Mental Health Exam 1

1. Week 3

1.1. Chapter 9: Working with Individual Patients

1.1.1. Social vs Therapeutic Communication

1.1.1.1. Social: interactions whereby two individuals are frequently both talking about their own lives, simultaneously

1.1.1.2. Therapeutic: nurse focuses on the patient’s agenda and does not share personal information

1.1.1.2.1. The nurse’s goal is to discover the patient’s story and perspective- to be curious of their experiences

1.1.1.2.2. Allows for ongoing assessment of the patient’s goals and needs

1.1.1.2.3. Establishment and maintenance of objectivity and goal-directedness is crucial

1.1.2. Stages of Nurse Patient Relationship

1.1.2.1. Orientation

1.1.2.1.1. Patients recognize needs and seek help; nurse helps patients understand their problem and accept the help that is available

1.1.2.1.2. Nurse works actively to foster trust and to develop relationship

1.1.2.1.3. Building trust, beginning assessment, managing emotions, proving emotional support, providing structure

1.1.2.2. Working

1.1.2.2.1. Clarification of perceptions and expectations about the relationship takes place

1.1.2.2.2. Problems and identification of tentative solutions are further defined

1.1.2.2.3. Patients become more motivated to take advantage of available resources to resolve problems

1.1.2.2.4. Patients might test the nurse and might fluctuate between dependence and interdependence

1.1.2.2.5. In depth data collection, promoting change

1.1.2.3. Resolution/Termination

1.1.2.3.1. Needs close attention to avoid destroying the benefits gained from the relationship

1.1.2.3.2. Focus in this stage is on the growth that occurred and on helping the patient develop self-responsibility for setting new goals. The entire relationship is viewed as promoting growth and as a learning experience for the nurse and the patients

1.1.2.3.3. Evaluation and summary of progress, synthesizing the outcomes, referrals, discussion of termination

1.1.3. Behaviors that interfere with the recovery process

1.1.3.1. Violent Behavior

1.1.3.1.1. stay out of striking distance (this also reduces the threat to the patient)

1.1.3.1.2. avoid touching patients without their approval

1.1.3.1.3. change the topic temporarily if the patient's behavior is escalating

1.1.3.1.4. suggest time out for the patient in a quiet area with fewer stimuli

1.1.3.1.5. avoid entering a room alone with a patient who is not in control of his or her behavior

1.1.3.1.6. leave temporarily if the patient is agitated and asking to be left alone

1.1.3.1.7. call for staff assistance if the patient's behavior escalates

1.1.3.2. Hallucinations

1.1.3.2.1. comment on behavior if the patient appears to be listening or talking with voices

1.1.3.2.2. ask what they hear

1.1.3.2.3. assess the hallucination

1.1.3.2.4. after content is known, focus on how to make the patient feel comfortable

1.1.3.2.5. encourage the utilization of distraction

1.1.3.3. Delusions

1.1.3.3.1. Patient is encouraged to share the meaning of the delusions... “tell me more about what the delusion means to you”

1.1.3.3.2. Monitor carefully if delusions might lead to harming themselves or others...they might stop eating because they believe it is poisoned

1.1.3.4. Conflicting Values

1.1.3.4.1. Nurses who display respect and affirm the patient’s experience and perspective provide an emotional platform conducive to nurturing trust in the nurse-patient relationship.

1.1.3.4.2. Such interactions offer a safe place, enabling the patient to overcome emotional resistance, engender sense-making, and move toward a deeper level of self-knowledge, which often precedes change.

1.1.3.4.3. The goal is to see and care for the patient, not the mental health problem

1.1.3.5. Severe Anxiety & Incoherent Speech Patterns

1.1.3.5.1. Clarify the meaning of the communications

1.1.3.5.2. if severely ill or anxious they might be unable to be clear and repeated questions may only increase their anxiety

1.1.3.5.3. key in on their feelings and underlying themes, rather than trying to make sense of the content of their speech

1.1.3.5.4. spend frequent, brief time intervals with them to offer support and build trust

1.1.3.6. Manipulation

1.1.3.6.1. it is a coping strategy that develops typically during childhood or adolescence; an attempt to over-connect with others

1.1.3.7. Crying

1.1.3.7.1. NORMAL response to sadness and should be allowed and encouraged

1.1.3.7.2. verbal = "it's ok to cry"

1.1.3.7.3. Non-verbal = quietly offering a tissue

1.1.3.7.4. Provide privacy, nurse should be quiet and unobtrusive as possible until crying has ceased

1.1.3.7.5. offer an opportunity to discuss

1.1.3.8. Sexual Innuendoes or Inappropriate Touch

1.1.3.8.1. calmly request that they stop the behavior

1.1.3.8.2. in the behavior continues, set limits

1.1.3.8.3. the nurse should refrain from touching patient who have sexual or boundary issues

1.1.3.8.4. it is a good idea for the nurse to ask a patient if she is ok with being touched for routine vital signs and other medical procedures

1.1.3.8.5. some patients who have experience sexual abuse could be triggered by being touched

1.1.3.8.6. other patients who are highly sexualized may misinterpret the nurse's touch as perhaps erotic

1.1.3.9. Treatment Refusal

1.1.3.9.1. some symptoms make it difficult or impossible for patient to know they have a serious problem and are in need of professional care

1.1.3.9.2. they might agree that they need help, but they disagree with the type of treatment offered

1.1.3.10. Depressed Affect, Apathy, and Psychomotor Retardation

1.1.3.10.1. Use patience, frequent contact, and empathy as effective methods for dealing with feelings of sadness, helplessness, hopelessness, lack of energy, negative attitude

1.1.3.10.2. encourage improvement in personal hygiene, proper nutrition, and gradual increase in activities

1.1.3.10.3. POSTPONE ANY MAJOR LIFE DECISIONS

1.1.3.11. Suspiciousness

1.1.3.11.1. nurse must communicate clearly, simply, and congruently

1.1.3.11.2. simple rationales or explanations for rules, activities, occurrences, noises, requests are offered regularly

1.1.3.12. Hyperactivity

1.1.3.12.1. patient might unintentionally harm themselves or others

1.1.3.12.2. keep them in a quiet area, with minimal auditory and visual stimulation

1.1.3.12.3. nurses must remain calm, speak slowly and softly, respect patient's personal space

1.2. Chapter 20: Introduction to Milieu Managment

1.2.1. Continuum of Care

1.2.1.1. Long-Term ( 6 months- years)

1.2.1.1.1. Nursing homes for dementia

1.2.1.1.2. State-run Institutions for uncontrolled schizophrenia

1.2.1.1.3. State Systems for pediatrics if they have no guardian

1.2.1.1.4. Prisons

1.2.1.2. Outpatient Services

1.2.1.3. Rehab Facilities

1.2.1.4. Residential Care

1.2.1.4.1. Allowing people to live together in a "group home"

1.2.1.5. Extended Care Facilities

1.2.1.6. Self-Help activities/ resources

1.2.1.7. GOAL: help them become independent

1.2.2. SAFER

1.2.2.1. S

1.2.2.1.1. keep the patient safe

1.2.2.2. A

1.2.2.2.1. use active listening

1.2.2.3. F

1.2.2.3.1. focus on feelings and/or fears

1.2.2.4. E

1.2.2.4.1. use empathy

1.2.2.4.2. decrease environmental stimuli

1.2.2.5. R

1.2.2.5.1. Re-evaluate

1.2.3. Milieu Therapy

1.2.3.1. The planned use of people, resources, and activities in the environment to assist in improving interpersonal skills, social functioning, and performing the activities of daily living, as well as safety and protection for all clients

1.2.3.2. The milieu is used to describe the environment or psychiatric setting

1.2.3.3. Elements of Treatment Environment

1.2.3.3.1. People, resources, acitivites

1.2.3.3.2. occurs in inpatient and outpatient settings

1.2.3.3.3. Provides a safe place

1.2.3.3.4. Use Limit Setting

1.2.3.3.5. Supports client privacy and autonomy

1.2.3.4. GOAL: stabilization, rehabilitation, and recovery of clients with psychiatric disorders

1.2.4. Behavior Modification

1.2.4.1. attempts to change ineffective or maladaptive behavioral patterns

1.2.4.2. focuses on the consequences of actions

1.2.4.3. POSITIVE reinforcement

1.2.4.3.1. Used to strengthen a behavior

1.2.4.4. NEGATIVE reinforcement

1.2.4.4.1. used to decrease inappropriate behavior

1.2.4.5. teaching new behaviors

1.2.5. Family Therapy

1.2.5.1. Identifies the entire family as the client

1.2.5.2. based on concept of the family as a system of interrelated parts forming a whole

1.2.5.3. focus is on the patterns of interaction

1.2.5.4. congruent and incongruent communication patterns and behaviors

1.2.5.5. GOAL: decrease family conflict

1.2.6. Cognitive Therapy

1.2.6.1. Replacing a client's irrational beliefs and distorted attitudes

1.2.6.2. Focused on problem solving behaviors

1.2.6.3. involves cognitive restructuring

1.2.6.4. GOAL: change thinking

1.2.7. Dialectical Behavior Therapy

1.2.7.1. Focuses on "para-suicidal" patients who have self-mutilation and suicide attempts in their history

1.2.7.2. concentrates on ways to change these behaviors through individual and group skills training

1.2.7.3. Mindfulness

1.2.7.3.1. they answer all their own questions

1.2.7.3.2. talked their way through it; restructure their own thinking

1.2.8. Group Intervention

1.2.8.1. Used with 2+ clients who develop interactive relationships and share a common goal

1.2.8.2. Types of groups: psychoeducation, supportive therapy (get help from experience of others who have similar experiences), self-help, psychotherapy

1.2.8.3. Common nurse lead groups: medication, symptom management, anger management, and self-care

1.2.8.4. PHASES of GROUP INTERVENTION

1.2.8.4.1. Orientation

1.2.8.4.2. Working

1.2.8.4.3. Termination

1.2.8.5. Advantages

1.2.8.5.1. development of socializing technique

1.2.8.5.2. opportunity for new behavior

1.2.8.5.3. promotion of a feeling of universality or not being alone with their problems

1.2.8.5.4. opportunity for feedback from group

1.2.8.5.5. opportunity for client to look at alternative ways of dealing with problems

1.2.8.6. Disadvantages

1.2.8.6.1. High jackers or people who jump in and talk over everyone else

1.2.8.6.2. those that get everyone worked up

1.2.9. CRISIS Intervention

1.2.9.1. Directed at reduction of immediate crisis, which the individual is unable to handle alone

1.2.9.1.1. previous coping strategies ineffective

1.2.9.1.2. state of disequilibrium

1.2.9.1.3. client in panic due to disorganization

1.2.9.1.4. identify support system

1.2.9.1.5. identify fast coping patterns; getting them away from the physical trigger

1.2.9.1.6. GOAL: return to pre-crisis level

1.2.9.1.7. Usually limited to 6 weeks

1.2.10. Hospital Based Care

1.2.10.1. GOAL: Crisis intervention and safety

1.2.10.2. Highest Priority: danger to self and others

1.2.10.3. Client deemed suicidal or homicidal

1.2.10.4. 24-hour supervisions in secure environment

1.2.10.5. Medical and psychiatric evaluation

1.2.11. Residential Care

1.2.11.1. Temporary or long-term housing

1.2.11.2. Extended care facilities (nursing homes)

1.2.11.3. Group homes

1.2.11.4. Halfway houses

1.2.11.5. Apartment living programs

1.2.11.6. Foster Care and shelters

1.2.11.7. not acute crisis but still could be in crisis

1.2.11.7.1. ex. foster care

1.2.11.8. Patients don't have anywhere to live and need to be safe

1.2.12. Outpatient Services

1.2.12.1. traditionally in mental health clinics and private offices

1.2.12.2. Services provided by psychiatrist, psychologist, social worker, psychiatric nurse or other professional.

1.2.12.3. Alice diagnosed with chronic schizophrenia attends a community support group. She meets with her case manger every other week, receive haloperidol injections once every 2-4 weeks. The nurse assesses for effectiveness of the medication and s/e. The psychiatrist meets with her every 3 months for medication evaluation.

1.2.12.3.1. ◦ Case manager is constant link between patient and system; follow the patient’s case

1.2.13. Day Treatment Programs

1.2.13.1. individuals require minimal supervision

1.2.13.2. John, has severe depression resulting from the unexpected death of his wife, is discharged from the hospital is unable to work. He attends a partial program for 2 weeks that meets from 10 am – 2 pm, Monday through Friday. He attends groups that focus on losses and self-esteem issues.

1.2.14. Self-Health Groups

1.2.14.1. Self-health groups meetings are conducted by members, not professionals, and may take place on a weekly basis.

1.2.14.1.1. o Alcoholic Anonymous o Narcotics anonymous o Eating disorders o Grief, divorce, bereavement support groups o Medically based groups o Preventive groups

1.2.15. Other Services

1.2.15.1. Psychiatric Home Care

1.2.15.1.1. homebound, home health visits

1.2.15.2. Mobile Crisis Teams

1.2.15.2.1. they go to the patient

1.2.15.2.2. Assertive Community Treatment (ACT)

1.2.15.3. Telehealth

1.2.15.3.1. patient may not have a car or access to public transportation to get treatment, may not have time to spend the day busing around the city to make it to one appointment

2. Week 1

2.1. Chapter 2: Historical Issues

2.1.1. Decade of the Brain 1990s

2.1.1.1. if we understand the brain, we can help millions of people with mental disorders  increase in funding for brain research, leading to new treatment strategies

2.1.1.2. Prior to the Decade of the brain, psychiatric nursing saw mental disorders as originating from psychodynamic causes --> meaning biology had nothing to do with it

2.1.2. Where individuals with mental illness live

2.1.2.1. Nursing Homes

2.1.2.2. Prison/Jail

2.1.2.3. State Hospitals

2.1.2.4. Homeless***

2.1.2.5. Home with families, group or board-and-care homes, or on their own

2.2. Chapter 3: Legal Issues

2.2.1. 3 Categories of Commitment

2.2.1.1. Voluntary Patient

2.2.1.1.1. person requests hospitalization and voluntarily agrees to be admitted

2.2.1.1.2. Most people with mental health problems are voluntary

2.2.1.2. Involuntary Commitment

2.2.1.2.1. a person with the legal capacity to consent refuses to do so and is treated against his will

2.2.1.2.2. the state must produce clear and convincing evidence to prove that a person is both mentally ill and dangerous

2.2.1.3. Commitment of an incapacitated person

2.2.1.3.1. treatment of a person who does not have the legal capacity to consent to treatment

2.2.2. Elements Necessary to Establish Negligence

2.2.2.1. Duty to Care = a legal obligation imposed on a person who is in a position to perform an action that could potentially harm others

2.2.2.2. Reasonable Care = A nurse must exercise expected professional judgments and actions within their scope of practice in the context of care provided

2.2.2.3. Breach of Duty = the failure to provide a reasonable standard of care owed to a person. This failure includes either doing or refraining from doing a particular act in a circumstance where the risk of harm exists.

2.2.2.4. Proximate Cause or Causation = a direct relationship exists between the negligent conduct and the resulting harm suffered by the patient

2.2.3. PATIENT RIGHTS

2.2.3.1. right to treatment with the least restricted environment

2.2.3.2. right to confidentiality of records

2.2.3.3. right to freedom from restraints and seclusion

2.2.3.4. right to give or refuse consent to treatment

2.3. Chapter 4: Psychobiological Bases of Behavior

2.3.1. Frontal Lobe

2.3.1.1. thinking and moving

2.3.2. Temporal Lobe

2.3.2.1. smelling, hearing, speaking

2.3.3. Parietal Lobe

2.3.3.1. Sensing

2.3.4. Occipital

2.3.4.1. Seeing

3. Week 2

3.1. Chapter 7: Models for Working with Psychiatric Patients

3.1.1. Recovery Model

3.1.1.1. Assumptions: Consumers are the experts with identifiable strengths and abilities

3.1.1.1.1. Goals & Approaches: Empowering the consumer and family to define and manage treatment options

3.1.1.2. Emphasizes that the nurse must partner with clients to help them achieve their preferred future --> setting goals to get better

3.1.1.3. the goal of treatment is to help consumers develop meaningful roles in their communities, not to develop long-term relationships with the mental health care system

3.1.2. Attachment

3.1.2.1. Assumptions: Emotions shape and organize one’s experience

3.1.2.1.1. Goals & Approaches: Developing safe and secure emotional bonds in relationships

3.1.2.2. helps explain how depression, anxiety, and other mental disorders can begin in childhood as a result of distressing parental interactions, experienced as traumatic for the child.

3.1.3. Psychoanalytical (Freud)

3.1.3.1. Assumptions: Change is a process of insight. Personality is developed by early childhood.

3.1.3.1.1. Goals & Approaches: Bringing the unconscious into consciousness by enhancing awareness of self and one’s effect on others

3.1.3.2. ALL WE NEED TO KNOW ABOUT FREUD: idea that we all have a subconscious...not everything a person does is thought out. It could be something they are not aware of.

3.1.3.3. Defense Mechanisms

3.1.3.3.1. Denial

3.1.3.3.2. Repression

3.1.3.3.3. Suppression

3.1.3.3.4. Rationalization

3.1.3.3.5. Intellectualization

3.1.3.3.6. Dissociation

3.1.3.3.7. Identification

3.1.3.3.8. Introjection

3.1.3.3.9. Compensation

3.1.3.3.10. Sublimination

3.1.3.3.11. Reaction Formation

3.1.3.3.12. Undoing

3.1.3.3.13. Displacement

3.1.3.3.14. Projection

3.1.3.3.15. Conversion

3.1.3.3.16. Regression

3.1.4. Developmental (Erikson)

3.1.4.1. Assumptions: Change involves re-experiencing and resolving developmental crisis. Lack of resolution of developmental tasks is related to difficulties in relationships.

3.1.4.1.1. Goals & Approaches: Analyzing developmental issues, fears, and barriers to growth to facilitate mastery of developmental tasks

3.1.4.2. Violent tendencies as adults have experience a tremendous amount of neglect or abuse as a child

3.1.4.3. Life Stages

3.1.4.3.1. Stage 1: Trust vs. Mistrust (0-18 mo.)

3.1.4.3.2. Stage 2: Autonomy vs. Shame and Doubt (18 mo- 3 yr)

3.1.4.3.3. Stage 3: Initiative vs. Guilt (3-5 yr)

3.1.4.3.4. Stage 4: Industry vs. Inferiority (6-12 yr)

3.1.4.3.5. Stage 5: Identify vs. Role Diffusion (12-20 yr)

3.1.4.3.6. Stage 6: Intimacy vs. Isolation (18-30)

3.1.4.3.7. Stage 7: Generative Lifestyles vs. Stagnation or self-absorption (30-65)

3.1.4.3.8. Stage 8: Integrity vs. Despair (65- death)

3.1.5. Interpersonal (Sullivan, Peplau)

3.1.5.1. Assumptions: Change is a process of relearning interpersonal relationships

3.1.5.1.1. Goals & Approaches: Learning effective interpersonal skills by using the nurse-patients relationship as a vehicle for analyzing interpersonal processes and testing new skills

3.1.5.2. explains how anxiety in childhood is related to a lock of awareness or skill in interpersonal relationships

3.1.5.3. Mental illness was viewed as any degree of lack of awareness or skill in interpersonal relationships

3.1.5.4. Relationships are viewed as sources of anxiety, maladaptive behaviors, and negative personality formation

3.1.5.5. Interpersonal Psychotherapy is used in treatment of depression and other mood disorders

3.1.5.5.1. Goal of therapy it to develop nature and satisfactory relationships that are relatively free from anxiety

3.1.5.6. Peplau used Sullivan’s concepts of anxiety as a critical part of her framework in the nurse-patient relationship. Her goal was to help patients manage anxiety and use it for learning interpersonal skills through the nurse-patient relationship.

3.1.5.6.1. Peplau described the effects of mild anxiety through panic levels on perception and learning. She saw the nurse’s role as helping patients decrease insecurity and improve functioning through interpersonal relationships that can be seen as microcosms of how patients function in other relationships

3.1.6. Cognitive-Behavioral (Beck, Ellis)

3.1.6.1. Assumptions: Irrational and illogical thoughts, feelings, and behaviors are all interrelated. A change in thinking will lead to a change in emotions and actions

3.1.6.1.1. Goals & Approaches: Substituting rational beliefs for irrational ones, reducing nonproductive behaviors

3.1.6.2. replacing irrational beliefs with rational beliefs can reduce stress and anxiety and self-defeating behaviors

3.1.6.3. Cognitive-behavioral therapy (CBT) is effective in directly changing behaviors, as well as changing faulty thinking

3.1.6.4. Motivational enhancement therapy, a variation of CBT, is more widely used in the treatment of individuals with addictions

3.1.6.4.1. non-confrontational approach includes expressing empathy, pointing out discrepancies between current behaviors and future goals, “rolling with resistance,” and promoting self-efficacy

3.1.6.5. Dialectical behavior therapy (DBT) was developed for the treatment of borderline personality disorder, which also has been viewed as complex post-traumatic stress disorder

3.2. Chapter 8: Learning to Communicate Professionally

3.2.1. Therapeutic Communication

3.2.1.1. Verbal and Non-verbal exchange which enhances the trusting nurse-patient relationship is...

3.2.1.1.1. Client centered

3.2.1.1.2. Goal specific

3.2.1.1.3. Theory based

3.2.2. Non-Verbal Behaviors designed to facilitate active listening

3.2.2.1. SOLER

3.2.2.1.1. S- sit squarely facing the client

3.2.2.1.2. O- observe an open posture

3.2.2.1.3. L- lean forward toward the client

3.2.2.1.4. E- establish eye contact

3.2.2.1.5. R- RELAX

3.2.3. Communcation

3.2.3.1. Acknowledgement

3.2.3.1.1. recognizing the client's opinion without imposing your own values and judgements

3.2.3.2. Clarifying

3.2.3.2.1. the process of making sure you have understood the meaning of what was said

3.2.3.3. Confrontation

3.2.3.3.1. used judiciously

3.2.3.3.2. calling attention to inconsistent behavior

3.2.3.4. Focusing

3.2.3.4.1. Assisting the client to explore a specific topic; which may include sharing perceptions

3.2.3.5. Information Giving

3.2.3.5.1. feedback about client's observed behavior

3.2.3.6. Open-Ended Question

3.2.3.6.1. questions that require more than a yes or no response

3.2.3.7. Reflecting/restating

3.2.3.7.1. paraphrasing or repeating what the client has said (be careful not to overuse, client will feel as though you are not listening)

3.2.3.8. Silence

3.2.3.8.1. can be used to control interaction, use carefully with paranoid client, may be misinterpreted or could be used to support paranoid ideation

3.2.3.8.2.  Silence when someone is in acute distress but do not leave them alone  let them know you are there

3.2.3.9. Suggesting

3.2.3.9.1. Offering alternative, for example, "Have you ever considered...?"

3.2.3.9.2. Suggesting is therapeutic if the suggestion is therapeutic  DO NOT make suggestions for their lives/relationships