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This 30 page One Day of Notes was uploaded by Briana Casiano on Wednesday October 15, 2014. The One Day of Notes belongs to a course at Indiana University taught by a professor in Fall. Since its upload, it has received 136 views.
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Date Created: 10/15/14
Psych Lecture Outlines Unit 13 101514 927 PM Overview Mental Status Examination o Appearance Yes appearance is just as straightforward as it seems For example how does your patient look smell behave orspeak How the patient relates to the interviewer is also important Is the patient withdrawn cooperative distant shy relaxed cautious hostile or FRIGHTENED o Speech Speech patterns can be assessed for speed Some illness conditions have concomitant speech patterns One of those patterns is a characteristic rate 2 Rate and amount Normal culturally derived Pressured rapid speech o Found in a lot of populations such as people from big cities people with higher IQs and it39s a SS of bipolar disorder Sigdifficulty finding words Impoverished or paucity of speech 0 Almost don39t talk Sometimes called prosody rhythm also alludes to the quality of the voice 2 Rhythm Stuttering Monotone Slurred o Could also be a sign of too much medication intoxication stroke etc So you have to determine whether or not the patient might have some problems because we don39t want to end up with a toxic patient Toxicity is a problem all throughout the hospital all the time Delirium are often toxic states caused by medication and otherissues Mumbled Poor articulation Clear Coherent The softness of loudness of voice can indicate sensory problems eg deafness mood problems eg depression or mania or cognitive problems eg dementia U Vmume What is loud Its culturally determined 2 Soft spoken U Loud 2 Poor articulation 2 Spontaneity Animated excited Little detail No speech 0 Eye Contact Usually included in the Appearance section be cautioned to respect the cultural component of eye contact No eye contact is considered rude in some cultures and direct eye contact is considered rude in other cultures Referenced for Peripheral Vision something very common in patients with schizophrenia 2 They don39t want you looking at them stealing their thoughts etc They are very afraid of eye contact 0 Mood and Affect Mood the subjective state of a person or how the person feels 2 How you bring individuals with hallucinations back into reality Don39t confront a patient by saying oh no your wrong or by going along with it but instead say I don39t see any over there 2 Mood Euthymic normal Euphoric elated 0 See often in bipolar disorder Dysphoric sad Some other recognized subjective feelings mood are 2 Anxious 2 Calm U Irritated 392 Angry o Affect Affect is the outward display of mood and can be judged on four parameters U Range The degree of variation in emotion 0 You can look at someones affect and see if its congruent with what they are saying Expansive o Outgoing loud excited Normal Restricted Du Blunted 0 Almost have a little expression but not all there m o No expression at all 2 Intensity Emotional power being emitted from the patient 0 High a lot of emotion 0 Low low energy a Lability Moodiness or the swing of moods Outside of highly emotional events such as weddings labile affect can be noted in some disease conditions eg chronic alcoholism or bipolar disorder 1 Labile affect 0 Extreme change in a short period of time o Laughing and crying at the same time 0 Individuals with chronic substance abuse often have labile affect 2 Appropriateness o Orientation Affect the outward display of mood should be congruent with mood and circumstances The patient below says I am so happy today His affect is inappropriate to his mood and circumstance Areas of orientation are 2 Person 2 Place 2 Time and Circumstance Failure of orientation usually occurs in the following sequence The reverse order of orientation 2 Time 2 Place 2 Person Never document person is oriented times three Proper documentation is person is oriented to person place and time D It doesn39t mean they are confused if they don39t know where they are it means they are disoriented 2 Not understanding what I going on in the environment is confusion but you can still know who you are where you are and what time it is Time the fourth aspect of orientation 0 Circumstance Not understanding that this presentation is a lesson on the mental status exam and thinking it is a group of cartoons is a misunderstanding of the circumstance or CONFUSION Confused is the attribute given to persons who become unaware of the circumstances surrounding them 2 Sometimes called disorientation to circumstance 2 Confusion is quite common in high anxiety states or in delirium dementia or mood disordered states 2 So a person can be oriented to person place and time and still be confused 0 Intellectual and Cognitive Functioning Two closely related attributes Intelligence is considered to be 2 Average 2 Above Average 2 Below Average Intellectual Capacity is based on 2 Vocabulary 2 Ability to understand complex concepts 2 General fund of information Cognition 2 Cognitive ability is usually examined by testing Level of Abstraction 0 Don39t cry over spilt milk 0 Does the patient interpret literally o How are an orange and a banana alike The way they interpret determines their cognitive level Executive Function o The ability to make a sequence or plan Memory 0 The first memory to be lost is recent 0 Recent within the relative past short time eg breakfast 0 Remote not in the relative past short time eg name of first boyfriend o Riam ability to say one s SS o Retain ability to learn and then recall new information eg nurse39s name Confabulation is sometimes used by persons with brain damage or dementia Confabulation is the construction of unreal events which seem real even to the person who construct them yet the e vents are unreal 2 I went out on a date with Brad Pitt last night 0 Thought Processes The only way to examine is by analyzing speech 2 Tangentiaity digressing often multiple times during the relating of an episode or story Noted in states of high anxiety 2 Circumstantiaity an unnecessary telling of details when relating an episode or story Circumstantiality is noted with persons who are highly anxious suffer from Bipolar disorders or from Dementia 2 Flight of Ideas Moving quickly from one idea to another in a very short period of time Often noted in persons with Bipolar disorder 2 Bocking train of thought stops in mid sentence Blocking is noted in high anxiety states depressive states and in thought disordered conditions El Loose Associations words spoken at random and not in sentence Loose associations are most often noted in persons suffering from Schizophrenia Perseveration Perseveration the inability to move on to another topic or the continual return to the same topic Now is the time for every good man to come to the aid of the country Now is the time for every good man to come to the aid of the country Now is the time for every good man to come to the aid of the country Now is the time for every good man to come to the aid of the country Now is the time for every good man to come to the aid of the country Now is the time for every good man to come to the aide of the country 0 Thought Content Deusions false beliefs El El El El Ideas of reference People are talking about me Paranoid People are after me Grandeur I am the President of UM Nihilistic My muscles are disappearing delusions of disappearing Life themes recurrent beliefs El El El Loss Anger Victimization Contro degree of control over one s thoughts El Thought Control Thought broadcasting thinking one s thoughts are being heard by others Thought insertion thinking one s thoughts are being inserted by someone or something else Thought withdrawal thinking one s thoughts are being stolen 0 These disorders of thought are often found in persons who suffer from schizophrenia o Perceptual Problems All senses can be involved in sensory perceptual problems 2 Haucinations the experiencing of a perception in the absence of a stimulus Auditory hearing voices lSTLEl seeing people of objects 0 More common in patients with alzheimers Taiile feeling things Gustatory tasting things Olfactory smelling aromas 0 Signs of brain tumor so patients have to go get an MRI ASAP 2 Iusions the experiencing of a mis perception common in fatigue and delirium Misinterpreting a stimulus So a stimulus is present in illusions where it is not in hallucinations Auditory hearing a sound and thinking it is a knock on the door lSTLEl seeing a towel and thinking it is a cat Tactile feeling a touch and thinking it is a burn Gustatory tasting onions and thinking they are chocolate Olfactory smelling fish and thinking it is apple pie 0 Final Components of MSE Judgment 2 stable quality of persons decision making 392 Decision making what kind of decision making to do in a certain situation 2 Judgement can become impaired in our mental illnesses especially depression mania and schizophrenia It can also be shown in high anxiety states Insight 2 the ability for one to understand his or her condition 2 99 of patients don39t have insight 2 They don39t understand whats going on with their condition Impulse control 2 the ability to talk out rather than act out Mental Heath Nursing In Acute Care Settings 0 Goals of Managed Care Coordinated and efficient care to control costs Appropriate utilization of care resources Increased access to preventive care Maintenance and improvement of quality care 0 Justification for Hospital Admission Least restrictive setting Clear risk of client danger to self and others Dangerous decompensation of long term treatment client Failure of community based treatmentneed for structure Medical need of psychiatric or non psychiatric nature 0 Goals for acute hospitalization Prevention of sef harm Prevention of harm to others Crisis stabilization and return to community Initiationmodification of psychotropic medications Brief specific problem solving to promote compensation Rapid planning for outpatient therapy 0 Government Actions Community Mental Health Centers Act of 1963 2 De institutionaization We used to have large mental heath facilities usually in small towns called asylums There were limited professionals to care for them and they were often away from family Patients were mistreated This was deemed as a cruel way to treat patients The institutions were closed down and small community health centers were opened but locals didn39t want those people around their communities so many of the patients were lost in the cracks died etc Was not an effective action Affordable Care Act 2 Patient Centered Medical Homes including Psychiatric Care 0 Case Management Advocate Establish and maintain ongoing relationship Rapid assessment Plan rapid stabilization Discharge planning Coordinate services Monitor service delivery Evaluate outcomes Mental Health Nursing in Community Settings 0 Helpful Attributes for CMHNs Awareness of self personal and cultural values Calm external manner nonjudgmental flexible Skills problem solving psychosocial and health assessment communication Ability to cross service systems recognize need for consultation see strength and ability in even the severely ill Knowledge of community resources psychopharmacology political vision Willingness to work with those identified by client as support people Understanding of the social cultural and political issues that affect mental health and illness 0 BioPsychosocial Nursing Assessment Additional Elements of Importance for CMHNs 2 Recent service utilization 2 Vocational successdifficuty 2 Income and source of income 2 Housing adequacy and stability 2 Family and support system 2 Level of activity 2 Meets needs independentlywith assistance 2 Cultural beliefs re care 0 Comparison Inpatient amp CMH settings Inpatient Settings 2 Locked unit 2 Staff set boundaries 2 Regular food housekeeping security services 2 Medication encouraged U Milieu 2 Health care team support CMH Settings 2 Locked apartment 2 Cient set boundaries 2 Erratic food housekeeping security services 2 Client may be noncompliant 2 Social isolation El Limited support 0 Comparison Inpatient amp CMH Goals Inpatient Goals El El Client symptoms will be stabilized Client will return to community CMH Goals El El Client will maintain stability in the community Client will participate as active member of treatment team Client will demonstrate improved ability to function 0 Comparison Inpatient amp CMH Interventions Inpatient El El Boundaries Enforced by seclusion and restraint Relationship Develop short term therapeutic relationship How do you know a schizophrenic manic or depressed patient is starting to have a metdown They stop Sleeping NCLEX Medication Supervised even court ordered Depression medication is recommended for life Inpatient Socialization Activities Provided and required Self Care Nutrition Health Care Assist self care nutrition Health assessment and intervention prn Sociocultural Context Develop plan of care that attends to sociocultural context of individual Boundaries Access negotiated with client or gained trough family police or landlord Relationship Maintain longterm therapeutic relationship Medication Negotiate consent for and adherence to taking medication 2 Socialization Activities Assist client to identify and use community resources 2 Self Care Nutrition Health Care Negotiate meaning of adequate self care nutrition and health care with client and social support system Assist client in assessing for needed community services 2 Sociocultural Context Work with client and support system to plan and implement care consistent with sociocultural belief system and context 0 Common Ethical Dilemmas in Community Mental Health Nursing Issue of Social Control 2 What39s best for individual vs what39s best for community Issue of Privilege 2 Confidentiality vs obligation to report Culture and Mental Illness Culturally Relevant Mental Health Nursing 0 Culture Beliefs and values held by people of a given culture about what is good right and normal 2 Causes a framework for which you act Cultures are different from race or minority status andor ethnicity Terms 2 Accuturation if you came here from another country From one country to another the group you are coming into they determine how much your mixing in with the new culture 2 Encuturation how much are you apart of the culture your already apart of within your own group Cultural Competence able to understand peoples culture impact them Ethnocentrism thinking your culture is the right definitive way of doing things 0 World Views The number one reason why people think they get sickcause sickness is higher power Other stresses you are what you eat religion etc are also causes Western El El El El El El El it Judeo Christina Muslim Human Being Body and Mind Starting Point Self E Linear Wisdom Prepare for future Disease Casual E Individual Rights Eastern El El El El El El El it Chinese Buddha Human Being Unified body mind and spirit Starting Point Family Circular Wisdom Acceptance Disease Imbalance yinyang hotcold E caring Indigenous El El El El El it nature Human Being no words Starting Point community E present Wisdom knowledge of nature Disease lack of personal environmenta spiritual harmony Ethics community good 0 Explanatory Models Cause of illness 2 Sometimes what one believes is the cause of an illness is not what you believe 2 There are very few people who use only one model for models of treatment When and why did it happen How distressful is it How long will it last How should it be treated How should others treat one who is ill 2 How you should be treated and how others should be treated are all idiosyncratic o Ethnorelativism Evaluating whether the theories being applied are relevant for the persons the nurse is helping Allows nurses to provide care that is not bound by Western culture Stigma varies from culture to culture 0 Genetics Psychiatric illness 2 Mood disorders 2 Schizophrenic disorders Psychiatric illness determined to have genetic causes for them For instance with schizophrenia there are abnormalities in the brain 2 Personality disorders 2 Substance abuse disorders Treatment 2 Anti psychotic medication actions 0 Nurse as Cultural Translator Facilitates ethno reativism by 2 translating language 2 explaining heath reated concepts related to client culture Best when cultural translator closely resembles the client is from same geographical region social class and gender Culture Bound Syndrome an illness caused by culture El Culture bound syndrome we find incidences of illness only in certain cultures For instance anorexia nervosa isn39t found in all cultures Post partum depression you wont find this in cultures where you find women around several people you commonly see that in cultures where the mother may walk outside with the baby and no one is around no social support Ethical Legal concerns 0 Ethics Study of philosophical beliefs about what is considered right or wrong in a society El El Beneficence Promoting good How are mental patients marginalized 0 They are allowed to smoke when in other facilities patients are expected to quit Autonomy The right to make one s own decisions Justice Treating others fairly and equally Fideity Doing no wrong to the client observance of loyalty and commitment to the client Veracity Telling the truth Tarasoff Decision El 1974 Tarasoff v Regents of University of California Duty to warn Duty to protect Psychiatric Hospital Admissions and the Baker Act El 1 Voluntary Admission Most people come to the hospital voluntary which is the best way because then you can leave when you want 2 II Involuntary Admission Commitment Judge can mandate that you be taken to a Baker Act facility to hold people in that agency for a couple days for observation Types of Procedures 0 Judicial 0 Administrative 0 Agency Nature amp Purpose of Involuntary Admission o Observational or temporary 0 Emergency 0 Longterm formal 2 III Doctrines that apply to all admissions Torts Habeus Corpus you have a right to go before a court Least restrictive alternative the Baker act has restrictions on how long you can keep somebody and then they have to go before a judge to determine further outcome 2 Intentional Assaut patients have been threatened in some way or another Battery patient has been beaten False imprisonment patient has been falsely accused Defamation of character 0 Someone should be in seclusion no longer than they should bed Every single time you put someone in seclusion you will NOT have an order It is against the law to write a PRN order for seclusion or restraint Breach of confidentiality El El El El El El El 0 Bioethics o Exceptions to Client Right of Confidentiality Unintentional When duty to warn and protect are mandated Tarasoff When nurse is a mandated child abuse reporter When nurse is a mandated elder abuse reporter State laws requiring reporting of certain communicable diseases State laws requiring reporting of gunshot wounds State laws that do not give nurses privilege re disclosures made within the context of the nurse client relationship Negigence Patient becomes dehydrated Malpractice Civil Rights of Patients Vote Civil service Driver39s license Purchases and contracts Press charges Humane care Religious freedom Social interaction Exercise and recreation Ethical concerns related to client care Milieu Therapy o What is Milieu Therapy A healing environment Use of the physical and social environment to promote safety optimal functioning develop interpersonal skills and to teach life management skills to use after discharge 0 Purpose Promote mental health and rehabilitation U Focus on group process Health Care Policy the payment that goes to the care of the psych patient is bundled That means that the facility will get the same amount of money regardless if they do group therapy or if they don39t 2 Democratic 2 Interdisciplinary approach 0 Func ons Containment we don39t have a lot of acting out in this area Support Structure Involvement Validation 0 Nurse as Manager Promotes atmosphere of Respect Safety Flexibility Open communication Predictability Active involvement 2 They run all of the inpatient groups 0 Components of Milieu Therapy Orientation to environment 2 Scheduled activities 2 Rules for behavior 2 Introductions to patients and staff Community Meetings 2 Welcome new members 2 Set expectations 2 Share responsibilities 2 Plan activities 2 Discuss conflicts Limit setting when patients come in it slows them down and less things can happen while in therapy System of positive and negative reinforcement U P v eges Seclusion and restraint 2 Indications Used primarily to prevent physical injury to client other clients staff and visitors 0 NOT USED AS PUNISHEMENT IT39S A TREATMENT Sometimes a quiet area is used to reduce stimulation for a client who is overwhelmed on an open unit Sometimes used to prevent major damage to a unit or major interference with a therapeutic environment 2 Assess The Need for Seclusion or Restraint Assess client needs and needs of others Talk to client in a quiet area Intervene early to prevent escalation Use least restrictive interventions principle 0 Continuum of Least restrictive Interventions Verbal intervention Involve in activities if possible PRN Medication Seclusion Medication given IM without the client39s consent chemical restraint Physical restraint as last resort Never use as punishment Document 0 Risk for injury 0 what was tried before restraint or seclusion was implemented 0 Client response to those interventions 2 Use of Seclusion or Restraint Assure adequate numbers of staff are available Give choice to walk to the seclusion area Give client a few seconds to decide if he or she will walk to the seclusion area If client does not adhere each staff member grabs a limb and lowers the client to the floor take down procedure Carry client to seclusion area Apply restraints Search client for dangerous objects Administer IM medication if ordered and appropriate D After Implementinq Restraints Consult physician or ARNP or notify as soon as practical Have physician or ARNP examine client within 13 hours and again every 12 hours Explain reasons to client and family Offer emotional support Document 2 Nursing Actions for the Client in Restraints Observe at least every 15 minutes and document 0 Level of consciousness 0 Mental status 0 Vital signs Every two hours document 0 Circulation in restrained extremities Pulse Color Movement Sensation Edema Loosen 4 point restraints one at a time every 2 hours Provide meals without utensils Offer food and fluids every 2 hours Provide for hygiene and toileting every 2 hours Release extremities one at a time every two hours and perform range of motion Evaluate continued need for restriction Gradually release client Debrief or discuss the episode with the client when she has regained control Theoretical Bases for PMHN Biological Basis for Understanding Psychiatric Mental Health Nursing 0 Mental Illness because symptoms come Across the CNS Hallucinations perceive something in the absence of stimulus Hallucinations Illusions has to so with sense data Delusions something we believe in Took a long time for psych illness to work their way into being a notion of an illness 2 In the 1950s it used to be believed that it was a sign of weakness or poor parenting 0 Functions of the Brain Monitor external world 2 30 o of psych patients have abnormal brain structures Monitor composition of body fluids Regulate skeletal muscle contractions Regulate internal organs Initiateregulate basic drives Conscious sensation Memory Mood Thought Regulate sleep cycle Language 0 Brian Imaging Techniques Computed Tomography CT 2 3D images using computed x rays 2 Detects Lesions Infa rcts Aneurysms Cortical atrophy Ventricular enlargement Magnetic Resonance Imaging MRI 2 3D visualization using a magnetic field and computed radio waves emitted by cells 2 Detects Edema Ischemia Infection Neoplasia Trauma Enlarged ventricles Positron Emission Tomography PET 2 Injected radioactive tracer travels to brain concentrates in areas of high activity 2 Scanned images are relayed to a computer for 3D images 2 PET Scan Schizophrenia LNb393lFFElZTED SCHIZEIPHREHIEI TNIH TlJIH gt E 6 SlI39E S 543 20 3 02 449 37 831 7 3 0 3 218 109 185 142 d 89383 Depression Front rCMBalu Sinqle Photon Emission Tomography SPET 2 Technique similar to PET but uses radio nuclides emitting gamma radiation 2 Detects oxygen utilization glucose metabolism blood flow neurotransmitter receptor interaction 0 Neurotransmitter Deficiency Norepinephrine Receptor T COO B Deficie nt n eurotran smitter A Norm al I C Deficient receptor 0 Neurotransmitter Excess Dopamine Dopamine receptor H0 A Normal B Excess neurotransmitter I C Excess receptors In schizophrenia we give meds that block receptor sites of dopamine to reduce the dopamine trigger o Neurotransmitter and Mental Health Dopamine 2 Increase schizophrenia mania 2 Decrease depression Parkinson39s Disease Norepinephrine 2 Increase mania anxiety states schizophrenia 2 Decrease depression Serotonin 2 Increase anxiety states 2 Decrease depression GABA 2 Increase reduced anxiety 2 Decrease anxiety disorders schizophrenia Acetylcholine 2 Increase depression 2 Decrease Parkinson39s disease Alzheimer39s disease Huntington39s chorea Histamine 2 Decrease depression 0 Mood vs Thinking Disorders Mood bipolar or depression 2 A lot more palatable 2 More accepted in general public Thinking Schizophrenia o Antipsychotics Untoward Effects Dopamine Blockage 2 Movement changes Pa rkinsonian Akinesia cant move a lot muscle tightness Akathisia restless Tardive dyskinesia tongue moves lips smack happen after a while of using dopamine blocking drugs 0 ie Haldol ciprexa 2 Decreased prolactin 2 Antipsychotics block dopamine Muscarinic Blockage 392 Blurred Vision 2 Dry mouth 2 Constipation 392 Urinary difficulty Alpha 1 Antagonism 2 Orthostatic hypotension 2 Ejaculatory failure 0 Antidepressant Possible Effects of Receptor Binding DA Dopamine NE Norepinephrine Alpha 12 speci c receptors 5HT 2 Serotonin H1 Histamine for noreplnephrlne ACh Acetylchollne People who take antidepressant meds who are not depressed because of the feeling of unhappiness Ionliness sadness grief is confused with depression With severe depression most people feel nothing o Actions of Benzodiazepines Benzodiazepine Benzodiazepine receptor GABA receptor Action 2 Increase the use of GABA by increasing receptors D It provides an immediate relief from anxiety plus a sense of euphoria so people feel good when they take benzos like Ativan valium or Xanax Medications Include 2 Xanax medium acting 2 Valium long acting 2 Ativan short acting So if you take it for sleep it only works for 4 hours where valium would last 20 hours both not good Indications U Seizures 2 Acute Anxiety atttck Only Length of times 13 2 Sleep There is no indication known to human beings for people to take Ativan everyday especially in anxiety disorder Benzos are also addictive meaning there is potential death with improper withdraw Administration 2 What39s the fastest acting way to give a Benzo 1 IV 0 Very few cases where we would give it IV Status Epilepticus Alcohol Withdrawl 2 Sublingual not IM 0 Action of Buspirone Buspirone 5HT1 presynaptic receptor Postsynaptic receptor Postsynaptic cell Presynaptic cell s serotonin It takes 3 weeks before it kicks in There is no euphoric feeling in buspirone like you find in benzos hence why people prefer benzos There is a decrease in symptoms There are more benzos prescribed and soled then there are disorders to treat them There are also more antidepressant meds sold then there are antidepressant cases