Psychiatric Nursing
Therapeutic communication techniques, defense mechanisms, and major psychiatric medication classes including SSRIs, MAOIs, antipsychotics, and mood stabilizers.
Therapeutic Communication Techniques
| Technique | Example | Purpose |
|---|---|---|
| Open-ended questions | "Tell me about your feelings." | Encourages patient to elaborate |
| Active listening | Nodding, eye contact, "mm-hmm" | Shows interest and engagement |
| Reflection | "You seem angry about that." | Identifies emotions; shows empathy |
| Restating | "So you're saying you feel alone?" | Confirms understanding |
| Clarification | "What do you mean by 'losing it'?" | Ensures accurate understanding |
| Silence | Sitting quietly with patient | Allows patient to collect thoughts |
| Offering self | "I'll sit with you for a while." | Shows availability and support |
| Focusing | "Let's go back to what you said about..." | Directs conversation to important topics |
| Summarizing | "During our talk, you've mentioned..." | Reviews main points of discussion |
Non-Therapeutic Communication (Avoid)
- False reassurance: "Everything will be fine" — dismisses feelings
- Giving advice: "You should..." — removes patient autonomy
- Why questions: "Why did you do that?" — implies judgment
- Changing the subject: Avoids patient's concern
- Approval/disapproval: "That's good" or "You shouldn't feel that way"
- Agreeing/disagreeing: Takes sides rather than exploring feelings
- Belittling: "Everyone goes through that"
Defense Mechanisms
| Mechanism | Definition | Example |
|---|---|---|
| Denial | Refusing to accept reality | Alcoholic says "I can stop anytime" |
| Projection | Attributing own feelings to others | Angry patient says "You're angry at me" |
| Displacement | Redirecting emotions to a safer target | Yelling at spouse after bad day at work |
| Rationalization | Making excuses to justify behavior | "I failed because the test was unfair" |
| Regression | Returning to earlier developmental behavior | Hospitalized child starts bedwetting |
| Repression | Unconsciously blocking painful memories | Abuse victim has no memory of events |
| Suppression | Consciously pushing thoughts aside | "I'll deal with that after the exam" |
| Sublimation | Channeling unacceptable impulses positively | Aggressive person becomes a surgeon |
| Reaction Formation | Acting opposite to true feelings | Being overly kind to someone you dislike |
| Intellectualization | Using logic to avoid emotions | Discussing cancer diagnosis in purely clinical terms |
| Undoing | Attempting to reverse an unacceptable action | Being extra nice after saying something hurtful |
| Splitting | Seeing things as all good or all bad | BPD patient: "You're the best nurse ever" then "You're terrible" |
Psychiatric Medications
SSRIs (Selective Serotonin Reuptake Inhibitors)
- Drugs: fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), escitalopram (Lexapro), citalopram (Celexa)
- Uses: Depression, anxiety, OCD, PTSD, panic disorder
- Side effects: GI upset, sexual dysfunction, insomnia, weight changes
- Key points: Takes 2–4 weeks for full effect; suicide risk may increase initially (especially in adolescents — black box warning); do NOT combine with MAOIs (serotonin syndrome); taper to discontinue
MAOIs (Monoamine Oxidase Inhibitors)
- Drugs: phenelzine (Nardil), tranylcypromine (Parnate), selegiline (Emsam patch)
- Uses: Treatment-resistant depression, atypical depression
- Critical teaching: Avoid tyramine-rich foods (aged cheese, red wine, cured meats, soy sauce, sauerkraut, broad beans) → hypertensive crisis
- Hypertensive crisis symptoms: Severe occipital headache, stiff neck, palpitations, diaphoresis, nausea. Treatment: phentolamine (alpha-blocker)
- Drug interactions: Do NOT combine with SSRIs, meperidine, pseudoephedrine, other antidepressants. Wait 14 days between switching
Antipsychotics
| Type | Typical (First Generation) | Atypical (Second Generation) |
|---|---|---|
| Drugs | Haloperidol (Haldol), chlorpromazine (Thorazine), fluphenazine | Risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), clozapine (Clozaril), aripiprazole (Abilify) |
| Target Symptoms | Positive symptoms (hallucinations, delusions) | Positive AND negative symptoms (flat affect, social withdrawal, avolition) |
| Major Side Effects | EPS: dystonia, akathisia, tardive dyskinesia, parkinsonism. NMS (neuroleptic malignant syndrome) | Metabolic syndrome (weight gain, hyperglycemia, dyslipidemia). Clozapine: agranulocytosis (requires weekly/biweekly ANC monitoring) |
- EPS treatment: Benztropine (Cogentin) or diphenhydramine (Benadryl) for acute dystonia
- NMS: Medical emergency — high fever (> 104°F), muscle rigidity ("lead pipe"), altered mental status, autonomic instability. Stop antipsychotic. Dantrolene + bromocriptine. Mortality: 10–20%
- Tardive dyskinesia: Involuntary lip-smacking, tongue protrusion, facial grimacing. May be irreversible. Assess with AIMS scale
Mood Stabilizers
- Lithium: See High-Alert Medications sheet. Therapeutic: 0.6–1.2 mEq/L. Monitor renal, thyroid
- Valproic acid (Depakote): Therapeutic: 50–100 mcg/mL. Monitor LFTs, platelets. Teratogenic (neural tube defects)
- Carbamazepine (Tegretol): Therapeutic: 4–12 mcg/mL. Monitor CBC (aplastic anemia risk), LFTs. Many drug interactions
- Lamotrigine (Lamictal): Titrate slowly. Watch for Stevens-Johnson syndrome (rash → discontinue immediately)