Exam 1 study guide
Exam 1 study guide NUR 314
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EXAM 1 Chapter I Mental Health and Mental Illness De nitions 0 De nition of Mental Health Figure 11 0 quotPsychiatry s de nition of mental health evolves over timequot Halter p 2 o It is a de nition shaped by the prevailing culture and societal values and it re ects changes in cultural norms society s expectations political climates and even reimbursement criteria 0 There are certain characteristics certain attributes o Attributes all contribute to mental health They help you cope with stressors deal with work life etc 0 De nition of Mental Illness 0 Mental Health and Mental Illness ContinuumFigure 12 Wellbeing is characterized by adequate to highlevel functioning in response to routine stress and resultant anxiety or distress Nobody is 100 mentally healthy and nobody is 100 mentally ill Contributinq Factors Resilencequotprocess of adaptingquot quotidentify problems and challenges accepting those things that cannot be changed and focusing on what can be overcome p 34 0 A characteristic of mental health is resilience This is closely associated with the process of adapting and helps people facing tragedies loss trauma and severe stress It is the ability and capacity for people to secure the resources they need to support their wellbeing This social support actually brings out chemical changes in the body through the release of oxytocin which mutes the destructive stress related chemicals Being resilient dos not mean being unaffected by stressors it means recognizing the feelings readily dealing with them and learning from the experience rather than falling victim to the negative emotion 0 Effect of mastering dif cultstressful situations and prefrontal cortex p 4 Those who don t adapt well don t fare better as someone who can You have to let go that are things that are out of your control 0 How resilient are you Box 11 Need adaptation Resiliency is important in recovery 0 Role of cultural o quotCultures differ in not only their views regarding mental illness but also the types of behavior categorized as mental illnessquot p 5 People interpret health and sickness in their own current views Cultures differ not only in their views regarding mental illness but also the types of behavior categorized as mental illness Culturebound Syndromes 0 Depending on the culture that you come from your perceptions of what you see in mental health could be different from your patients 0 Suicide is different across cultures Schizophrenia bipolar disorder all seen everywhere 0 You have to look at cultural differences and discuss what you can do in the care plan that goes with their cultural beliefs 0 Culture bound syndromes seem to occur in speci c sociocultural contexts and are easily recognized by people in those cultures 0 Social In uences on Mental Health Care 0 Consumer Movement and Mental Health Recovery 0 National Alliance for the Mentally Ill NAMI 1979 1979 patients and families led a consumer movement for them to take more control of their care They were looking for recovery vs just detainment containment Components of Recovery Substance Abuse and Mental Health Services Administration SAMHSA 2011 p 8 o SelfDirected Consumers lead control exercise choice over and determine their own path of recovery Can t make people get better we lead them we create that environment we give them tools and help them build resiliency but we cannot make people get better 0 Individual and personcentered Recovery is based on unique strengths and resiliencies as well as needs preferences experiences including past trauma and cultural backgrounds Avoid blanket care plans 0 Empowering Consumers have the authority to choose from a range of options participate in all decisions that will affect their lives and be educated and supported in so doing Support their healthy decisions 0 Holistic Recovery is based on continual growth including mind body spirit and community Look at how their families and communities impact them 0 Noanear Recover is based on continual growth occasional setbacks and learning from experience Can expect remissions and exacerbations o Strengthbased Recovery is focused on valuing and building on the multiple capacities resiliencies talents coping abilities and inherent worth of individuals Use the patient s own strengths to help them 0 Peersupported Consumers encourage and engage each other in recover and provide a sense of belonging supportive relationships valued roles and community Patients and families share their support groups 0 Respect Community systems and societal acceptance and appreciation of consumers including protecting their rights and eliminating discrimination and stigma are crucial in achieving recovery Acceptance of them and their illness 0 Responsibility Consumers have a personal responsibility for their own selfcare and recovery for understanding and giving meaning to their experiences and for identifying coping strategies and healing processes to promote their own wellness Not doing them any favors Need them to take responsibility for how they respond to their illness Recovery provides the essential motivating message of a better future that people can and do overcome the barriers and obstacles that confront them Hope is the catalyst of the recovery process Needed for recovery 0 Decade of the Brain 1990 see page 7 o In 1990 President George HW Bush designated the last decade of the 19005 as the Decade of the Brain The goal of this was to make legislators and the public aware of the advances that had been made in neuroscience and brain research This stimulated a worldwide growth of scienti c research Among the advances that were made 0 Understanding the genetic basis of embryonic and fetal neural development 0 Mapping genes involved in neurological illnesses including mutations associated with Parkinson s disease Alzheimer s disease and epilepsy o Discovering the brain uses a relatively small number of neurotransmitters but has a vast assortment of neurotransmitter receptors 0 Uncovering the role of cytokines proteins involved in the immune response in brain disorders such as depression 0 Re ning neuroimaging techniques such as positron emission tomography PET scans MRIs magnetoencephalography and EEGs has improved our understanding of normal brain functioning as well as areas of difference in pathological states 0 Bringing together computer modeling and laboratory research which resulted in the new discipline of computational neuroscience Surgeon General s Report on Mental Health 1999 o The two most important messages from this report are quotMental health is fundamental to overall healthquot quotThere are effective treatments for mental healthquot p 7 0 Human Genome Project 19902003 0 13 year project 0 Strengthens biologicalgenetic explanations President s New Freedom Commission on Mental Health 2003 Box 12 0 quotmental health care in America was 39in a shambles p8 0 quotsystem with a less fragmented delivery of carequot p 8 0 Goals for a transformed mental health system in the United States Americans understand that mental health is essential to overall health Mental health care is consumer and family driven Disparities in mental health services are eliminated Early mental health screening assessment and referral to services are common practice Excellent mental health care is delivered and research is accelerated Technology is used to access mental health and information c Institute of Medicine 2005 Improving quality for Mental Illness amp SA identi es high quality care is 0 Safe 0 Effective o Patientcentered o Timely 0 Efficient o Equitable c Institute of Medicine 2011 The Future of Nursing Focus on Education Robert Wood Johnson Foundation Quality and Safety Education for Nursing QSEN basis of MCN s clinical evaluations 0 Patient centered care 0 Teamwork and collaboration 0 Evidencebased practice 0 Quality Improvement 0 Safety 0 Informatics Legislation and Funding Mental Health 0 Parity for Mental Health care 2010 0 Affordable Care Act STIGMA and ACCESS TO CARE ISSUES REMAIN Epidemiology o Helps ID high risk groups understanding 0 262 of Americans aged 18 and older 82 MILLION people 0 Disability Neuropsych disorders leading category next is Cardiovascular diseases 13 of all disability is due to Depression 0 Many have more than one disorder comorbidity 0 Incidence number of new cases 0 Prevalence total number of new and existing see Table 11 Look at table ll Classi cation of Mental Illness 0 Diagnostic and Statistical Classi cation of Mental Disorders DSM 5 Box 13 quot classi es the quotdisorders people havequot p 11 O O O 0 See Appendix A p 651 664 It organizes diagnoses for psychiatric disorders on a developmental hierarchy This hierarchy means that disorders that are usually seen in infancy childhood and adolescence are not listed in the rst chapter Those that appear later in life are listed later in the list Within each chapter speci c disorders are listen based on when they typically occur from youngest to oldest Psychiatric Mental Health Nursing 0 Basic psychosocial nursing concepts used in all areas of nursing O O Selfre ectionselfawareness is crucial What do we do Phenomena of concern Box 15 Promotion of optimal mental and physical health and wellbeing and prevention of mental iHness Impaired ability to function related to psychiatric emotional and physiological distress Alterations in thinking perceiving and communicating due to psychiatric disorders or mental health problems Behaviors and mental states that indicate potential danger to self or others Emotional stress related to illness pain disabilities and loss Symptom management side effects or toxicities associated with selfadministered drugs psychopharmacological intervention and other treatment modalities The barriers to treatment ef cacy and recovery posed by alcohol and substance abuse and dependence Selfconcept and body image changes developmental issues life process changes and endoflife issues Physical symptoms that occur with altered physiological status Interpersonal organization sociocultural spiritual or environmental circumstances or events that have an effect on the mental and emotional wellbeing of the individual and family or community Elements of recovery including the ability to maintain housing employment and social support that help individuals reengage in seeking meaningful lives Societal factors such as violence poverty and substance abuse PsychiatricMental Health Nursing Scope and Standards of Practice 2007 39promotes mental health through the assessment diagnosis and treatment of human responses to mental health problems and psychiatric disorders p13 Standards on back cover of text Nurses don t treat the disorder we treat the responses to the disorder Classi cation of Nursing Diagnoses Outcomes and Interventions NANDA40 of the 201 standardized diagnoses are psychosocial See Appendix B p 665 Nursing Outcomes Classi cation NOC Nursing Interventions Classi cation NIC Levels of Psychiatric Mental Health Clinical Nursing Practice 1415 Basic Level RN and RNC certi cation through ANCC Table 14 0 Coordination of care 0 Health teaching and maintenance 0 Milieu therapy 0 Pharmacological biological and integrative therapies Advanced Practice added roles with advanced education in Psychiatric Nursing 0 All of the above 0 Medication prescription and treatment 0 Psychotherapy Consultation Future Challenqes and Roles 0 Educational Challenges Aging population Cultural diversity amp competency Science Technology and Electronic Health Care 0 Psych oors aren t high tech and advanced and new 0 There aren t a lot of sites available 0 There isn t a lot of funding Advocacv amp Leqislative Involvement 0 Role of the patient advocate and combating stigma o What are YOU committed to do 0 The nurse upholds patient con dentiality and support s the patient s right to make decisions supporting treatment 0 Look in book Chapter 2 All Theories with focus on broad categories and PMH Implication 0 Why theories 0 We need to understand theories so that we can support what the patients are learning from o It helps to organize our interventions o A certain theory doesn t apply to everyone 0 Psvchoanalvtic Theories and Therapv Comparisons in Table 25 0 Takes a long time not a rapid approach 0 First 5 years of life There is a problem because of something that happened in those rst 5 years 0 Sigmund Freud s Psychoanalytic Theory Levels of Awareness Conscious o The tip of the iceberg o It contains all the material a person is aware of at any one time including perceptions memories thoughts fantasies and feelings o Preconscious 0 Just below the surface of awareness 0 Contains material that can be retrieved rather easily through conscious effort 0 Unconscious 0 Includes all repressed memories passions and unacceptable urges lying deep below the surface o It is believed that the memories and emotions associated with trauma are often placed in the unconscious because the individual nds it too painful to deal with them 0 The unconscious exerts a powerful yet unseen effect on the conscious thoughts and feelings of the individual 0 The individual is usually unable to retrieve unconscious material without the assistance of a trained therapist however with this assistance unconscious material can be brought into conscious awareness Personality Structure Figure 21 0 Id 0 At birth 0 The source of all drives instincts re exes needs genetic inheritance and capacity to respond as well as the wishes that motivate us 0 The id cannot tolerate frustration and seeks to discharge tension and return to a more comfortable energy 0 The id lacks the ability to problem solve it is not logical and operates according to the pleasure principle 0 The only needs that count are its own Think of a hungry screaming infant o Ego 0 Classical Psychoanalysis O O 0 Within the rst 5 years of life as the child begins to interact with others The ego is the problem solver and reality tester It is able to differentiate subjective experiences memory images and objective reality and attempts to negotiate the outside world The ego follows the reality principle which says to the id quotyou have to delay grati cation nowquot and then sets a course of action 0 Reality testing factoring in reality to implement a plan to decrease tension Superego 0 Last portion to develop represents the moral component of personality 0 Consists of the conscious and the ego ideal o The superego represents the ideal rather than the real it seeks perfection as opposed to seeking pleasure or engaging reason In a mature developed person these all work together as a team under the administrative leadership of the ego Defense Mechanisms and Anxiety Defense mechanisms are designed to alleviate the anxiety or combat the stressors Unconscious level except suppression quotdeny falsify or distort reality to make it less threateningquot p 21 Problem when the defense mechanisms work to well they become the problem Psychosexual Stages of Development Table 21 LOOK IN BOOK Implications for PMH nursing Personalities 39rooted from many past events Value of talking for client value of 39attentive listening of themes for nurse Defense Mechanisms not used today p 21 Freud s premise that all mental illness is cause by early intrapsychic con ict is no longer wildly thought to be valid and such therapy requires an unrealistically lengthy period of treatment Implications for PMH nursing Countertransference NURSE 0 When the nurse has feelings for the patient 0 Think of the nurse standing behind the counter transferring feelings onto the patient TransferencePATlENT o The patient has feelings for the nurse 0 The patient over identi es with the nurse 0 Psychodynamic Therapy rapid approach You have a speci c goal in mind Borrows from psychoanalytic model free association dream analysis transference and countertransference began after Vietnam Best clients are healthy functioning with speci c area needing change Common elements Rapid Assessment Clear expectations about 10 sessions Goals are concrete focus on what is wrong or certain symptoms Always looks at the present not historical No cure learn to cope better Therapist more involved Implications for PMH nursing One on one counseling Inforce what is learned from the sessions 0 Erikson s Psychosocial Stages of Development Different than Freud look at things over a lifetime not the rst 5 years Eight Stages of Development Review Table 22 Implications for PMH nursing 0 Basics of nursing and developmental assessments 0 Approach people based on developmental level not their age 0 Value of reapproaching 0 Approach the level that they are at not where they should be 0 Do not want them to re ect on their life if they didn t accomplish anything 0 As human beings we are never a done deal and it is never too late to go back and accomplish these things 0 2 Interpersonal Theories and Therapies Harry Stack Sullivan s Interpersonal Theory Am Psychiatrist 18921949 0 O 0 quotdefined personality as behavior observed within interpersonal relationshipsquot p 24 quotpurpose of behavior is to get needs met through interpersonal interactions AND decrease or avoid anxietyquot p 24 Implications to PMH nursing Purpose of therapy educate patient and help with insight development 0 quotParticipant observerquot p 24 o Underscores that professional helpers cannot be isolated from the therapeutic situation if they are to be effective 0 The nurse has to interact with the patient as an authentic human being 0 Be a good listener and give feedback 0 Unconditional acceptance respect and empathy necessary 0 Value of the psychotherapeutic environment Interpersonal Psychotherapy Adolph Meyer and Harry Stack Sullivan quotgoal of therapyreduce or eliminate psychiatric symptoms particularly depression by improving interpersonal functioning and satisfaction with social relationshipsquot p 24 Implications for PMH nursing Give them a safer behavior to deal with that anxiety 0 Something that is not violent or addictive 0 Believed that therapy should educate patient and assist them in gaining personal insite Hildegard Peplau s Theory of Interpersonal Relationships in Nursing 1909 99 and in uenced by Sullivan Identi ed PMH nursing as an quotessential element of general nursing and a specialty areaquot D 24 quotfocus from what nurses do to patients to what nurses do with patientsquot quotp 24 Mother ofPsychatric Nursing and the nursepatient relationship Identi ed Stages of NursePatient Relationship Psychiatric Nurse skills Observation Interpretation Intervention Develop interventions based on what is important to that patient Emphasized the importance of selfawareness Nursing is a science and an art quotcare for the person as well as the illness and 39think exclusively of patients as persons p 25 0 Think of patients as persons not disorders Implications for PMH nursing 0 RELATIONSHIP with the patient 0 Levels of Anxiety and interventions o Promotes interventions to lower anxiety with the aim of improving patient s abilities to think and function at more satisfactory levels 0 3 Behavioral Theories and Therapies Pavlov s Classic Conditioning Theory 0 Dogs that salivated in anticipation of the meat coming without actually tasting the meat He hypothesized that the psychic component was a learned association between two events the presence of the experimental apparatus and the serving of meat Classic Conditioning c When a neutral stimulus a bell was repeatedly paired with another stimulus food that triggered salivation eventually the sound of the bell alone could elicit salivation in the dogs 0 Classical conditioning responses are involuntary not under conscious personal control and are not spontaneous choices 0 Watson s Behaviorism Theory Founder of quotbehaviorismquot 0 Which he believed was more objective or measurable 0 Watson contended that personality traits and responses adaptive and maladaptive were socially learned through classical conditioning He made a loud noise with a hammer every time an infant would reach for the white rat and after that the infant became terri ed of the sight of white fur or hair even in the absence of loud noise Believed in role of social environment 0 He concluded that controlling the environment could mold a behavior and that anyone could be trained to be anything from a beggar man to a merchant o Skinner s Operant Conditioning Theory Operant Conditioning quotvountary behavior learned through consequencesquot quotbehavioral responses are elicited through reinforcement which causes a behavior to occur more frequentlyquot p27 A consequence could be a positive reinforcement such as receiving an award or a negative reinforcement such as the removal of an objectionable or aversive stimulus walking freely through a park once the vicious dog is picked up by the dog catcher Other techniques can cause behaviors to occur less frequently 0 One technique is an unpleasant consequence or punishment 0 Absence of reinforcement or extinction also decreases behavior by withholding a reward that has become habitual Implications for PMH nursing Foundation of all behavior programs to alter behavior 0 Programmed learning and Token Economics Behavioral Therapy can change behavior without insight into cause 0 Works best with Phobias schizophrenia amp substance abuse 0 How Behavioral Therapy works 0 Identify problem 0 Goals well de ned 0 Don t need insightjust do it Reinforced Do it again 0 Implications for PMH nursing Use of behavioral techniques such as 0 Role playingModeling In modeling the therapist provides a role model for speci c identi ed behaviors and the patient learns through imitation Role playing therapists demonstrate patterns of behavior that might prove more effective than those usually engaged in and then have the patients practice these new behaviors o Operant Conditioning Behavior Modi cationToken Economy Token economics 0 When desired goals are achieved or behaviors are performed patients might be rewarded with tokens which can be exchanged for food small luxuries or privileges Take your pills you get a sticker 0 Behavior is rewarded Uses positive reinforcement to increase desired behaviors 0 Systematic Desensitization Involves the development of behavior tasks customized to the patient s speci c fears these tasks are presented to the patient while using learned relaxation techniques Do things in increments Someone gets level 7 anxiety about ying 0 Take them to the airport till they get used to it then put them on a plane then eventually they get on a short ight Get them used to doing whatever they hate to do 0 Aversion Therapy Used widely to treat behaviors such as alcoholism violent and aggressive behaviors and selfmutilation Punishment for a certain behavior Sometimes the treatment of choice when other less drastic measures have failed to produce the desired effects 0 Biofeedback Learn to identify the early stages of a stressor or anxiety and then learn to control it Takes time and training 0 4 Cognitive Theory Therapy RationalEmotive Behavior Therapy REBT Albert Ellis quoteradicate core irrational beliefs by helping people recognize thoughts that are not accurate sensible or usefulquot p 28 A activating event B beliefs CEmotional Consequence Focus onquot current attitudes painful feelings and dysfunctional behaviorsquot p 29 quotthoughts negative and selfdeprecatingmore susceptible to depression and anxietyquot p29 quotwe can t change the past we can change the way we are nowquot p 29 CognitiveBehavioral Therapy CBT Aaron Beck How you think is how you feel Based on Cognitive and Behavioral theories feelings and behaviors are largely determined by the way people think about the world and their place in itquot p 29 quotcognitions based on attitudes or assumptions developed from previous experiencesquot quotThese cognitions may be fairly accurate or they may be distorted p 29 Automatic thoughts or cognitive distortions common in depression and anxietyquotirrationa and lead to false assumptions and misinterpretationsquot p 29 Works well with depression anxiety phobias and pain disorder Implication for PMH nursing 0 Term Cognitive ReframingRestructuring 0 Typical therapy that is used in psychiatry today 0 5 Humanistic Theories Comparisons in Table 25 Abraham Maslow s Humanistic Psychology Theory Maslow thought the earlier things were focused on the negative whereas Maslow was looking at what was achieved and what has been accomplished Author of quotselfactualized personalityquot review Box 22 Focused on strengths Heirarchy of Needs Review Figure 25 0 Starting from the bottom Physiological needs 0 The most basic needs food oxygen water sleep sex and a constant body temperature Safety needs 0 Once physiological needs are met these needs emerge 0 Security protection freedom from fear anxiety and chaos and the need for law order and limits 0 These take precedence during a crisis Belonging and love needs 0 People have a need for intimate relationships love affection and belonging and will seek to overcome feelings of loneliness and alienation Esteem needs 0 People need to have a high selfregard and have it re ected to them from others Selfactualization Human beings are preset to strive to become everything they are capable of 0 Implications for PMH Nursing 0 Human potential and strengths ID 0 Prioritizingsequencing 6 Biologic Theories and Therapies 0 The advent of psychopharmacology 1954 chlorpromazine Thorazine developed 19905 Decade of the Brain 0 The Biologic Model Neurological chemical biological and genetic components quothow does the brain interact to create emotions memories and perceptual experiencesquot p 33 Physical interventions used We have to encourage medical compliance Implications Revolutionalized treatment 0 Legitimatized MI helps with stigma More to mental illness than biology o 7 Additional Therapies 0 Milieu Therapy p33 1948 Bruno Bettelheim Controlling the environment Nurses role is to manage the Milieu quottotal environment people patients and staff setting structure and emotional climate important to healingquot p 33 Implications for PMH nursing Therapeutic Milieu SafeSecure Structured Decreased stress Promotion of socializing and involvement Supportvalidation Chapter 3 Visualizing the Brain 0 Structural o Anatomic changes CT lesions abrasions infarct 0 Psychiatric relevance and preliminary ndings 0 Schizophrenia Cortical atrophy Third ventricle enlargement Cognitive disorders Abnormalities MRI edema ischemia infection neoplasm 0 Psychiatric relevance and preliminary ndings 0 Schizophrenia 10 Enlarged ventricles Reduction in temporal lobe and prefrontal lobe 0 Functional Physiologic activity 0 PET 02 utilization glucose blood ow 0 Psychiatric relevance and preliminary ndings Schizophrenia 0 Increased D2 and D3 receptors in caudate nucleus Abnormalities in limbic system Mood disorder Abnormalities in temporal lobe Adult ADHD o Decreased utilization of glucose 0 SPECT Circ CS uid Figure 35 36 37 0 Psychiatric relevance and preliminary ndings See PET Look for ischemia infarction trauma when doing CT scans Looking for something that is either structural or functional know the difference between the different kinds of testing Disturbances of Mental Function Much is still unknown Do know drugs hormones infection physical trauma mental dysfunction 0 LSD prescription drugs estrogen imbalance too much or too little testosterone infection concussion Genetic predispositionstwin studies concordance Environmental in uences NT in limbic system 0 Norepinephrine dopamine serotonin monoamine transmitters o GABA and glutamate aminoacid transmitters and corticotropin releasing hormone CRH and endorphin neuropeptides and acetylcholine De ciency of norepinephrine andor serotonin depression Figure 39 Excess of dopamine plus others schizophrenia Figure 310 0 Too much dopamine schizophrenia 0 Too little dopamine Parkinson s disease De ciency of GABA anxiety disorders quotAlterations in neurotransmitter activity due to a mental disturbance or to the drugs used to treat the disturbance can affect more than one area of brain activity changes in basic drives sleep patterns body movements and autonomic functions quot p 50 Drugs affect other areas of the brain not just the parts where there is mental dysfunction Mechanisms of Action of Psvchotropic Druqs Pharmacodynamics effect on body mech of action 0 How the drug effects the body the mechanisms of action Pharmacokineticsaction of body on drugs 0 How its absorbed metabolized excreted Pharmacogeneticssee Considering Culture Box page 51 0 Different drugs work differently on different cultures and ethnicities and races 34n ideal psychiatric drug would relieve the mental disturbance of the patient Without inducing additional cerebral mental or somatic physical effect Unfortunateythere are no druds that are both fulV effective and free of undesired side effects p 51 quotBecause all activities of the brain involve actions of neurons neurotransmitters and receptors these are the targets of pharmacological interventionsquot p 52 Psychotropic drugs increase or decrease activity of NT receptors p 52 11 NO speci c meds Chapter 4 Clinical Orientation Continuum of P vchiatric Mental Health Ca Movement along the continuum is uid and can go in any direction Least restrictive to most intensive o Primary care providers 0 Specialty care providers 0 Patientcentered medicalhealth homes 0 Community clinics Transitional outpatient treatment 0 l Psychosocial rehabilitation program PRP 0 Clinical case management Then there s o Psychiatric home care 0 l Assertive community treatment ACT 0 l Intensive substance abuse program 0 Partial hospitalization program PHP Most acute treatment 0 ER 0 Crisis stabilization unit 0 l Locked inpatient unit Prevention in Communitv Care Treatment is based on a public health model that takes a community approach to prevention There s primary secondary and tertiary levels of prevention Primary occurs before any problem is manifested and seeks to reduce the incident or rate of new cases 0 There is evidence that primary prevention might prevent or delay the onset of symptoms in genetically or otherwise vulnerable individuals Secondary prevention is also aimed at reducing the prevalence or number of new and old cases at any point in time of psychiatric disorders 0 Early identi cation of problems screening and prompt and effective treatment are hallmarks of secondary prevention 0 This level of prevention is the secondary defense against disease Tertiary prevention is the treatment of disease with a focus on preventing the progression to a severe course disability or even death 0 Encompasses the term rehabilitation which aims to preserve or restore functional ability Outpatient and Communitv P vchiatric Mental Health C Psychiatric mental health nursing in the outpatient or community setting requires strong problem solving and clinical skills cultural competency exibility solid knowledge of community resources and comfort in functioning more autonomously than acute care nurses Community treatment hinges on enhancing patients strengths in the daily environment making individually tailored psychiatric care imperative Primary care providers 0 Primary care providers recognize that psychiatric illness can be manifested by physical symptoms and also realize that psychiatric disorders can intensify preexisting conditions 0 Many psychiatric disorders are discovered in the primary care setting Specialty psychiatric care providers 0 More efficient comprehensive psychiatric care 0 This is someone whose practice focuses solely on psychiatric care such as an advanced practice psychiatric nurse psychiatrist psychologist social worker or licensed therapist 0 Provide numerous services such as prescribing meds practicing individual psychotherapy and leading group therapy 12 0 Ideal for people looking for treatment speci cally for their problem 0 Patientcentered medical homes 0 CoIocation of primary and specialty care in communitybased mental health settings 0 Integration of primary care and behavioral health care helps eliminate stigma o More accessibility to service 0 Community mental health centers 0 The range of services available at the centers varies but generally includes emergency services adult services and children s services 0 Common treatments include medication administration individual therapy psychoeducational and therapy groups family therapy and dualdiagnosis treatment 0 Clinical may be aligned with a psychosocial rehab program that offers a structured day program convocational services and residential services 0 Some have an associated intensive psychiatric case management service to assist patients in nding housing or obtaining entitlements 0 Psychiatric home care 0 De ned by Medicare regulations as requiring 4 elements homebound status of the patient presence of a psychiatric diagnosis need for the skills of a psychiatric registered nurse and development of a plan of care under orders of a physician Assertive community treatment 0 Intensive type of case management developed in response to the hard to engage community Iiving needs of people with serious persistent psychiatric symptoms and patterns or repeated hospitalization for services such as emergency room and inpatient care 0 Multidisciplinary teams typically composed of psychiatric mental health registered nurses social workers psychologists advanced practiced registered nurses and psychiatrists 0 Partial hospitalization programs 0 Intensive shortterm treatment similar to inpatient care expect that the patient is able to return home each day 0 Typically 56 hours per day and usually last 12 weeks 0 Other outpatient venues 0 Mobile health units 0 Telephone crises counseling telephone outreach and the internet Biopsychosocial assessment 0 Assessment of the biopsychosociaI needs and capacities of patients living in the community requires expansion of the general psychiatric mental health nursing assessment 0 To be able to plan and implement effective treatment the nurse must also develop a comprehensive understanding of the patient s ability to cope with the demands of living in the community 0 Key elements are related to the probability that the patient will experience successful outcomes 0 Assessment of the Biopsychosocial needs and capacities of patients living in the community Key elements related to the probability that the patient will experience successful outcomes 0 Treatment goals and interventions 0 Treatment goals and interventions are patientcentered and are therefore negotiated rather than imposed on the patient 0 Community psych nurses must approach interventions with exibility and resourcefulness 0 Treatment goals and interventions table 41 Goals 0 Stable or improved level of functioning in the community Interventions Establish longterm therapeutic relationship 0 Develop comprehensive plan of care with patient and support system with attention to sociocultural needs and maintenance of community living 0 Encourage adherence with medication regime Teach and support adequate nutrition and selfcare with referrals as needed 0 Assist patient in selfassessment with referrals for health needs in community as needed 0 Use creative strategies to refer patient to positive social activities 13 0 Communicate regularly with familysupport system to assess and improve level of functioning Case management 0 The role of the community psychiatric mental health nurse includes coordinating mental health physical health spiritual health social service educational service and vocational reams for the mental health patient 0 Integrating a nurse case manager to assist patients with primary care needs facilitates greater success with followup and adherence with appointments 0 Promoting continuation of treatment 0 Shared decision making is the key to improving treatment adherence and success 0 Patientfamily education and behavioral strategies in the context of a therapeutic relationship with the clinician promote adherence with the medication regimen Nursing education 0 A baccalaureate degree is preferred un more autonomous community settings and will become increasingly in demand as the trend away from hospitalbased acute care settings continue however educators believe that nonbaccalaureate prepared nurses should be trained to meet the challenges of providing community care Teamwork and collaboration 0 Look in book pg 72 0 Emergency care and crisis stabilization o The primary goal in emergency services is to perform triage and stabilization o In reality ED care often provides a bridge from the community to more intensive psychiatric services 0 Primary goal is to perform triage and stabilization 0 Comprehensive emergency service model Often affiliated with a fullservice ED Dedicated cinica space with specialty staffing o Hospitalbased consultant model Generally not dedicated cinica space or comprehensive separate staffing Psychiatric clinical staff members are assigned to a speci c hospital and are onsite or on call 0 Mobile crisis team model Stabilization quotin the field Clinicians are available to respond to where the crisis is and will conduct psychiatric evaluations in the community with a goal to assess and stabilize without a full ED visit 0 Crisis stabilizationobservation units 0 Care models that prioritize rapid stabilization and short length of stay 0 Overnight shortterm observation often 13 days are designed for individuals who have symptoms that are expected to remit in 72 hours or less Inpatient Psychiatric Mental Health Care 0 Entryadmission criteria 0 lmminent danger to self or others 0 Unable to care for basic needs impairment ofjudgment imminent risk based on inability to protect oneself 0 Rights of the hospitalized patient selfexplanatory Working as a Team in Inpatient Ca o Multidisciplinary treatment team 0 Psychiatric mental health registered nurses psychiatric mental health advanced practice registered nurses psychiatrists psychologists social workers counselors occupational and recreational therapists medical advanced practice nurses or medical doctors and physician assistants mental health workers pharmacists 0 Clinical pathways 0 Documentbased tools that provide suggestions and time frames fro managing speci c medical conditions 14 0 Provide a link between evidencebased knowledge and clinical practice 0 Used to provide standardization in treatment and improve outcomes 0 Therapeutic milieu 0 Managing behavioral crisis Codes lf preventative measures fail and imminent risk or harm persists each member of the team participates in a rapid organized plan to safely manage the situation 0 Safety need identi ed and individualized interventions made 0 Unit design to promote safety Room doors open Continuous hinges on doors rather than threebutt hinges to prevent hanging risks Furniture anchored in place Drapes mounted on a track that is rmly anchored to the ceiling rather than curtain rods Mini blinds contained within window glass rather than mountings No bathroom towel bars Steel boxes around plumbing Mirrors are stainless steel and not gass 0000000 0 Inpatient Psvchiatric Nursinq Care 0 Assessment 0 Risk for violence to self or others and disturbed sensory perception auditory o SAFETY Identity patient correctly Use medicine safely Prevent infection ldentify patient safety risk 0 Therapeutic groups 0 Speci c structured activities involving the therapeutic community special groups or families 0 Psychoeducational groups for patients and families on topics such as stress management coping skills grieving medication management and communication skills 0 Preparation for discharge to the community 0 Modi ed as required by the patient s condition 0 Typically patients are discharged when serious symptoms are in control and there is a discharge plan in place 0 Nurses assist patients and their families to prepare for independent or assisted living in the community 0 Communitybased programs provide patients with psychosocial rehabilitation which moves the individual beyond stabilization toward recovery and a higher quality of life 0 Focus on precipitating factors that led to the crisis and hospital admission Chapter 5 Culture and Mental Health 0 Where do Psychiatric theoriesmethods have their roots p 86 o Are part of a cultural tradition and our nursing care is a culturally derived set of interventions designed to promote the verbalization of feelings teach individually focused coping skills and assist patients with behavioral and emotional selfcontrol a consistent with Western cultural ideals Understand meaning of enculturation ethnocentrism cultural imposition o Enculturation we have to learn from that culture The culture s worldview beliefs values and practices are transmitted to its members in this process 0 Ethnocentrism you believe there is only one way and your way is the right way The universal tendency of humans to think their way of thinking and behaving is the only correct and natural way 0 Cultural imposition pushing that way onto different culture 0 Compare and contrast between AmericanWestern Culture and other Cultures 15 0 Selected Nonverbal Communication Patterns Table 33 0 LOOK IN BOOK 0 Norms of Etiquette Box 51 0 Whether quotpromptnessquot is expected and how important it is to be on time Which people deserve recognition and honor and how respect is shown How formal one should be in addressing others Whether shaking hands and other forms of social touch are appropriate Whether or not shoes can be worn in the home How much clothing should be worn to be modest What it means to accept or reject offers of food or drink and other gestures of hospitality What importance is given to quotsmall talkquot and how long it should continue before quotgetting down to businessquot Whether communication should be direct and forthright or circuitous and subtle What the tone of voice and pace of the conversation should be Which topics are considered taboo Whether or not the children in the home can be touched and admired 0 Cultural Belief and Value Systems Table 54 0 LOOK IN BOOK 0 Cultural Beliefs and Values about Health and Illness Table 55 0 LOOK IN BOOK 0000000 000 O Barriers to Quality Mental Health Services 0 Communication Barriers 0 Therapeutic communication is key to the care of patients with mental illnesses yet often nurses and patients do not even speak the same language 0 Interpreters can also act as a cultural broker interpreting not only the language but also the culture 0 Interpreters should not be friends or family members of the patient 0 Lack of eye contact might be a red flag for us in our culture but in other cultures lack of eye contact shows a sign of respect 0 Nonverbal communication patterns should be interpreted from within the patient s cultural perspective not from the Western medical perspective 0 Create barriers to people getting quality mental health services 0 Many people in all sectors of society in the United States associate mental illness with moral weakness 0 In cultural groups that emphasize the interdependence and harmony of the family mental illness may be perceived as a failure to the family 0 Stigma and shame can lead to reluctance to seek help 0 Misdiagnosis 0 Black afro Caribbean Hispanic and Asians get misdiagnoses a lot Symptoms can be somatic but it is psychologic distress There are a lot of assumptions They are often misdiagnosed with schizophrenia when the true diagnosis is bipolar disease or an affective disorder 0 One reason for misdiagnosis is the use of culturally inappropriate psychometric instruments and other diagnostic tools 0 Also psychological stress is manifested in different cultures in different ways 0 Somatization When you re having physical complaints but they are actually psychological distress that exhibits physical symptoms 0 CultureBound Syndromes Box 52 Sets of signs and symptoms that are common in a limited number of cultures but virtually nonexistent in other culture groups Look in book 0 Genetic Variation in Pharmacodynamics Ethnopharmacology 0 Different ethnicities have genetic variations and the drugs may not work so well on them 0 Impacts a lot of Africans and Asians 16 0 There is a genetic variation in drug responses Populations at Risk review in bookI pg 92 o Immigrants o Refugees 0 Cultural minorities nonwhites Culturallv Competent Care 0 Cultural competence 0 Nurses adjust their practices to meet their patients cultural beliefs practices needs and preferences 0 Having cultural sensitivity or awareness is an essential component of cultural competence o Culturally competent care goes beyond culturally sensitive 0 Cultural Awareness 0 Through culture awareness the nurse recognizes the enormous impact culture makes on what patients health values and practices are how and when the patients decide they are ill and need care and what treatments they will seek when iness occurs 0 We have to be aware of how culture affects disease and illness we have to be aware of our own culture and that there are differences from group to group 0 Cultural Knowledge 0 Cultural knowledge is proactive when it prevents nurses from assuming that they share a patient s underlying worldview and values it highlights areas in which there may be cultural differences 0 Knowledge of different cultures and helps to prevent misinterpretation of behaviors Cultural Encounters 0 Opportunities that you can take to get to interact with a culture You do not want to avoid that culture Take a chance to work with someone who is a different culture than you It will help you avoid generalization and stereotyping Generalization o Saying that everyone in that culture does a certain thing assuming that because they are of that culture they always follow certain practices generalization based on fact Stereotyping 0 Something that isn t based on facts a generalization that is not based on fact 0 ntraethnic diversity 0 There are different cultures within every race look up 0 Although there are patterns that characterize a culture individual members of the culture adhere to the culture s norms in diverse ways 0 Cultural Skill 0 Learning to assess in a sensitive way depending on their culture 0 The ability to perform a cultural assessment in a sensitive way 0 Cultural Desire 0 Not being afraid to learn from the patient about their culture 0 Indicates that the nurse is not acting out of a sense of duty but from a sincere and genuine concern for patients welfare Chapter 6 Ethical concepts 0Ethics quotstudy of philosophical beliefs about what is right or wrong p99 0Bioethics ethica questionshealthcare p99 o Bene cence promoting good 0 Autonomy making own choices 0 lustice fair and equal treatment 0 Fidelity doing no wrong 0 Veracity teing the truth 0 Ethical dilemma con ict between two or more courses of action p 99 0 Two concepts are at odds l 17 Mental Health Laws 0 Created to regulate the care and treatment of the mentally ill State by state httpwwwiloaoovleoislationilcsilcsZasoChapterlD34 Community Mental Health Centers Act of 1963 deinstitutionalization Drug Courts and Mental Health Courts Better place to get people a better treatment instead ofjust putting them in jail Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Acteffective July 2010 O O O 0 Affordable Care Act2010 Insurance Funding Civil Rights of Persons with Mental Illness see list on pages 99 100 They can still vote They can enter into contracts They can have a driver s license They have the right to be treated humanely oThey have the right to religious freedom 0 They are allowed to exercise and socialize oThey can still press charges on people Admission and Discharge Procedures 0 Admission ProceduresBasic Guidelines 0 Discharge Proceduresdependent on admission process and patient condition 0 0 Voluntary Admissions A patient applies to be admitted They want to be in a controlled environment Due Process in Involuntary Admission O O O Involuntary admission 39massive curtailment of liberty p 100 Fifth AmendmentFourteenth Amendment Writ of habeas corpus legal procedure to challenge unlawful detention Least restrictive alternative doctrine O O O 0 O 0 Can this person be treated on an outpatient basis rst Will they be okay if they go to a PHP program rst Will something else work before they are unwillfully detained on an inpatient unit Admission to psychiatric facilities has nothing to do with ability to make their own informed decisions For instance if they don t want to take a certain drug because they have had it before and it made them feel bad they can say no and are not forced to take it A medical standard orjusti cation for admission must existquot p 100 DSMV diagnosis needed quotimmediate crisis situation developed g other less restrictive alternatives are inadequate or unavailablequot p 100 quotreasonable expectation that the hospitalization and treatment will improve situationquot p 100 Voluntary Admissionarrangements with patient and physicianED ltltltltneed to know voluntary vs involuntarygtgtgt I Involuntary Admissionquotcommittedquotadmitted without consent due to a danger to self b or others and0r c unable to meet his or her basic needs 0Still considered competent until determined otherwise 0Has freedom from unreasonable restraints and the right to refuse meds 0Still have right of informed consent oHave the right to refuse medications oHave the right to not be unreasonably restrained 0What the proposed treatment is the risk and benefits of that treatment alternative options how successful that treatment is and the risks of not having it Voluntary patients Discharged by physician 5 day noticewant to leave sign paper requiring them to stay 5 work days team determines in that time frame IF safe to leave or begin commitment proceedings to become involuntary 18 olf the treatment team believes the person is a threat to themselves or someone else they will not let them out 0lf they re not any better you either have to take them to court and put an involuntary admission on them OR if they are not better by our terms but are not a harm to themselves we have to let them go AMA 0Leaving against medical advice because they are not a threat to themselves or others olnvountary patients Dependent on physician discharge or court mandated discharge Can sign in voluntary Patient Rights Tort aw Right to treatment humane quali ed staff individualized care p 101 Right to refuse treatment see Tables 61 and 62 olnvountary committed client has right to refuse meds oMedicated against their will quotIn an emergency to prevent a person from causing serious and imminent harm to self or other a person may be medicated without a court hearingquot p 102 Following court hearing a person can be medicated if he or she meets all of the following criteria SM 0Serious mental illness Deteriorating OR suffering OR threating BH Bene ts outweigh harm I Person acks capacity to make decision Less restrictive measures don t work p 103 Right to informed consent 0 quotquotthe presence of psychotic thinking does not mean that the patient is incompetent or incapable of understandingquot p 103 o Competent unless declared by courts 0 Much of what nurses do require implied consent ECT requires informed consent Rights regarding involuntary admission and advance psychiatric directives o Allows patient to plan ahead seect surrogate and express treatment wishes Rights regarding Restraint and Seclusion 0 Least restrictive doctrine more on this with Clinical TIE Rights regarding con dentiality oHlPAA 1996 Constitutional right to privacycan t disclose EVEN TO EMPLOYERS o ANA Code of Ethics for Nurses Box 62 Right of privacy 0 Con dentiality after death Dead Man s Statute p 105 oProfessionaI communications nurse does have con dentiality oCon dentiality and the HIV Status Exceptions to the rule Duty to warn and protect third party 0Tarasoff vs Regents of University of California 1974 p 106 oRole of the nurse the nurse MUST Report to the team and DOCUMENT oStatutes for Reporting Child and Elder Abuse Nurses MUST oReport eder and child abuse Box 63 Failure to protect patients Liability issues failure to maintain safety quotcivil wrong for which money damages may be collectedquot Intentional quotwillful vioation of rightspropertyinvasionquotp 108 Unintentional quotunintended actsquot p 108 negligenceprofessional malpractice Box64 oDuty must be able to do the job 0 Breach of duty not meeting standard of care commission or omission 0 Cause Ask quotWould this have occurred if the nursequot 19 Had acted differently o Proximate cause legal cause 0 Damages including pain and suffering p 108 o Foreseeability of harm quotIf the average reasonable nurse could foresee that injury would result from that action or lack of actionquot p 108 Determination of a Standard of Care 0quotNurses are held to a basic standard of carequot p 109quotbased on what other nurses who possess the same degree of skill or knowledge in the same or similar circumstances would doquot p 109 0Remember NCLEX passages assures minimum quali cation 0PMH Nursing Scope and Standards of Practiceinside back cover of this text Guidelines for ensuring adherence to Standards of Care 0Negligence lrresponsibility or Impairment oCommunicate Document Report to supervisor and use channels of command 0Unethical or Illegal Practices oCommunicate Document Report to supervisor and use channels of command oDuty to Intervene and Duty to report when patient s safety is jeopardized oCommunicate Document Report to supervisor and use channels of command 0 Always document always pass on to the team Documentation of Care 0Medical Records and Quality Improvement oMedical records as evidence 0Guidelines for electronic documentation 0 There are privacy issues surrounding electronic documentation Violence in the Psvchiatric Settinq 0quotGood judgment not placing oneself in a potentially violent situationquot p 111 oWorkplace violence legislation ANA 2012 Fig 61 oWant to anticipate that it s a problem before it s a problem 0You want to keep everyone safe and deescalate the situation before it gets out of control oYou want to protect yourself oDo not go into a room alone with someone where they have access to the door and you don t oWant to let someone know if you are going somewhere that is going to be private 0 Scan the area to see if there is support staff if you are around someone who might be dangerous 0 Use good judgement and anticipate a situation that may become dangerous Chapter 7 Clinical Orientation Integration of Nursing Process and Standards 0 Assessment 0 Construct database Mental status exam looking at appearance behavior speech mood cognition perceptual disturbances hallucinations and illusions and assessing if the individual has ideas of harming self or others Psychosocial assessment looking at previous hospitalizations educational and occupational backgrounds family life social patterns sexual patterns coping abilities spirituality and substance use Physical examination History taking Interviews Standardized rating scales 20 0 Verify the data 0 Diagnosis 0 Identify problem 0 Identify etiology 0 Construct nursing diagnosis 0 Prioritize nursing diagnosis 0 Outcomes and identi cation 0 Identify attainable and culturally expected outcomes 0 Document expected outcomes as measurable goals 0 Include time 0 Planning 0 Identify safe pertinent evidence based actions 0 Document plan 0 Evaluation 0 Document results o If outcomes have not been achieved at desired level gather additional data reassess and revise the plan Levels of Intervention Basic level and advanced practice interventions 0 Coordination of care 0 Health teaching and health promotion Selfcare activities 0 Milieu therapy Helps patients feel comfortable and safe Orienting patients to their rights and responsibilities by selecting speci c activities that meet the patients physical and mental health needs and ensuring that the patients are maintained in the least restrictive environment safety permits 0 Pharmacological biological and integrative therapies Teaching medication to pt and family including adverse effects action drug interactions and dietary restrictions 0 Advanced practice interventions o Prescriptive authority and treatment Prescribing psychiatric drugs 0 Psychotherapy 0 Consultation Chapter 8 Clinical Orientation Table 83 Common patient behaviors and Nurse Respons s o If patient threatens suicide 0 Assess whether the patient has a plan and the lethality of the plan 0 Tell the patient you need to share the information 0 Discuss with the patient the feelings and circumstances that led up to this decision 0 Patient asks the nurse to keep a secret 0 Nurse cannot make such a promise let the patient know that o If the patient asks the nurse a personal question 0 Nurse may or may not answer the question o If the nurse decides to answer he or she answers in a word or 2 then refocus back to the patient 0 Patient makes sexual advances 0 Nurse needs to set clear limits on expected behavior quotI am not comfortable with having you touch mequot 0 Frequently restating the nurse s role throughout the relationship can help maintain boundaries o If patient doesn t stop nurse might sayquotlf you can t stop this I will have to leave I will be back at time to spend time with you themquot return at stated time o If patient cries 0 Nurse should stay with the patient and reinforce that it is all right to cry 21 o If patient leaves before the session is over 0 Patient might be testing the nurse say quotI will wait for you here for 15 minutes until our time is upquot during this time the nurse does not engage in conversation with any other patient or staff When time is up nurse approaches patient says the time is up and restates the day and time the nurse will see the patient again o If the patient doesn t want to talk 0 Can say quotIt is all right I would like to spend time with you we don t have to talkquot 0 Nurse might spend short frequent periods ex 5 mins with the patient throughout the day quotour 5 minutes is up I will be back at 10am and stay with you 5 more minutesquot o If the patient gives the nurse a present o If the gift is expensive graciously refuse o If it is inexpensive If given when a relationship has developed can accept If given at beginning graciously refuse and explore the meaning behind the gift are they giving it to you because they are concerned you will overlook them o If another patient interrupts during time with your current patient 0 quotI am with Mr Rob for the next 20 minutes At 10am after our time is up I can talk to you for 5 minutesquot Chapter 8 Concepts of NP Relationship Patientcentered care quotgold standardquot Core concepts p 132 o Dignity and respect 0 Information sharing You can t help that patient if they don t share with you what is going on with them and you have to be open with the patient 0 Patient and family participation Having them participate in the care and treatment plan helps to continue the care when the patient leaves the hospital 0 Collaboration Patient is in the middle nurse makes sure everyone collaborates quotThe nurse patient relationship is the basis of all psychiatric mental health nursing treatment approachesquot p 132 0 Therapeutic use of selfwhat are YOUR unique gifts 0 Have to know what your talents are and what your gifts are and use them to develop a therapeutic relationship with your patient 0 quotthe efficacy of this therapeutic use of self has been scienti cally substantiated as an evidencebased intervention quotRandomized clinical trials have repeatedlyquot p 132 o quotpsychotherapy talk therapy actually changes brain chemistryquot same as medications do quotthe best treatment for most psychiatric problems less so with psychotic disorders isquot the combination of medication with psychotherapy p 132 0 quotEstablishing a therapeutic relationship with a patient takes time Skills in this area gradualy improve with guidance from those with more skill and experience p 132 0 Note Students have quotTherapeutic Encountersquot students are not there to actively help the client as much as to learn how to help future clients Even Therapeutic Encounters can be powerful to the patientand the student nurse The STAFF should have the therapeutic relationship and are charged with actively helping the client 0 Positive relationships predict positive outcomes 0 Goals and Functions of the nursepatient relationship 0 quotFacilitating communication of distressing thoughts and feelings Communication is extremely important 0 Assisting patients with problem solving to help them facilitate their activities of daily living What can t they do because of their mental illness and how can we problem solve it 0 Helping patients examine selfdefeating behaviors and testing the alternative 0 Promoting selfcare and independencequot p 132 0 Review Social versus Therapeutic page 132 22 o If the nurse allows the relationship to become too social it is no longer therapeutic and the patient will get the wrong idea of what your relationship is Therapeutic Relationships Accountability 0 Behavior and consequences for action 0 Focus on patient needs 0 Want to focus on patients needs not our own 0 It s better for patients to do things independently and on their own because you doing everything for them is not therapeutic 0 Clinical competence o Staying current using EBP Delaying Judgment 0 Do not direct your beliefs on the patient Supervision Clinical Supervision Role of Faculty and Mentors o What is needed for novice nurses Relationship of boundaries and roles 0 Establishing Boundaries Boundaries protect the patient and nurse 0 Physical General environment Locked vs open unit 0 Day room vs their room 0 Contract Con dentiality What you have to share with other people and who that is 0 Personal space Can be physical or emotional physical space Set by rules starting further away than moving closer Blurring of Boundaries 0 Problems with talking too social with patient selfdisclosure Problems when nurse s needs are met at expense of patient p 134 0 Make sure your PT is independent and you are not doinggetting everything for them 0 A shift in the nursepatient relationship may lead to nontherapeutic dynamics Boundaries are primarily necessary to protect the patient Values Beliefs and Self Awareness 0 quotSelf awareness we have an understanding of our own values and attitudes so we may become aware of the beliefs or attitudes we hold that may interfere with establishing positive relationships with those under our care p 137 o If our values are different than our patients you want to be sure they don t interfere with the care you are going to give 0 Our values and attitudes o All of us have a bias about something 0 Re ect our culturesubculture 0 Come from a range of choices 0 We have chosen from a variety of in uences and role models 0 See page 137 for a list of examples of possible con icts o Vey strong feelings about Abortion Suicide Divorce Supervision by an experienced colleague can prove invaluable 23 States of Nurse Patient Relationship 0 Table 83 Common Patient Behaviors will be reviewed as part of your Clinical Orientation the 1st day of clinical Use this Table as a valuable resource 0 Preorientation Deal with your anxiety with open mindedness nonjudgmental attitude and empathic approach 0 Before you meet the patient where you are doing selfre ection Orientation 0 Establishing rapport Offerintroduce yourself 0 Parameters and contract How much time you have with that patient and what your role is going to be Let them know what you are going to be doing and how long you have 0 Con dentiality What and to who you can disclose to Have to share info with treatment team 0 Terms of termination When the relationship is going to be up 0 Housekeeping is accomplished in orientation 0 Working Phase 0 Working on the actual problem that the patient has 0 Termination Phase 0 Dealing with guilt and how to say goodbye The goodbye is a healthy thing you want to see your patient move on 0 Review on what you ve worked on together and how far you ve come Hinders Nurses39 lack of awareness of feelings and the impact on the patient 0 Awareness is very important 0 Make sure that when you are using relaxing and empathetic comments that you are not going through a routine 0 When you use blanket statements all the time patients pick up on it o Inconsistency and unavailability of the nurse 0 The nurse not approaching the patient or not being approachable o If the nurse doesn t follow through on what he or she says they are going to do If you say you are going to go back to the room you have to go back 0 When the nurse is inconsistent it can be very hot and cold It can affect the relationship between the nurse and the patient You need consistency you need to leave your problems at the door Helps Helps rst 5 are in nurses control 0 Consistency As a supervisor assigning the same nurse to the same patient 0 Pacing don t push but do lead Takes time Short frequent approaches are important 0 Listening quotthe most important skill for nurses to masterquot p 142 More than simply not talking or simply hearing Has to do with processing that and being able to re ect back on that with them 0 Initial impressions watch preconceptions and judgments You never have a second chance to make a rst impression 0 Promoting patient comfort and balancing control caring behaviors Don want to be too cold don t want to be too social You have to be uid 0 Patient factors trust and active participation by patient 24 Factors that encourage and Promote Patient39s Growth GenuinenessCongruence quotwhat is displayed on the outside of the person is congruent with the internal processesquot p 143 Selfawareness needed 0 Genuineness promotes patient growth 0 Empathy versus Sympathy 0 With sympathy you get over involved and feel their problem 0 With empathy you understand but you don t feel their problem 0 quotcognitive rather than emotional skillquot p 143 Feel sympathy empathy is more cognitive because you can think and understand but not feel 0 quotconsistent with improved patient outcomes and increased patient satisfactionquot p 143 0 YES we can learn to increase our depth of understanding another s experiences 0 Remember we never understand quotI understandquot NO NO 0 How do we make empathic comments It must be hard scary difficult etc How difficult how hard how sad how scary 0 You do not want to say quotI understand because even if you think you can identify with someone you can t 0 Positive Regard 0 Respect Communicated via 0 Attitudes quottakes the patient and the relationship seriouslyquot 0 p 144 Opportunity to grow personally and help pt grow not a job 0 Actions 0 Attending quotspecial kind of listening that refers to an intensity of presence or being with the patientquot p 144 o Suspending value judgments quot nurses are more effective when they guard against using their own value systems to judge patients thoughts feelings or behaviorsquot p 144 0 Helping clients develop resources quotIt is important that patients remain as independent as possible to develop new resources for problem solvingquot p 144 Build on their strengths so that they become independent 0 You have genuine carring and you really want to work with them Chapter 9 Communication Process Communication Process 0 Stimulus need for information comfort advice etc is sent to the sender then the message either verbal or nonverbal is sent to the receiver through some type of media then the receiver perceives the message and formulates feedback Agrees with the message Disagrees with the message Needs clari cation quotis this what you meant Provides info Requests more info Gives feedback verbal nonverbal or both 0 Factors that affect communication 25 Personal factors Environmental factors Relationship factors Verbal and NonVerbal 0 Get mixed messages when verbal and nonverbal communication is not congruent o Verbal message content of the message 0 Nonverbal behavior process of the message Posture and body movements and gestures Facial expressions Personal appearance Physical characteristics Eye expressions Voice tone pitch pauses etc 0 Double bind message mix of content what is said and process what is conveyed nonverbally Example when I want to go out and my mom says quotoh go ahead and have fun I ll just sit her all by myselfquot even though she said I could go out she actually doesn t want me to because she wants me to stay home so she can spend time with me Therapeutic Communication Techniques 0 Use of silence Silence can be based on anxiety If during the time youre silent and you get anxious it is no longer therapeutic because the pt will feel your anxiety because it is contagious 0 Giving recognition 0 Restating o Re ecting 0 Exploring 0 Giving info 0 Active listening Observing the pts nonverbals Listening to and understanding the context of social setting Listening for areas needing clarification or are inconsistent Providing pt with FEEDBACK Active listening always makes it easier for the pt to solve their own problem Active listening increases self esteem and encourages the client to nd a way to deal with their problems 26 o Clari cation If you need a clearer understanding what the client is saying or means Paraphrasing quotin other wordsquot 0 When the client says something then you put it in your own words to clarify and help with communication Restating repeating same key words Re ecting questions or a simple statement that conveys the nurse s observation Exploring tell me more describe to me give me an example Asking open ended questions Using closed ended questions sparingly Nontherapeutic Communication Techniques 0 Excessive questions it might overwhelm them 0 Giving approval or disapproval 0 Giving advice 0 Don t ask why questions because the client may think that you re accusing them 0 Don t said I understand Cultural considerations 0 Communication styles 0 Eye contact don t stare look across the room when you are talking to the patient when the client is talking always look at the client even if heshe isnt looking at you the best way you can pay attention is to look at the client 0 Touch use cautiously 0 Cultural Filters Clinical Interview 0 Introduce yourself 0 Pace yourself 0 Speak brie y 0 When you do not know what to say say nothing 0 When in doubt focus on feeling 0 Avoid advice 27 0 Avoid relying on question s 0 Pay attention to verbal cues 0 Keep the focus on the patient 0 Eye contact is important when they are speaking 0 Have an open approach to clients 0 Focus is on you the nurse so you can be a better more effective nurse to your pts Chapter 31 clinical orientation Serious Mental lllness Across the Lifespan Occurs in any gender age culture or location 0 There are two type of people 0 Those who are old enough to have experienced long term institutionalization before 1975 0 Those young enough to have been hospitalized only for acute care during exacerbations of their disorders Development of Serious Mental Illness 0 Example from the book a person with schizophrenia may experience disturbed though processes and social skills which causes interactions with others to become increasingly awkward and anxiety provoking for both the patient and others People begin to avoid interactions with the affected person an din turn the person s self esteem and social skills weaken Issues Confrontinq those with Serious Mental Illness 0 Establishing a meaningful life Comorbid Conditions 0 Physical conditions 0 Depression and Suicide 0 Substance Abuse 0 Social Problems 0 Stigma 0 Isolation and loneliness o Vicitimization 0 Economic Challenges 0 Unemployment and Poverty 0 Housing Instability o Caregiving burden 0 Treatment Issues 0 Nonadherence Anosognosia lack of insight Medication side effects Treatment inadequacy Residual symptoms 0000 Fa15dcaw 28
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