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Mental Health Nursing

by: Everett Heidenreich

Mental Health Nursing NURS 352

Everett Heidenreich
GPA 3.92

Ellen Birx

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Ellen Birx
Class Notes
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This 12 page Class Notes was uploaded by Everett Heidenreich on Monday October 19, 2015. The Class Notes belongs to NURS 352 at Radford University taught by Ellen Birx in Fall. Since its upload, it has received 16 views. For similar materials see /class/224696/nurs-352-radford-university in Nursing and Health Sciences at Radford University.


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Date Created: 10/19/15
Conceptual Models for Mental Health Nursing 0 You have specific levels starting from the most basic to the most complex 0 Each level depends on one another and each level is a part of each other 0 Example Cell Tissue Organ Body System Individual bodymindspirit Family Group Community Society Biosphere 0 We can intervene on an individual level and give them therapy 0 Most of the time we have multiple interventions such as medications therapy and family 0 We can look at subdivisions Le a lack of neurotransmitters for serotonin leads to depression 0 Even sleep and nutrition can affect the individual Indicators of Mental Health 0 Positive attitudes towards self a positive self esteem 0 Growth Development and SelfActualization an ongoing process that needs to be maintained 0 SefActuaization the achievement ofone39sful potential through creativity independence spontaneity and a grasp of the real world 0 Integration may be good at work but could be bad at taking physiological care of themselves You need a balancewell integration 0 Reality Perception does the person know what is realunreal 0 Environmental Mastery can the person function in their daytoday routine 0 Resilience ability to bounce back after a trauma loss depression etc DSMlVTR o Describes disorders based on 5 different axes in order to perform a clinical diagnosis 0 Axis I Clinical Syndromes schizophrenia depression major disorders some may have a combination of 2 such as bipolar and alcoholism 0 Axis II Personality Disorders paranoid schizoid antisocial borderline histrionic narcissistic avoidant dependent obsessivecompulsive mental retardation o Cluster A includes personality disorders of an odd or eccentric nature paranoid schizoid and schizotypal personality disorders Cluster B disorders of an erratic dramatic or emotional nature antisocial borderline histrionic and narcissistic personality disorders 0 Cluster C includes disorders of an anxious or fearful nature avoidant dependent and obsessive compulsive personality disorders 0 0 Axis III General Medical Conditions diseases of the nervous circulatory respiratory systems hypertension etc 0 Axis IV Psychosocial amp Environmental Problems loss ofa job bankruptcy educational problems problems with primary support group problems with access to health care etc 0 Axis V Global Assessment of Functioning how well can they take care of themselves 0 Cultural Formulation intended to supplement the multiaxial diagnostic assessment and to address difficulties that may be encountered in applying the DSMIV criteria in a multicultural environment 0 You may see things differently based on culture Nursing Process 5 Steps 0 Assessment 0 Diagnosis 0 Planning Outcome Identification 0 Implementation 0 Evaluation 0 As a bachelor ofnursing you should be able to implement everything you ve learned toward the nursing process NANDAAggroved Nursing Diagnosis NAN DA North American Nursing Diagnosis Association Has specific general health problems and the risks associatedcausing each Examples risk for suicide anxiety ineffective coping substance abuse may be the cause disturbed thought processes hallucinations may be the cause and may think that the CIA is out to get them risk for otherdirected violence may need to be restrained caregiver role strain think about the family Psychiatric Assessment Content information gathered Process the interaction between the nurse and client while gathering the information Conveying empathy and building trust and rapport sympathetic relation Begin with open ended questions so that you can hear the client s story in his or her own words in depth Mental Status Examination An evaluation of the client s current state Considered the quotVITALSquot of mental health nursing Description of appearance behavior and verbal communication rather than judgments interpretations or conclusions 0 Speech qualityquantity Thought content themes phobic thoughts obsessions delusions Perceptions any unusual perceptual experiences illusions hallucinations Mood and Affect dominant mood range liability and appropriateness of affect Orientation person place time Memory remote recent immediate Intellectual Functioning general fundamentals of knowledge calculation concentration abstract thinking judgment insight OOOOOO Thought Content Overty communicated information Delusion false belief that is firmly maintained even though it is not shared by others and is contradicted by social reality 0 Religious belief that one isfavored by a higher being or is an instrument of that being Somatic belief that one s body or parts ofone s body are diseased or distorted Grandiose belief that one possesses greatness or special powers Paranoid excessive or irrational suspicion and distrust ofothers characterized by systematized delusions that others are quotout to get them or spying on them Thought Broadcasting belief that one s thoughts are being aired to the outside world Thought Insertion belief that thoughts are being placed into one s mind by outside people or influences Depersonalization the feeling of having lost selfidentity and that things are the person are different strange or unreal Hypochondriasis somatic overconcern with and morbid attention to details of body functioning Ideas of Reference incorrect interpretation of casual incidents and external events as having direct personal references Magical Thinking belief that thinking equates with doing characterized by lack of realistic relationship between cause and effect Nihilistic Ideas thoughts of nonexistence and hopelessness OOO o Obsession an idea emotion or impulse that repetitively and insistently forces itself into consciousness although it is unwelcome o Phobia a morbid fear associated with extreme anxiety Thought Process How the communication occurs and includesfeelings intuition and behaviors that accompany speech and thought Circumstantial thought and speech associated with excessive and unnecessary detail that is usually relevant to a question and an answer is eventually provided Flight of Ideas overproductive speech characterized by rapid shifting from one topic to another and fragmenting ideas Loose Association lack of logical relationship between thoughts and ideas that renders speech and thought inexact vague diffuse and unfocused Neologisms new word or words created by the patient often a blend of other words Perseveration involuntary excessive continuation or repetition of a single response idea or activity may apply to speech or movement but most often verbal Tangential similar to circumstantial but the person never returns to the central point and never answers the original question Thought Blocking sudden halt in the train of thought or in the middle of a sentence Word Salad series of words that seem totally unrelated Thought Content and Process may not always be congruent Suicide Assessment and Intervention 0 Self Injury a person has harmed themselves can selfmutilate to relieve tension cutting physiological pain is relieved by physical pain 0 Suicidal Behavior the intent is to kill yourself 0 Suicide ldeation suicidal ideas thought to kill 0 Suicide Threat can be direct quotif you break up with me l ll or indirect quotcan you take care of my dog I may not be here much longer Suicide Attempt the attempt to kill yourself Completed Suicide person has successfully killed themselves I A psychological autopsy is usually done 0 The nurse should remain calm and respond in a therapeutic manner only reflect observations back to the patient 00 Suicide Assessment 0 Ask directly llAre you thinking of killing yourself o If yes ask llDo you have a plan o If yes ask llDo you have a gun sleeping pills or whatever client stated was his or her plan 0 Document client s response to these questions and the level of suicide precautions instituted 0 Low Risk 03 points Moderate Risk 49 points High Risk 10 points 0 White males over the age of 65 have the highest risk for suicide Suicide Intervention o 1 priority is safety 0 Do a suicide assessment and institute suicide precautions immediately and then get a doctor s order 0 Know the levels of suicide precautions at the agency where you are working These are specified in the policy and procedure manual They are different in medical and behavior health units 0 Remove dangerous objects from the environment belts glass razor blades scissors 0 Client should have someone with them at all times even to go to the bathroom Help the client identify strengths if they can t help them realize what strengths they have Reinforce reasons for living try to increase their self esteem Promote realistic expectations Encourage awareness labeling and appropriate expression of feelings Anger management regulating emotions and behaviors Enhance coping strategies Mobilize social support Therapeutic Relationships between the Nurse and Patient Goals ofthe Relationship Selfrealization Selfacceptance and Selfrespect try to increase these Sense of personal ID and Personal integration try to make clear Ability to formmaintain relationships with a capacity to give and receive love HigherIncreased functioning try to improve this Assess needs ability to satisfy Make realistic goals try to achieve them Goals are directed toward achieving the patient s optimal growth Essentials of a Psvchiatric Nurse J Campbell 1980 Aspects of Self Awareness 0 Goal is to achieve authentic open and personal communication 0 Psychological knowledge of emotions motivations selfconcept and personality Being sensitive to feelings and outside events that can affect those feelings Physical knowledge of personal and general physiology as well as bodily sensations body image and physical potential 0 Environmental knowledge of relationships between humans and nature sociocultural events in life 0 Philosophical broad meaning in life responsibility beliefs sense of living having a meaning The key therapeutic tool of the psychiatric nurse is the use of oneself o Selfanalysis is the first building block in providing quality nursing care Communicate through a dialoguediscussion not a monologue this allows the patient to more fully define ego identity 0 Johari s Window Has 4 quadrants 1 Known to self and others 2 Known only to others 3 Known only to self 4 Unknown by self and others The goal is to increase the first box known to self and others Can the Windows Change 0 As long as we are still breathing we can change Know that every child is born with an innate drive to grow toward better health The goal of that growth is to increase the size of square 1 There is complete comfort with oneself when we are able to show others our blemished scarred imperfect selves Self Growth in Nursing Has to be learned and nurtured Authenticity being open to selfexploration of thoughts needs emotions values defenses actions communication problems and goals 0 A process of equalizingaccepting external realities with internal ldeals Values Clarification awareness of one s own values helps the nurse to be honest to accept differences in others and to avoid the unethical use of patients to meet personal needs 0 empathize be genuine even if your values are very different 3 Domains choosing relies on cognitive prizing relies on emotional and acting relies on behavioral the one you can see Only action makes our ideals known to others Authenticity vs Objectivity o The task becomes 0 Become aware of our feelings 0 Open to others feelings o Mastery over acting out our own feelings 0 Patients cannot explore their feelings clarify values integrate their life experiences if the nurse is pejorative belittling condescending or angry with value conflicts 0 Example patient may be divorcing and your beliefs are that marriage should be sacred and kept together even though this is taking place be aware of the patient s value system 0 Nurses have many feelings especially based on the patient s reactionsprogress o View feelings as barometers and feedback instruments Role Models 0 Be aware of your power to influence 0 Patients have unique opportunity to try out new ways of reacting to others 0 It is not possible to separate work and personal life in psychiatric nursing because the main tool is the therapeutic use of self 0 If a nurse has a chaotic life it will show in their work with their patients leading to a decreased effectiveness of care Altruism concern for the welfare of others 0 What is your incentive to help others 0 Self fulfilling Financial SelfDenial Powerful Neat Identity Deep love for Humanity I You can have a deep love for humanity but you have to have other reasons as well 0 Main ideal is to change the larger structure and process of society in ways that will promote the individual s health and wellbeing Ethics and ResponSIbility 0 Psychiatric nursing is full of ethical dilemmas 0 Would you allow a drug dependent mother to nurse her infant 0 Would you forcecoercedeceive a schizophrenic patient into accepting meds against his belief 0 Would you explain the side effects thoroughly even if they worry the patient 0 Always assume responsibility for your behavior and decisions you make Phases ofa NursePatient quot 39 39 39 39 o Preinteraction begins before the nurse s first contact with the patient 0 There are many common fears such as acutely selfconscious afraid of being rejected by the patients anxious because of the newness of the experience etc I Talk with your instructorsu pervisor about any fears concerns I 1 Fear anxiety or nervousness 0 Initial Task Self Exploration Have a SelfAnalysis question your own mental health status 0 Also gather data about patient and plan for your first interaction 0 Communication is your most important tool in mental health 0 Orientation Phase when the nurse an patient first meet 0 Goal to find out why the patient is seeking help 0 In this phase the patient is testing the nurse s judgment 0 Establish a Mutual Contract with Introductions Trust building clarify misperceptions on behalf of the nurse and the patient Confirm Confidentiality Limit Setting perhaps Gaining Information chart and your assessment Expore yourfeeings Energy and Commitment is What the patient is up against 0 0 Working Phase where most of the therapeutic work is done 0 0 Goal to get an actual behavior change Mutual Development ofa Roadmap I Where are you now where would you like to be at discharge I What are the strengths on which to build what are the obstacles I What resources can we facilitate include in the plan I What are our measures of change 0 We want it to be measurable I Explore stressors and promote the development of insight 0 Termination Phase happens throughout every phase people rarely go to termination and nurses rarely talk about it some people have cycles of hospitalizations and they need to go back 0 0 Goal learning to bear the sorrow of the loss while integrating positive aspects of the relationship into one s life A very difficult phase to accomplish patient once again tests nurse s judgment a lot of times they view termination as rejection One day you will let them know that their sessions will be coming to an end ask them what they hope for and what they want when they re done Evaluation of Progress coping skills higher functioning improved selfesteem healed relationships better expression of feelings Share feelings of pleasure and loss Discuss symptoms of improvement and regression Communication 0 All behavior is communication and all communication affects behavior 0 All languages are literal and symbolic difference between cultures are immense o All communication is bidirectional 0 0000000 There is an innate need to be understood based on the survival drive within our brain stem and limbic systems Communication can facilitate development or it can put up a barrier if done poorly Without communication a therapeutic relationship is impossible Verbal communication less effective way of communicating Nonverbal Communication 80 of all communication is nonverbal Voice speed tone cues of inflection Body language posture proximityspaces intimate personal social public action cues Object cues of furniture decoration color Sense of smell perfume colognes fear Eye contact windows to the soul Sense of touch most fundamental means of communicating How do differences in culture affect nonverbal communication Analvsis of the Process 0 Considerthe parts O O O O O Sender originator of the message errors incongruent affect and cognition Message information that is transmitted errors inadequate information Receiver perceiver of the message errors perceptual difference Feedback verbal or behavioral response of receiver to sender errors invalid information Context setting in which communication takes place errors constraints in context loud noisy I Knowedge ofcontext is necessary to understand the meaning of communication Transactional Analysis Games Peogle Play by Eric Burne o The study of communication or transactions that take place between people Similar to Freud s id ego and super ego 0 Parent attitudes and wisdom taught by parents 0 Adult logical rational and realistic ways of dealing with reality 0 Child contains all the feelings of a child ll want it now 0 Burne believed that communication flows when the lines are parallel o Crossed Transaction If the lines connect different ego states communication will stop of become highly emotional o Ulterior Transaction If the verbal exchange has a verbal meaning that is parallel but a covert or hidden agenda the communication becomes nonproductive Therapeutic Communication 0 Goal preservepromote respect of both individuals 0 Both parties be clearly understood before any suggestionsadvice giving 0 The nurse is the listener ask permission to offer advice it s usually not wanted 0 Advice is carried out WITH the patient not FOR the patient quotquot inT39 39f 0 Listening first rule of therapeutic relationships foundation on which all other therapeutic skills are build 0 Essential to understanding the patient must be an active not passive process sign of respect 0 Broad openings rather than yes and quotnoquot questions llCan you tell me more 0 Restating llls this what you meant o Clarification ll do not quite understand could you explain 0 ReflectionValidation reflect back the feeling expressed can signify empathy repeat 0 Focusing time sequencing directing client to their personal interpretation of the experiences actions feelings o Helps patient expand on topics of importance helps them face and analyze problems 0 Sharing Perceptions quotSo you were feeling very scared I think I would have also 0 Theme Identification lllt seems this happens fairly often in your life 0 Silence the most powerful intervention in communication is often silence allow patient to break silence if they created it 0 Humor the greatest of coping mechanisms offering control closeness relaxation and increases learning 0 Be careful not to laugh at imperfections can be dangerous because you don t want to belittle them 0 Informing med education orientation to schedules 0 Suggesting used mainly in the Working Stage of the relationship after trust has been established 0 Patient is aware of problems and looking for alternative responses lmpasses blocks the progress ofthe nursepatient 39 39 39 39 0 Resistance after problem identification and settling goals progress plateaus patient is often fearful of change or unwilling to change 0 Patient s reluctanceavoidance of verbalizing experiencing troubling aspects of oneself during working phase provokes intense feelings 0 Examples flight into health acting our or irrational behavior superficial talk hopelessness rules again increased somatic o Transference the patient expresses feelings and attitudes about the nurse that have been previously felt about another significant person in their life the patient has feelings for the nurse 0 Could be the patient s attempt to decrease anxiety 0 Therapeutic value if confronted and openly clarified 0 Be especially aware of hostility or dependency felt in a transference reduces selfawareness o Countertransference the nurse identifies feelings and attitudes towards the patient that she has felt about a significant other in her past 0 Not harmful if addressed with the supervisor and does not include intense love hate anger disgust or anxiety 0 Seek peer view with when relationship becomes adversarial Boundam Violations When the nurse goes outside the boundaries of the relationship and establishes a social economic or personal relationship with the patient Role Time Place and Space Money Gifts and Gratuities Clothing Language Self Disclosure Post Discharge Physical Contact Others roleplaying catharsis Empathetic Understanding quotTo sense the client s private world as ifit were your own but without losing the quotas if quality A high degree of empathy is one of the most potentfactors in bringing about change and learning one of the most delicate and powerful ways we have of using ourselves Carl Rogers Ability to enter into the life of another person to accurately perceive hisher current feelings and their meanings and to communicate this understanding with the patient lnvolves sensitivity to the patient s current feelings and the verbal ability to communicate this understanding in a language attuned to the patient Crisis Intervention presents both danger and opportunity What do you say to someone who has had a tremendous loss soldier lost a leg 1 Listen and Respond with Empathy Realistic Perception ofthe Event you can help people get in touch with what happened a lot of times the view isn t realistic 0 Example quotNo one will want to marry me because I have no leg Adequate Situational Support who do they have to support them Nurses friends chaplain etc Keep the patient connected with their support at all times Adequate Coping Mechanisms their normal coping methods aren t working so get them to evaluate what helps plus provide them with additional coping strategies Types of Crisis 1 Maturational Crisis something that happens to everyone over a course of life going off to preschool 2 Situational Crisis things that don t happen routinely over the course of a lifetime 911 house burning down Phases of Disaster Response Warning Phase not all situations have a warning phase Impact Phase when it startshits Rescue or Heroic Phase the response Remedy or Honeymoon Phase feeling of survival immediately after Inventory Phase when you start realizing what s gone house business everything Reconstruction or Recovery Phase getting help or just pulling through on your own Ifyou intervene right away the person is more likely to not have problems later on Goal of Crisis Intervention For the individual to return to a precrlsls level of functioning Focuses on problem solving and stabilization Levels of Crisis Intervention Environment Manipulation trying to provide concrete help putting electricity back on finding family members General Support coping strategies psychiatric help Generic Approach expertise on how that type of crisis evolves working on a prenatal floor and family having a premature child Individual Approach when one person goes into crisis and the other one doesn t because of their level of expertiseteaching quotindividual psychotherapy Intervention Technigues Catharsis allowing a person to express their feelings Clarification do a followup if story is unclear clarify Suggestion try to get them to suggest first but then you can Reinforcement reinforce the good actions they re doing Support of Defenses if they re in denial let them continue to be Enhancing Self Esteem encourage their strengths Exploring Possible Solutions problem solving helping them Linking with Resources with additional resources outside of yourself Make sure to do a suicide assessment Violence Assessment and Intervention Contributing Factors 0 Physiological Factors head injuries Alzheimer s dementia substance abuse 0 Psychological Factors fight with spouse and are already angry o Sociological Factors if they already live in an area with violence neighborhoods schools Assessment 0 History of Violence 0 Substance Abuse 0 Psychosis or Disorlentation o Anger Extreme Anxiety or Labile Effect they rapidly switch from one affect to another laughing to crying o Pacing Restlessness Clenched Fist 0 Swearing Shouting Threatening 0 Poor Impulse Control if they have a history of this 0 A history of violence will have a combination ofafew of these Homicide Assessment 0 Ask directly quotAre you thinking of harming or killing anyone o If yes find out who and what their plan is if they have one 0 Document and notify psychiatrist if homicidal ideatlon intent andor plan is present Crisis Escalation Violence 0 How does a crisis situation rise to violence o If they have anxiety or agitation verbal aggression or threats or physical aggression Interventions to Prevent Violence Empathy and listening offer help Responding to unmet needs Providing a calm structured environment Limit setting we state behavior we want and consequences and state behavior we don t want and consequences has to be realistic Behavioral Contract more for long term patients TimeOut person goes and spends quiet time in a designated room PRN Medication ordered meds to calm them down not meds that are regularly taken Ethical and Legal Principles 0 Intervene in least restrictive way that is effective in preventing harm to client and others 0 Don t restrain them until they become physical Management of Physical Aggression o If they do become aggressive Call for help team intervention at least 5 team members to safely restrain client you only one want person talking to the client 0 Physical restraint if client is a danger to self or others 0 Personal safety have a 3ft zone around client but when you go in notify them what you re doing I Make an quotLquot shape so that they don t feel cornered keep hands by your side wear correct shoes Restraint training every hospital has a code for violence Follow agency policy and procedure 00 Care ofthe Client in Restraint 0 Need physician s order and renewal of order 0 OnetoOne and documentation on flowsheet q15mln what are they doing every 15 minutes o If they re restrained a staff member always has to be there 0 Monitor VITAL slgns circulation skin integrity 0 Provide food and fluids 0 Offer urinal or bedpan q2hr and pm 0 Remove one limb at a time with assistance for ROM 0 Administer medications per MD s order Interventions to Prevent Further Incidents 0 Teach anger management skills 0 Teach assertive communication especially the difference between assertiveness and aggression 0 Critical incident debriefing document if you did this


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