the reason for resistance.
3. Counter transference
In the nurse emotional response to specific client. The response to a specific patient the response is irrational, inappropriate, highly charge counter transference occur when the feeling are intense either positive or negative.
When patient displaying aggressive and resistive behavior, is the nurse still angry with the patient as the result of these behavior, the nurse will lose the objectivity needed to promote healthy change.
To deal with counter transference, nurse should conduct an honest self appraisal throughout the course of the therapeutic relationship while gaining a good understanding of patient background. 
4. Boundary violations  
Occur when the nurse go beyond the establishing therapeutic relationship. Standard and enter into social or personal relationship with the client. For example the nurse discloses to much personal information to the client in order to benefit the nurse.

4. The role of common neurotransmitters in the functioning of the central nervous system.

Neurotransmitters are chemicals located and released in the brain to allow an impulse from one nerve cell to pass to another nerve cell. Neurotransmitters can excite or inhibit neurons (nerve cells). Some common neurotransmitters are acetylcholine, norepinephrine, dopamine, serotonin and gamma aminobutyric acid (GABA). Acetylcholine and norepinephrine are excitatory neurotransmitters while dopamine, serotonin, and GABA are inhibitory. Each neurotransmitter can directly or indirectly influence neurons in a specific portion of the brain, thereby affecting behavior.
A nerve impulse travels through a nerve in a long, slender cellular structure called an axon, and it eventually reaches a structure called the presynaptic membrane, which contains neurotransmitters to be released in a free space called the synaptic cleft. Freely flowing neurotransmitter molecules are picked up by receptors.
Neurotransmitters are chemicals that transmit messages from one nerve cell (neuron) to another. The nerve impulse travels from the first nerve cell through the axon. A single smooth body arising from the nerve cell to the axon terminal and the synaptic knobs. Each synaptic knob communicates with a dendrite or cell body of another neuron, and the synaptic knobs contain neurovesicles that store and release neurotransmitters. The synapse lies between the synaptic knob and the next cell. For the impulse to continue traveling across the synapse to reach the next cell, the synaptic knobs release the neurotransmitter into that space, and the next nerve cell is stimulated to pick up the impulse and continue it.
In a structure called the postsynaptic membrane of another nearby neuron. Once the neurotransmitter is picked up by receptors in the postsynaptic membrane, the molecule is internalized in the neuron and the impulse continues. This process of nerve cell communication is extremely rapid.
Once the neurotransmitter is released from the neurotransmitter vesicles of the presynaptic membrane, the normal movement of molecules should be directed to receptor sites located on the postsynaptic membrane. However, in certain disease states, the flow of the neurotransmitter is defective. For example, in depression, the flow of the inhibitory neurotransmitter serotonin is defective, and molecules flow back to their originating site (the presynaptic membrane) instead of to receptors on the postsynaptic membrane that will transmit the impulse to a nearby neuron.
The mechanism of action and localization of neurotransmitters in the brain has provided valuable information concerning the cause of many mental disorders, including clinical depression and chemical dependency, and in researching medications that allow normal flow and movement of neurotransmitter molecules.
Excitatory neurotransmitters are excitatory transmitters regulate many of the body’s most basic functions including: thought processes, the body’s fight or flight response, motor movement and higher thinking.  Physiologically, the excitatory transmitters act as the body's natural stimulants, generally serving to promote alertness, energy, and activity.  Without a functioning inhibitory system to put on the brakes, things can get out of control.
Inhibitory neurotransmitters Excitation in the brain must be balanced with inhibition. Too much excitation can lead to restlessness, irritability, insomnia, and even seizures.  The inhibitory system slows things down.  Physiologically, the inhibitory transmitters act as the body's natural tranquilizers, generally serving to induce sleep, promote calmness and decrease aggression. 
Excitatory neurotransmitters
·         Dopamine
·         Histamine
·         Norepinephrine
·         Epinephrine
·         Glutamate
·         Acetylcholine

Inhibitory neurotransmitters
·         GABA
·         Dopamine
·         Serotonin
·         Acetylcholine
 Acetylcholine helps with memory and learning. Dopamine is primarily responsible for, mood, alertness, and movement. Norepinephrine and epinephrine influence alertness, arousal, and mood. Serotonin is involved in mood, appetite control, emotional balance, and impulse control. GABA helps with relaxation and sedation.

Acetylcholine neurotransmitter
Acetylcholine release can be excitatory or inhibitory depending on the type of tissue and the nature of the receptor with which it interacts.  Acetylcholine plays numerous roles in the nervous system. Its primary action is to stimulate the skeletal muscular system. It is the neurotransmitter used to cause voluntary muscle contraction or relaxation in the muscles.  But particularly high concentrations occur in the basal nuclei and motor cortex of the brain. It often called cholinergic

In the brain, acetylcholine is involved in learning and memory.  Acetylcholine is a small molecule transmitter that is also found in the hippocampus and prefrontal cortex. The hippocampus is responsible for memory and memory retrieval. Alzheimer’s disease is associated with a lack of acetylcholine in certain regions of the brain.


Dopamine is a hormone and neurotransmitter occurring in a wide variety of animals, including both vertebrates and invertebrates. In the brain, this phenethylamine functions as a neurotransmitter, activating the five types of dopamine receptors  D1, D2, D3, D4 and D5, and their variants. Dopamine is produced in several areas of the brain, including the substantia nigra and the ventraltegmental area. Dopamine is also a neuro hormone released by the hypothalamus. Its main function as a hormone is to inhibit the release of prolactin from the anterior lobe of the pituitary.

Dopamine can act as both an excitatory or inhibitory neurotransmitter Dopamine’s functions are diverse, affecting memory, motor control, and pleasure.  It allows us to be alert and motivated and to feel satisfied.  Dopamine is associated with positive stress states such as being in love, exercising, listening to music.  Once produced, dopamine can convert into the brain chemicals norepinephrine and epinephrine.

High levels

Increased level of dopamine in the frontal lobe of the brain contributes to the incoherent and disrupted thought processes that are characteristic of schizophrenia.  Excessive levels of dopamine cause our thinking to become excited, energized, then suspicious and paranoid as we are hyper stimulated by our environment.  With low levels of dopamine we lose the ability to focus.  When dopamine levels are too high our focus becomes narrowed and intense.  High dopamine levels have been observed in patients with poor gastrointestinal function, autism, mood swings, aggression, psychosis, anxiety, hyperactivity, and children with attention disorders. 

Low levels

Low level of dopamine in the motor areas of the brain is responsible for Parkinson's disease, which involves uncontrollable muscle tremors.  A decline in dopamine levels in the thinking areas of the brain is linked to cognitive problems (learning and memory deficits), poor concentration, difficulty initiating or completing tasks, impaired ability to “lock onto” tasks, activities, or conversations, lack of energy, lack of motivation, inability to “feel alive”, addictions, cravings, compulsions, a loss of satisfaction in activities which previously pleased you, and slowed motor movements.  
Epinephrine, also known as adrenaline, is an excitatory neurotransmitter.  It is derived from norepinephrine and is secreted along with norepinephrine in response to fear or anger.  This reaction, referred to as the “fight or flight” response, prepares the body for strenuous activity. Epinephrine regulates attentiveness, arousal, cognition, sexual arousal, and mental focus. It is also responsible for regulating the metabolism.  Epinephrine is used medicinally as a stimulant in cardiac arrest, as a vasoconstrictor in shock, as a bronchodilator and antispasmodic in bronchial asthma, and anaphylaxis.
High levels
Epinephrine levels which are too high can result in restlessness, anxiety, sleep problems, acute stress, and ADHD.  Excess amounts of epinephrine can also raise the blood pressure, increase the heart rate, cause irritability and insomnia. 
Low levels
Low levels of epinephrine can also contribute to weight gain, fatigue, lack of focus, decreased sexual arousal, and poor concentration. Stress tends to deplete our store of adrenalin (epinephrine), while exercise tends to increase it. 

GABA is the abbreviation for Gamma-aminobutyric acid. GABA is the major inhibitory neurotransmitter in the central nervous system and plays a major role in regulating anxiety and reducing stress.  GABA has a calming effect on the brain and helps the brain filter out “background noise”.  It improves mental focus while calming the nerves.  GABA acts like a brake to the excitatory neurotransmitters which can cause anxiety if the system is over stimulated.  It regulates norepinephrine, adrenaline, dopamine, and serotonin and is a significant mood modulator. The primary function of GABA is to prevent over stimulation.
High levels
Excessive GABA levels result in excessive relaxation and sedation
Low levels
Insufficient GABA results in the brain being over stimulated. People with too little GABA tend to suffer from anxiety disorders and may have a predisposition to alcoholism.  Low levels of GABA are associated with bipolar disorder, mania, poor impulse control, epilepsy, and seizure disorders.  Since proper GABA functioning is required to induce relaxation, analgesia, and sleep, dysfunction of the GABA system is implicated in the pathophysiology of several neuropsychiatric disorders, including anxiety and depression. 

Glutamate is a major excitatory neurotransmitter that is associated with learning and memory.  It is also thought to be associated with Alzheimer’s disease.  Glutamate has been implicated in epileptic seizures and is a key molecule in cellular metabolism.  It is also one of the major food components that provides flavor.  Glutamate is found in all protein-containing foods such as cheese, milk, mushrooms, meat, fish, and many vegetables.  Monosodium glutamate is a sodium salt of glutamate.

High levels

Excessive levels of glutamate are toxic to neurons and have been implicated in the development of neurological disorders such as amyotrophic lateral sclerosis and Huntington's chorea, peripheral neuropathies, chronic pain, schizophrenia, stroke, and Parkinson's disease. 

Low levels
Insufficient levels of glutamate may play a role in impaired memory and learning.

Histamine is most commonly known for its role in allergic reactions but it is also involved in neurotransmission and can affect your emotions and behavior as well. Histamine helps control the sleep-wake cycle and promotes the release of epinephrine and norepinephrine. 
High levels
High histamine levels have been linked to obsessive compulsive tendencies, depression, and headaches.
Low levels
Low histamine levels can contribute to paranoia, low libido, fatigue, and medication sensitivities.
Monoamines This is a class of neurotransmitters which includes serotonin, norepinephrine, GABA, glutamate, and dopamine. The monoamine hypothesis holds that mood disorders are caused by depletion in the levels of one or more of these neurotransmitters. 
Norepinephrine is an excitatory neurotransmitter that is important for attention and focus. Norepinephrine is synthesized from dopamine and is strongly associated with bringing our nervous systems into the “fight or flight” state.  Norepinephrine triggers the release of hormones from the limbic section of the brain that signal other stress hormones to act in a crisis.  It can raise blood pressure and increase heart rate. It can elevate the metabolic rate, body temperature and stimulate the smooth bronchial muscles to assist breathing.  It is also important for forming memories. 
High levels
Elevated norepinephrine activity seems to be a contributor to anxiety. Also, brain norepinephrine turnover is increased in conditions of stress.  Increased levels of norepinephrine will lead to alertness and mood elevation and increased sexual interest. However, high amounts raise blood pressure, increase heart rate, and cause anxiety, fear, panic, stress, hyperactivity, an overwhelming sense of dread, irritability, and insomnia. 
Low levels
Low levels of norepinephrine are linked to lack of energy, focus, and motivation.  Insufficient norepinephrine levels also contribute to depression, loss of alertness, and poor memory. 
Serotonin is an inhibitory neurotransmitter involved in the regulation of mood, anxiety, libido, compulsivity, headaches, aggression, body temperature, eating disorders, social anxiety, phobias, sleep, appetite, memory and learning, cardiovascular function, muscle contraction, and endocrine regulation. Other brain neurotransmitters, such as dopamine and norepinephrine, also influence mood and arousal. However, serotonin generally has different effects. Serotonin plays a major role in sleep and mood regulation. Proper amounts of circulating serotonin promote relaxation.  Stress reduces our serotonin levels as our body uses up serotonin in an attempt to calm itself. 
Low levels
Low levels of serotonin can result in depressed mood, anxiety, panic attacks, low energy, migraines, sleeping problems, obsessions or compulsions, feeling tense and irritable, craving sweets or loss of appetite, impaired memory and concentration, angry or aggressive behavior, slowed muscle movement, slowed speech, altered sleep patterns, and having a reduced interest in sex.
High levels
Excess amounts of serotonin cause sedation, a decrease in sexual drive, a sense of well being, bliss, and of being one with the universe if serotonin levels become too high they can result in Serotonin Syndrome. Extremely high levels combining different agents known to increase levels of Serotonin, such as an SSRI and an MAOI, can result in violent trembling, profuse sweating, insomnia, nausea, teeth chattering, chilling, shivering, aggressiveness, over-confidence, agitation, and malignant hyperthermia.
5. The relationship of neurotransmitters’ dysfunction to mental disorder
Serotonin and its close chemical relatives dopamine and norephenephrine , are the neurotransmitters and most widely involved in various form of depression. there appears to be abnormal excess or inhibition of signals that control mood, thoughts, pain, and other sensations. Depression is treated with antidepressants that affect norepinephrine and serotonin in the brain. The 2 major classes of antidepressant tricyclic and selective serotonin reuptake inhibitor (SSRI)
The antidepressants help correct the abnormal neurotransmitter activity. A newer drug, fluvoxamine @Luvox, is a selective serotonin reuptake inhibitor (SSRI) that appears to establish the level of serotonin required to function at a normal level. As the name implies, the drug inhibits the re-uptake of serotonin neurotransmitter from synaptic gaps, thus increasing neurotransmitter action. In the brain, then, the increased serotonin activity alleviates depressive symptoms.
 Other anti depressant is monoamine Oxidase Inhibitor (MAOI) and an enzyme that typically deactivates serotonin and dopamine .deactivating this enzyme leaves the  system unable to run off the effect of these transmitter substance. MAOI reduces the transmission  between the two neuron.  Catechole 0 methyl tranferase (COMT) an enzyme normally responsible for deactivating norepenephrine to much of this enzyme  prevent adrenergic  neuron from effectively communicating with one and other. Anti depressant  that reduce level of  Catechole 0 methyl  tranferase restore neuronal communication  ability because  norephineprine is importance  in regulating heart rate activities eg. Blood pressure and heart rate.
Impairment of dopamine which is containing neurons in the brain is implicated in schizophrenia, a mental disease marked by disturbances in thinking and emotional reactions. Medications that block dopamine receptors in the brain, such as chlorpromazine and clozapine, have been used to alleviate the symptoms and help patients return to a normal social setting.
Parkinsonism is cause by dopamine deficiency in basal nuclei involved in motor coordinator . patient who suffering in Parkinson’s disease  display tremors, a shuffling gait, is characterized by memory loss and the eventual inability for self-care. The disease seems to be caused by a loss of cells that secrete acetylcholine in the basal forebrain region of brain that is the control center for sensory and associative information processing and motor activities). Some medications to alleviate the symptoms have been developed, but presently there is no known treatment for the disease.

Generalized anxiety disorder

People with generalized anxiety disorder (GAD) experience excessive worry that causes problems at work and in the maintenance of daily responsibilities. Evidence suggests that GAD involves several neurotransmitter systems in the brain, including norepinephrine and serotonin.

Attention-deficit/hyperactivity disorder

People affected by attention-deficit/hyperactivity disorder (ADHD) experience difficulties in the areas of attention, over activity, impulse control, and distractibility. Research shows that dopamine and norepinephrine imbalances are strongly implicated in causing ADHD.

Drug addictions

Cocaine and crack cocaine are psycho stimulants that affect neurons containing dopamine in the areas of the brain known as the limbic and frontal cortex. When cocaine is used, it generates a feeling of confidence and power. However, when large amounts are taken, people "crash" and suffer from physical and emotional exhaustion as well as depression.
Opiates, such as heroin and morphine, appear to mimic naturally occurring peptide substances in the brain that act as neurotransmitters with opiate activity called endorphins. Natural endorphins of the brain act to kill pain, cause sensations of pleasure, and cause sleepiness. Endorphins released with extensive aerobic exercise, for example, are responsible for the "rush" that long-distance runners experience. It is believed that morphine and heroin combine with the endorphin receptors in the brain, resulting in reduced natural endorphin production. As a result, the drugs are needed to replace the naturally produced endorphins and addiction occurs. Attempts to counteract the effects of the drugs involve using medications that mimic them, such as nalorphine, naloxone, and naltrexone.Alcohol is one of the depressant drugs in widest use, and is believed to cause its effects by interacting with the GABA receptor. Initially anxiety is controlled, but greater amounts reduce muscle control and delay reaction time due to impaired thinking.

The Components Of Assessment By Using Mental Status And Psychosocial Criteria In Order To Provide A Quality Psychiatric-Mental Health Care.

The components of assessment by using mental status and psychosocial are:-
1.    Appearance
·         Dress, grooming, hygiene, cosmetic, age posture, facial expression
2.     Behaviour and activity
·         hypo activity or hyperactivity, rigid, relaxed, agitated motor movement, gait(way of walking) and coordination facial grimacing, gesture or abnormal movement.
3.     Attitude
·         interactions with the interviewer, : cooperative , resistive, friendly.
4.    Speech
·         Quantity: Poverty of speech, poverty of content or voluminous( too many word).,
·         Quality: articulate (well spoken),Congruent (make sense) monotone. Talkative repetitious.circumlocutary.Circular, confabulation superficial fragmented broken speech.
·         Rate: slow . rapid or normal.
5.    Mood and affect
·         Mood _ (intensity, depth , duration,) sad, fearful , depressed, angry, anxious, ambivalent, (opposing feeling,)Happy ,ecstatic, grandiose( Feeling of greatness)
·         Affect intensity depth, duration);appropriate, sad, apathy(indifferent),constricted(narrowed) blunted, flat no expression. Labile, euphoric(exaggerated, happiness), Bizarre( add, abnormal

6.    Perception
·         Hallucination ,( can be auditory , visual, tactile, olfactory,)illusion (misinterprets reality can be auditory, visual, tactile, olfactory, depersonalization,(detachment)dereaization disconnects from reality, distortions, (view object out of proportion)

7.    Thoughts
·         Form and content: logical and illogical loose associations(fragmented) flight of ideas rapid, Thought ,autistic(internally stimulated thoughts),bloking broadcasting, neologism, New word. Word salad(mixed up word) obsession(persistence thought)rumination , rethinking, same thought, delusions(Fixed believe)abstract(conceptual) or concrete(literal)
8.    Sensorium and cognition
·         Level of consciousness: orientation (aware of person, Place , time and situation.) , Attention span, recent and remote memory (can recall current and past event.)Concentration. Ability to comprehend and process information; intelligence, fund of knowledge(sufficient amount of knowledge),judgement(makes rational decision),insight(aware of situation such as own illness and reason for hospitalization),ability to abstract and use proverbs(understands meanings of common sayings and expressions).
9.    Judgement
·         Ability to asses and evaluate situations, make rational decisions, understand consequences of behaviour, and take responsibility for actions.
10.  Insight
·         Ability to perceive and understand the cause and nature of own and others’ situation; aware of his or her mental illness and effects or symptoms.

11.  Reliability
·         Interviewer’s impression that individual reported information accurately and completely.

1.    Stressors
·         Internal: Psychiatric or medical illness, including pain, perceived loss, such as loss of self concept/self esteem.
·         External: Actual loss(e.g. death of loved one,divorce,lack of support system, job or financial loss, retirement, dysfunctional family system)
2.    Coping skills
·         Adaptation to internal and external stressors; use of functional, adaptive coping mechanisms and techniques; management of activities of daily living; ability to solve problems associated with daily life.
3.    Relationships
·         Attainment and maintenance of satisfying, interpersonal relationships congruent with developmental stage; includes sexual relationship as appropriate for age and status.

4.    Cultural
·         Ability to adapt and conform to prescribed norms, rules, ethics, and mores of an identified group.

5.    Spiritual (value belief)
·         Presence of a self satisfying value belief system that the individuals regard as right, desirable, worthwhile and comforting.

6.    Occupational
·         Engagement is useful, rewarding activity, congruent with developmental stage and societal standards (work, school, recreation).

2. The Rights Of Mental Health Clients And Its Application In Practice.
1.    Rights of clients
When patient  enter a mental health  facilities. There are basic rights such as to send and receive unopened mail; to wear owns clothes, to receive visitors, to keep and use personal possessions and to access to telephone.

Patient has a right to be informed regarding potential risk, benefit and reasonable alternative before giving consent for any specific therapy, surgery or treatment, including, medication, and nurse need to disclose side effect that will be uncomfortable or reversible to patient.

2.    Right to treatment
A  Movement bean in Alabama, 1980 for the right to treatment for people with mental illness. With financial limitation within the mental health system, employee at Bryce  Hospital were laid off because of budget shortfall as a result of this situation, a class action suit on behalf of the employees and patient was field, alleging that fewer employees the patient could not receive the proper treatment. And settle by consent at 1986, and then many jurisdictions continue follow some of the standard and guidelines specified, including the right to privacy, and dignity. The right to the least restrictive treatment and individual treatment plan.

3.    Right to refuse treatment
The right of a patient to refuse treatment is based upon five constitutional protections:  

·         the 8th amendment’s protection against cruel and unusual punishment
·         the 1st  amendment’s protection of free speech (freedom of thought / ideas)
·         the 1st amendment’s protection of freedom of religion
·         the more broadly interpreted right to privacy
·         the 14th amendment’s protection of liberty (the right to be free from unjustified intrusions on personal security)

In fact, these protections constitute a competent individual’s right to accept or refuse an intervention, based upon the principles of patient autonomy and informed consent.   Within psychiatry, however, these guarantees have been variably interpreted and restrained.   First, the state has been permitted a range of activities under its police authority, in which the rights of the public have super ceded the rights of the mentally ill    Second, the state has been permitted a range of activities under the doctrine of parens patriae  --the 14th century theory which established the legitimacy of the state to act as guardian for those unable to care for themselves (

4.    Application to practice
Nurses practicing in mental health facilities need to be aware of the state and case laws and policies and procedures for that jurisdiction regarding the administration of medication to voluntary and involuntary competent patient.
Frequent nursing assessment for side effect and careful documentation of patient  for patient complaint to side effect for adjustment or discontinuance of medication.


M.F.Katherine (2008): Psychiatric mental health nursing (4th edition) Canada: Mosby