Exam 1 Flashcards
mental health
the emotional and psychological well-being of an individual. requires that one can interest with others, deal with daily stress, and perceive the world realistically.
-important part of overall health
-impossible to be healthy without being mentally healthy, but possible to be mentally healthy and have a chronic mental disorder.
mental health wellness
a state of well-being in which the person realizes own abilities, can cope with normal stresses, can work productively and fruitfully, and can make contributions to society.
-often, those with serious mental health problems face disadvantages that result in less than adequate/competent care.
8 dimensions of wellness
emotional, financial, social, spiritual, occupational, physical, intellectual, environmental.
-problems in one dimension can impact another!
-wellness is not just the absence of disease, but having a purpose in life, being active in satisfying work and plan, joyful relationships, healthy body, healthy environment, and being happy.
mental disorders
-organized and diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders-5 (disorders with a definable diagnosis)
-degree of disability or impairment varies
-some disorders may be influenced by cultural factors
-one of the most common causes of disability
-evidence of alterations in thoughts, feelings, behaviors
-associated with distress or impaired functioning
-mental illness is a syndrome-set of symptoms that cluster together, may have multiple causes, different disease states
-depression one of the leading burdens in middle and high income countries
recovery from mental illness
SINGLE MOST IMPORTANT GOAL FOR PERSONS WITH MENTAL DISORDERS
-a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.
cultural considerations of mental disorders
-in mental disorders, alterations in behaviors, thoughts, and feelings are unexpected and are outside normal, culturally defined limits.
-be mindful of behaviors that are considered normal within a specific culture, it is not a psychiatric symptom.
four dimensions of recovery
- health: managing disease, living healthy lifestyle
- home: safe, stable living environment
- purpose: meaningful activity, independence, resources, income
- community: relationships, social connections
recovery oriented treatment
-mental illness and emotional disturbances are treatable
-recovery is an expectation!!!
-recovery benefits both the individual and society
-recovery is not orderly and sequential-expect setbacks.
-treatment looks at the impairment to function- how is mental disorder impacting day to day?
-we treat symptoms, not the diagnosis!
public stigma
one of the biggest barriers to treatment and recovery!!!
-major reason individuals and families do not seek treatment
-stereotypes leading to prejudice and discrimination (dangerous, unpredictable, unable to function independently, weak, immoral)
-negative images in media and film
self-stigma
person with mental illness internalizes negative stereotypes and agrees with the public’s negative perception
-person believes negative stereotypes
-develops low self-esteem, loss of self-respect
label avoidance
person avoids treatment in order to avoid being labeled as mentally ill.
-a reason why many do not receive mental health care
guiding principles of recovery
-emerges from hope: for a better future and that they can overcome challenges!
-is person driven: self determination and self direction, definition own life goals and path
-occurs via many pathways
-holistic: involves the whole life, integrated with various services
-supported by peers and allies: mutual support and community
-supported through relationship and social networks: presence and involvement of people who believe in ability to recovery and offer support, suggesting strategies and resources
-culturally based and influenced: include values, traditions, and beliefs
-supported by addressing trauma: trauma informed services to foster safety
-involves individual, family, and community strengths and responsibilities
-based on respect
culture definition
way of life for those who identify or associate with each other based on a common purpose, need, or similarity of background; totality of learned, socially transmitted. beliefs, values, and behaviors that emerge from members’ interpersonal transactions
-dynamic and constantly changing
acculturation and cultural identity
-acculturation: socialization process by which minority groups learn and adopt of certain aspects of dominant culture
-cultural identity: set of cultural beliefs with which one looks for standards of behavior.
linguistic competence
ability to communicate and convey information to a diverse audience for easy understanding.
cultural competence
a set of academic and interpersonal skills that are respectful and responsive to the health beliefs, health care practices, and cultural and linguistic needs of diverse patients to bring about positive health care outcomes
-nurses demonstrate cultural competence by valuing patients’ cultural beliefs, recognizing the need to bridge language barriers, and understanding the impact of literacy levels.
Hispanic Americans mental illness cultural beliefs
tendency to use all other resources before seeking help from mental health professionals. belief that mental health facilities do not accommodate their cultural needs. cost of care and concerns of immigration status are barriers.
African Americans mental illness cultural beliefs
extensive family networks relied on for support, older adult members treated with great respect.
-when affected by mental illness, may experience double stigma: from cultural group and longtime racial discrimination- possibly within health community
-diagnosis and treatment often racially biased
-disproportionately diagnosed as having schizophrenia when compared to other groups (stable for past 3 decades)
Asian Americans, Polynesians, and Pacific Islanders mental illness cultural beliefs
-tend to deny or disguise of existence of mental illnesses
-embarrassment if a family member is treated for mental illness
-culture-bound syndromes: neurasthenia, Hwa-byung (suppressed anger syndrome- Korean culture- subjective and expressed anger, sensations of heat and feelings
Native Americans mental illness cultural beliefs
-emphasis on respect and reverence for earth and nature
-healers and healing treatments: herbal medicines, healing ceremonies and feasts
-varying views of mental illness among tribes, may be viewed as supernatural possession
-stigmatization: degree not the same for all disorders, variable among tribes
Rural cultures mental illness culture beliefs
-limited access to health care which is typically located in urban areas
-higher suicide rate; use of firearms common
-diverse in geography and culture
-treatment approaches may differ based on geography
importance of legal rights in mental health
-persons with mental illness are vulnerable to mistreatment and abuse
-mental health providers must be knowledgeable about patients rights
-preservation of self- determinism is the basis of many questions about right
-important balance of supporting the well being and preserving safety but also respecting an individual’s rights for self determination
-fine line!!
self-determinism
-internally motivated to make choices based on personal goals, not to please others or be rewarded
-engages in activities due to the positive feelings they bring; no need for other reward
-key values: personal autonomy, avoidance of dependence others
in mental health care:
-right to choose one’s own health-related behaviors
-possibly different from those recommended by health professions
-right to refuse treatment and to seek a second opinion
-may be complicated due to issues of competency, informed consent, voluntary or involuntary commitment, public safety.
patient self determination act
provides patients with the following rights:
-information about advance care documents
-to be asked whether they have an advance care document and that this fact be recorded in the medical record
-information about rights to complete advance care documents and refuse medical care
advance care directives: living will, durable power of attorney for health care (health proxy)
advance care directives in mental health
-psychiatric advance directives=PADs
-allow patients, though competent, to document their voices of treatment and care. declaration must be made in advance, and signed by patient and two witnesses. empower patients to direct their treatment.
-protect the person with mental illness from periodic poor decision making abilities
-documentation of choices for treatment and care, such as choices related to medication and hospitalization
-can be revoked during periods of competency
-a physician can override during times when the patient is not able to make decisions, done through a court proceeding.
protection of patient rights
-Bill of Rights for Mental Health Patients
-Americans with Disabilities Act (ADA)- protects persons with disabilities from discrimination
-Public Law 99-319: requires each state mental health provider to implement a system to protect rights of persons with mental illness and investigate incidents of abuse and neglect
-External advocacy systems: health organizations that advocate for mental health patients rights (American hospital association)
-accreditation: the recognition/approval of an institution according to the accrediting body’s criteria (joint commission)
-most units have these posted and/or available for patients
competency
a legal determination (determined by legal entity), generally understood as the degree to which a patient can understand and appreciate the information given during the consent process
-cognitive ability to process information at a specific time
-decision specific: person may be competent to decide about a simple, predictable treatment, but not competent to make complex treatment decision
-different from rationality, which is a characteristic of a patient’s decision, not the patient’s ability to decide
one of the most important concepts underlying the legal rights of individuals is competency to consent to or to refuse treatment.
-a competent patient can refuse any aspect of the treatment plan
-an irrational decision is one that involves hurting onself pointlessly. a person who is competent may make what appears to be an irrational decision, and it CANNOT be overruled by health care providers.
determination of competency
assessment of 4 abilities:
-communicate choices
-understand relevant information
-appreciate situation and consequences
-use a logical thought process to compare risks and benefits of treatment options
informed consent
legal procedure to ensure that the patient knows the benefits and risks of treatment.
-complicated in mental health treatment: competency is necessary to give consent, decision-making ability often compromised in mental illness, nurse’s role may include structuring consent document, educating the patient, ensuring that consent has been obtained.
-not an option but MANDATED by state laws; must inform patient in such a way that an average reasonable person would be able to make an educated decision about the interventions.
involuntary commitment
mandated treatment without the person’s consent
-laws about involuntary commitment vary from state to state
-three common elements required my most states:
1-mentally disordered
2-dangerous to self or others
3-unable to provide for basic needs (ex- “gravely disabled”= someone who may suffer serious harm because he or she fails to provide for basic human needs and refuses to accept necessary hospitalization)
-person has the right to receive treatment; may also have right to refuse treatment
-most states have provisions for emergency short-term hospitalization of 48-92 hours
-PEC=physician emergency certificate- patient deemed unsafe and has to be in facility
-MEDS CAN ALWAYS BE REFUSED, UNLESS COURT ORDERED OR PATIENT IS HARM TO SELF OR OTHERS
CT laws of voluntary and involuntary commitment
-a “voluntary patient” is a person 1-at least 16 who has applied in writing and been admitted to a hospital for psychiatric disabilities, or 2- under age 16 for whom a parent or guardian has obtained admission
-an “involuntary patient” is one who has been hospitalized by order of a probate court after a hearing or by certification of a qualified physician for emergency diagnosis, observation, or treatment.
seclusion
the involuntary confinement of a person in a room or an area where the person is physically prevented from leaving.
-person is placed in seclusion for purposes of safety
-24 hour observation required for any patient placed on seclusion
-an extremely negative patient experience that is last resort
-no furniture in the room except a mattress and a blanket, walls are usually padded, the room is environmentally safe, no hanging devices, electrical outlets, no windows
-patient is observed at all times
restraint
most restrictive safety intervention!
-defined as any manual method, physical or mechanical, that immobilizes or reduces the ability of the patient to move
-nurse must choose the least restrictive type of restraint to keep the patient safe!
confidentiality
ethical duty of nondisclosure- provider has information about patient and should not disclose it.
-involves two people: the individual who discloses and the person with whom the information is shared.
privacy
if confidentiality is violated, the person’s privacy is also violated.
breach of confidentiality
release of patient information without the patient’s consent in the absence of legal compulsion or authorization.
duty to warn
a legal mandate to inform a foreseeable victim about a patient’s potential violence
-judgment that the patient has harmed someone or is about to injure someone
-based on Tarasoff vs Regents of the University of California
accountability
legal liability in psychiatric nursing practice
-assault: threat of unlawful force
-battery: intentional, unpermitted contact
-medical battery: intentional and unauthorized harmful or offensive contact (treatment without informed consent)
-negligence: breach of duty of reasonable care for a patient for whom the nurse is responsible; results in injury
-common areas for lawsuits: patient who are suicidal or violent
documentation
-handwritten or electronic
-common for all disciplines to record on one progress note and for notes to be problem focused
-patients have access to their records
-nursing documentation is based on nursing standards and institutional policies
-required nursing documentation: observations of subjective and objective physical, psychological, and social responses to mental disorders and emotional problems; interventions implemented and patient’s response; observations of therapeutic and SE of medications; evaluation of outcomes of interventions
-OBJECTIVE! not subjective- no opinions in documentation, can be used in court of law.
-patient record: primary documentation of patient’s problems; verifies behavior and describes care provided
-handwritten documentation always in pen, no erasures
-corrected entries initialed by person making correction
-entry written clearly and without jargon
-meaningful, accurate, objective descriptions; no general or stereotypical statements
-electronic records held to same standards as non-electronic records
-what happened, the intervention, response to intervention.
ANA code of ethics for nurses
purpose:
-informs nurse and society of the profession’s ethical expectations and requirements
-provides framework for ethical decision making
-questions for reflection to determine best ethical action
ethical principles
-autonomy
-beneficence
-justice
-nonmaleficence
-paternalism: professionals have the knowledge and education needed to make decisions for others and should do so- can be in direct conflict with the mental health recovery belief of self-determination
-veracity: one’s duty to tell the truth
-fidelity: faithful to obligations and duties
scope and standards of psychiatric-mental health nursing
-actual or potential mental health problems that occur with psychological changes
-symptom management of patients with mental disorders
six components of standards of practice
- assessment
- diagnosis
- outcomes identification
- planning
- implementation
- evaluation
standards of professional performance
-ethics
-education
-leadership
-collaboration
-EBP and research
-quality of practice
-communication
-professional practice evaluation
-resource utilization
-environmental health
levels of practice-advanced
master’s level preparation- nationally certified by the ANCC
-clinical nurse specialist or psychiatric nurse practitioner
-may have doctorate in nursing practice (DNP), doctorate in nursing science (DNS), or Doctor of Philosophy (PhD)
tools of psychiatric nursing practice
-self
-clinical reasoning and reflection
-interdisciplinary care: expect inter professional collaboration
-plan of care: patient and family, if appropriate, should participate in plan development
challenges of psychiatric nursing
-knowledge development, dissemination, and application
-overcoming stigma
-integration of mental health care and medical care
-health care delivery system challenges: providing care in integrated community based settings
-impact of technology and EHRs: protecting confidentiality may be more challenging
psychodynamic theories and models
-psychoanalytic model: sigmund freud
-neo-fruedian model: karen horney
-interpersonal relations: harry stack sullivan
-humanistic theories: abraham maslow; carl rogers
psychoanalytic model
sigmund freud
-study of unconscious
-personality and its development: id (wants), ego (us normally, at ease) and superego (overthinker-ethics, standards, self critique)
-object relations: psychologic attachment to another person or object
-anxiety and defense mechanisms
-sexual instinct/libido (exists in the id)
-transference and countertransference
-psychoanalysis: form of therapy to help patient access unconscious conflicts beginning in childhood and resolving in adulthood. attempts to reconstruct the personality by examining whatever comes to mind.
neo-freudian model
karen horney= feminine psychology
-recognized a male bias in psychoanalysis (challenged this)
-rejected traditional psychoanalytic belief that women felt disadvantaged because their bodies were unlike those of men
-women are at a disadvantage because of authoritarian culture
interpersonal relations
harry stack sullivan
-importance of human relationships; instincts and drives are less important
-interpersonal relations as the basis for human development and behavior
-viewed health as dependent upon managing one’s ever-changing physical, social, and interpersonal environment and life experiences
humanistic theories- carl rogers
-client centered therapy
-empathy, genuineness, and unconditional positive regard
-THE EMPATH!
-nonjudgmental approach towards clients
humanistic theories-abraham maslow
-hierarchy of needs
-ranges from basic food, shelter, warmth (first level), to high-level requirements for self-actualization
1-physiological needs
2-safety and security
3-love and belonging
4- self-esteem
5- self-actualization
psychodynamic theories
important concepts: interpersonal relationships, defense mechanisms, transference and countertransference
A THERAPEUTIC INTERPERSONAL RELATIONSHIP: CORE OF PSYCHIATRIC-MENTAL HEALTH NURSING INTERVENTION.
cognitive behavioral theories
thoughts and how they are related to behavior, and how they feel.
1. stimulus-response theories: pavlov= classical conditioning/involuntary response
2. reinforcement theories: BF Skinner= operant conditioning/voluntary behaviors- rewarded behaviors tend to be repeated (token economy)
3. cognitive theories: aaron beck=thinking, feeling, cognitions, faulty beliefs cause judgment errors that become habitual errors in thinking. verbal or pictorial events in one’s stream of consciousness (he introduced CBT)
CBT applicability to nursing
widespread use of behavioral theories in practice, patient education interventions, privilege systems and token economies, changing an entrenched habit.
developmental theories
erik erikson: psychological development
applicability to nursing: developmental theories
-useful in understanding childhood and adolescent experiences and manifestations as adult problems
-applicability limited because of assumption of stages progressing in a linear fashion
-lack of accounting for gender differences and diverse lifestyle and cultures
social theories
how does this person function in a unit?
-family dynamics: patterned interpersonal and social interactions; based on systems theory; change in one part affects functioning of entire system
-formal and informal social support: formal would be large organizations, informal would be family, social distance is degree to which the values of the formal organization and primary group members differ.
-role theories: emphasis on social interaction, a foundation of milieu therapy (group therapy)
-sociocultural perspectives: leininger’s transcultural nursing
social theories: applicability to nursing
-important to consider the role of individual within the family and society
-interventions are based on the understanding and significance and cultural norms
-viewing inpatient unit as a social community can help nurse design the unit’s social environment
-basis for many group interventions
nursing theories: interpersonal relations models
hildegarde peplau
-introduction of the nurse-patient relationship
-empathic linkage: the ability to feel in oneself the feelings experienced by another person
-interpersonal transmission of anxiety or panic is most common empathic linkage
-anxiety: mild, moderate, severe, panic
self-awareness
the process of understanding one’s own beliefs, thoughts, motivations, biases, and limitations, and recognizing how they affect others; requires a willingness to be introspective
-how we avoid bias!
self-examination
reflecting on the personal meaning of current nursing situation
-avoidance of bias if self-examination involves perspective of a trusted other person
-transference and countertransference
understanding personal feelings and changing behaviors
1-understand own personal feelings and beliefs and try to avoid projecting them onto patients
2-solicit feedback from colleagues and clinical supervisor about how personal beliefs or thoughts are being projected onto others
3- through self-awareness and conscious effort, the nurse can change learned behaviors to engage effectively in effective interactions
biopsychosocial self
-biologic: physical characteristics, genetic makeup, chronic illness, unobservable physical disability
-psychological: psychological makeup, emotions, motivations, beliefs
-social: sociocultural values, cultural beliefs, patterns of communication
communication
verbal, nonverbal, and therapeutic communication!
-verbal= spoken word, underlying emotion, context, connotation
-nonverbal= gestures, expressions, body language
-therapeutic communication= ongoing process of interaction in which meaning emerges
principles of therapeutic communication
-patient is primary focus!
-professional attitude sets the tone
-limit self-disclosure
-no advice or social relationships with patients
-maintain patient confidentiality
-assess patient’s intellectual competence to determine understanding
-maintain nonjudgmental attitude
-avoid giving advice
-guide patient to reinterpret experiences rationally
-avoid changing the subject unless it’s in patient’s best interest
verbal techniques
-silence and listening
-passive listening (not therapeutic)
-active listening
-acceptance
-confrontation
-voicing doubt
-interpretation (verbalizing the implied)
-observation
-open-ended statements
-reflection
-restatement
-silence
-validation
nonverbal communication techniques
-nonverbal messages: can mirror or enhance verbal messages; varies from culture to culture
-gestures
-facial expression, eye contact
-body language
professional boundaries and ethics
nurse refrains from sharing personal information or attempting to meet own needs through the relationship.
factors that affect communication
-personal: cognitive, social, emotional factors
-environmental: physical, societal factors
-relationship (RN to client): status factors (ex-social standing, age)-remember clients are in a state of vulnerability!!!
considerations for effective communication and relationships
-rapport: interpersonal harmony characterized by understanding and respect
-empathy: ability to experience, int he present, a situation as another did at some time in the past
-empathic linkages: direct communication of feelings (recognition of these from Peplau- the direct communication of feelings, requires being aware of personal feelings, requires analyzing one’s own feelings to determine the source, and addressing associated problems)
boundaries
-friendships and/or sexual relationships are inconsistent with the professional nursing role and are considered unethical
-when concerns arise related to therapeutic boundaries, the nurse must seek clinical supervision or transfer the care of the patient immediately.
-no exchanging gifts, no keeping secrets, no favoring patients
phases of the nurse-patient relationship
peplau
1-orientation phase: first meeting and anxiety is common. confidentiality, discussion os pt’s expectations, review of purpose of relationship, boundaries, patient’s perception of the problem, obtain baseline.
2- working phase: identification of problems, problem solving, transference and countertransference are important issues here, assessment, questioning.
3- resolution phase: begins when problems are resolved, ends with termination of therapeutic relationship, figuring our next steps.
defense mechanisms
physiological mechanisms that help an individual to respond to and cope with difficult situations, emotional conflicts and external stressors.
-often unaware we use them
-can be maladaptive or adaptive
-evaluate purpose of a defense mechanism; determine whether or not to discuss with patient.
non-therapeutic relationships
-nurse and patient feel frustrated, vary their approaches with each other in effort to establish meaningful relationship
-grappling and struggling to reach a common ground mutual withdrawal
deteriorating relationships
-non-therapeutic
-pt perceives nurse as withholding support
-pt feels uncomfortable, anxious, frustrated, guilty about being ill, feels lack of trust
-pt avoids nurse and perceives nurse as avoiging him/her
-pt struggles and tries to understand the unsatisfactory relationship; experiences hopelessness and frustration
group intervention
-two or more people developing interactive relationships
-more than the sum of its parts
-sharing of at least one common goal or issue
-a group develops its own personality, patterns of interaction, and rules of behavior
-sense of community
member selection for group
criteria:
-does purpose of group match members needs?
-does member have social skills to function comfortably in the group?
-will other group members accept them?
-what is the potential of the member to commit to attending meetings?
small group sizes
-less than 8 members
-cohesive
-fewer subgroups
-richer interpersonal experience
-1 to 2 leaders
-ideal for complex individual issues
large group sizes
-more than 8 to 10 members
-can be therapeutic
-more cost effective
-open ended, ongoing
-less intense transference and countertransference
direct vs indirect leadership style for group
-direct: direction and information, little discussion, tells members what to do
-indirect: reflective of group members’ discussion, little guidance or information to the group, balance of direction and group freedom
first meeting planning
-leader sets tone
-introduction- avoidance of self-disclosure by leader
-explanations of group structure, purpose, and rules
-observation of group dynamics- all verbal and nonverbal interactions within the group
group dynamics and stages
- beginning stage (honeymoon): rapport, getting to know one another, techniques for leading groups, testing by members and possible conflict
- working stage: sharing of ideas, development of closeness, development of norms, realization of purpose
- termination stage: grieve for loss of group’s closeness, reestablishment of self as individual, summary and future plans.
role of group members
-formal group roles: leader and member
-informal group roles: task, maintenance, individual
challenging behaviors: disliked members, silent members, monopolizers.
types of groups
-psychoeducation groups: to enhance knowledge, improve skills, solve problems
-task groups: focus on specific activities; group cohesiveness important
-decision-making groups: plan activities; “groupthink” may emerge
-supportive therapy groups: focus on helping members cope
-psychotherapy groups: focus on examining emotions and helping members face their situations
-self help groups: usually led by non-professional
-age related groups: attends to developmental needs of members
nursing intervention groups
-medication groups
-symptom management groups
-anger management groups
-reminiscence groups
-self care groups
dialectical behavior therapy (DBT)
a spinoff of cognitive behavioral therapy that is helpful for a range of mental health issues.
-includes DBT house (foundation=foundation as a person, walls=support, roof=shelter/protection, chimney=how to blow off steam, billboard= what you’re proud of, 3 floors= 1-changing areas, 2-career goals, 3-things that make you happy)
mental status exam (MSE)
evaluation of the patients current status.
includes:
-appearance and behavior
-mood and affect
-speech
-motor behavior
-thought content and perceptual abnormalities
-sensorial, cognitive, and intellectual functioning
-memory (recent and remote)
to assess mental health, MSE performed on EVERY PATIENT!
appearance general description
poise, posture, grooming, hygiene, clothing, weight
sensorium=LOC general description
alert and oriented x ?
behavior general description
how the clients relate to you during interview.
-any bizarre posturing
-hostile
-guarded
-agitation
-friendly/cooperative
mood general desciption
the underlying emotion the patient feels
-happy, sad, angry, depressed, anxious
affect general description
what the provider notes
-labile (rapid shifting between extremes), blunted, flat, inappropriate (laughing about sad events).
speech general description
assess rate, tone, volume, rhythm of speech.
motor behavior general description
pacing, wringing of hands, tics, fidgeting, tremors, rigidity, little movement or activity
thought content general description
look for unusual or dangerous ideas/themes that are present during the exam.
-delusions/hallucinations
-paranoia
-preoccupations, obsession, compulsions
-phobias
-ideas of reference: false beliefs that random events in the world directly relate to them
-poverty of content/word salad
-SI/HI?
cognitive and intellectual functioning
-assess level of intelligence
-judgement
-insight
-evaluate patients understanding of current health status
-assess memory: remote and recent
goal of biologic foundations of psych nursing
to make connections between psych symptoms, alteration in brain functioning linked to those symptoms, and reason for treatment and care practices.
cerebrum
-largest region of human bran, left and right hemispheres
-outermost surface is cortex, making up 80% of brain4 to 6 layers thick, each layer made of cell bodies and capillary blood vessels, making cortex gray brown (gray matter)
-lobes: frontal, parietal, temporal, occipital
-association cortex: allows lobes to work in integrated manner.
corpus callosum
connects two hemispheres
-bundle of neuronal tissue that allows information to be exchanged quickly between right and left hemispheres
-intact is required for smooth and coordinated functioning
frontal lobe
executive functions, planning, initiating, insight, judgment, reasoning, problem-solving, abstraction
-contains Broca’s area: controls motor function of speech. damage here produces expressive aphasia, or difficulty with the motor movements required for speech.
-highest or. most complex aspects of cortical functioning, making up large part of personality
-important role in development of symptoms common to psych disorders, such as schizophrenia, ADHD, and dementia
parietal lobe
posterior areas of cerebrum, appear to coordinate visual and somatosensory information. writing, drawing, calculating abilities, organizing spatial directions
-damage here produces sensory deficients, include neglect of contralateral sensory stimuli and spatial relationships
-contribute to ability to recognize objects by touch, calculate, write, recognize fingers of the opposite hands, draw, and organize spatial directions
temporal lobe
primary auditory and olfactory areas; hippocampus, modulating mood and emotions
-contains primary auditory and olfactory areas
-contains Wernicke area at the posterior aspect of superior temporal gyrus, responsible for receptive speech
-integrates sensory and visual information involved in control of written and verbal language as well as visual recognition.
occipital lobe
visual integration of information
subcortical structures
beneath the cortex
-many subcortical structures are essential for regulating emotions and behaviors
-basal ganglia: involved with motor functions, association in both the learning and the programming of behavior or activities that are repetitive and become automatic over time
-damage to portions of these nuclei may produce changes in posture or muscle tone, or produce abnormal movements, such as twitches or tremors
-basal ganglia can be adversely affected by some medications for psych disorders leaning to motor related problems
limbic system
hippocampus, thalamus, hypothalamus, amygdala, and limbic midbrain nuclei
-modulates basic emotions, needs, drives, and instincts
-also involved with aspects of memory due to emotion generation
-
CNS structures
-extrapyramidal motor system: controls muscle tone, common reflexes, automatic voluntary motor functioning
-brains stem: important life-sustaining functions
-cerebellum: controls movement and postural balance
neuroplasticity
ability of the brain to change
-compensates for loss of function in specific area
-nerve signals may be rerouted
-cells learn a new function
-nerve tissues may be regenerated
-the sensitivity or number of cells may increase or decrease, and some nerve tissue may undergo limited regeneration
-mostly plastic during infancy and young childhood, when large adaptive learning learning tasks should normally occur
-brains become less plastic with age
-neuroplasticity contributes to understanding how function may be restored over time after brain damage occurs, or how an individual may react over time to continuous pharmacotherapy
neurotransmitters
directly or indirectly control opening or closing of ion channels
-excitatory: enhance the transmission of the signal between neurons
-inhibitory: slow down nerve impulses
cholinergic neurotransmitters
acetylcholine
-primary cholinergic neurotransmitter
-excitatory
-greatest concentration in the peripheral nervous system
-involved in higher intellectual functioning and memory
-individuals with alzheimers or down syndrome often exhibit patterns of cholinergic neuron loss in regions innervated by these pathways like the hippocampus. leads to memory and cognitive deficits
-some cholinergic neurons are afferent to these areas, bringing information from the limbic system, highlighting the role that ACh plays in communicating one’s emotional state to the cerebral cortex.
biogenic amines
dopamine
norepinephrine
serotonin
dopamine
excitatory, stimulates body’s natural feel good reward pathways, producing pleasant, perhaps even euphoric sensation
-involved in regulating action, emotion, motivation, and attention
-also involved in cognition, motor, and endocrine functions
-decreased levels in parkinsons, abnormally high activities in schizophrenia
norepinephrine
excitatory neuro-chemical that plays a major role in generating and maintaining mood states.
-heavily concentrated in the terminal sites of sympathetic nerves, it can be released quickly to read fight or flight response to threats in environment. thought to play role in physical symptoms of anxiety.
serotonin
excitatory neurotransmitter
plays role in emotions, cognition, sensory perceptions, and essential biologic functions, such as sleep and appetite.
-during REM phase of sleep, or dream state, serotonin concentrations decrease, and muscles subsequently relax.
-involved in control of food intake, hormone secretion, sexual behavior, thermoregulation, and CV regulation
melatonin is derived from serotonin, produced in the pineal gland, and plays a role in sleep, aging, and mood changes.
amino acids
building blocks of protein that can function as neurotransmitters
-histamine: derived from amino acid histadine and appears to have a role in autonomic and neuroendocrine regulation. many psych meds can block effects of histamine post-synaptically and produce SE such as sedation, weight gain, and hypotension.
-glutamate: most widely distributed excitatory neurotransmitter, with pathways connecting with hippocampus, learning, and memory. too much is harmful to neurons and can cause neurotoxicity. damage to CNS from chronic malfunctioning of glutamate system may be involved in neurodegenerative diseases.
-GABA= gamma aminobutyric acid
GABA= gamma-aminobutyric acid
primary inhibitory neurotransmitter
-calms you down
-dysregulation of GABA and receptors is associated with anxiety disorders
decreased GABA activity is involved in the development of seizure disorders
mood
pervasive and sustained emotion that colors one’s perception of the world and how one functions in it
-when depressed feelings interfere with daily activities and relationships, mood can impair judgment and contribute to negative views of the world
-normal mood variations are time limited and are not usually associated with significant functional impairment
affect
expression of mood, outward emotional expression, related to concept of mood
-provides clues to person’s mood
can be:
-blunted: significantly reduced
-flat: absent/nearly absent
-bright: smiling
-inappropriate: discordant affective expression
-labile: varied, abrupt shifts
-restricted or constricted: mildly reduced
depression
a common mental state characterized by sadness, loss of interest or pleasure, feelings of guilt or low self-worth, disturbed sleep or appetite, low energy, and poor concentration.
depressive disorders
-disruptive mood dysregulation
-MDD, single or recurrent
-persistent depressive (dysthymia) disorder
-premenstrual dysphoric disorders
-substance/medication induced disorder or medical condition
when a sad mood interferes with daily life, a depressive disorder may exist that will benefit from treatment. in DDs, a sad, irritable, or empty mood is present with somatic and cognitive changes that interfere with functioning. they vary according to duration, timing, or cause.
-people experience a lower quality of life and are at greater risk for development of physical health problems. so widespread that they are generally diagnosed and treated in the primary care setting
-characterized by severe and debilitating depressive episodes, associated with high levels of impairment in areas of functioning. frequently undetected and untreated, and associated with premature death.
symptoms of major depressive disorder
-depressed mood most of the day, nearly every day
-markedly diminished interest or pleasure
-poor appetite or overeating
-insomnia or oversleeping
-psychomotor agitation or retardation
-low energy or fatigue
-feelings of worthlessness or excessive guilt
-poor concentration or difficulty making decisions
-recurrent thoughts of death/SI
SIG E CAPS= sleep disturbances, interest decreased, guilt, energy decreased, concentration problems, appetite/weight changes, psychomotor agitation or retardation, SI (depression screening mnemonic)
depressive disorders in the child and adolescent
-anxiety and somatic symptoms more likely
-may have decreased interactions with peers, avoidance of plan and recreational activities
-may have irritable rather than sad mood
-risk of suicide peaks mid-adolescence
-in children, more likely to have anxiety symptoms like fear of separation, somatic symptoms, like stomach or headaches.
-use of substances intensifies depressive symptomatology and the risk of suicide
depressive disorders in the older adult
-commonly associated with chronic illness: symptoms possibly confused with those of bipolar disorder, dementia, or stroke
-suicides rate peak during middle age, with a second peak occurring aged 75 and older
-often undetected or inadequately treated
-successful tx in 60-80%, but response is slower than in younger adults
often associated with chronic illnesses, such as heart disease, stroke, and cancer
-s/sx may have more somatic focus
-differential diagnosis may be required to ascertain the root and cause of symptoms
-suicide is very serious risk, especially for risk
-suicide rates peak middle age, but second peak during 75+
risk factors for depression
-prior episode of depression
-family history of depressive disorder
-lack of social support
-lack of coping abilities
-presence of life and environmental stressors
-current substance use or abuse
-medical and/or mental illness comorbidity
goals of treatment for depressive disorders
-reduce or control symptoms, and if possible, eliminate signs and symptoms of the depressive syndrome
-improve occupational and psychosocial function as much as possible
-reduce the likelihood of relapse and recurrence through recovery-oriented strategies
-PRIORITY CARE ISSUES: SAFETY AND ASSESSMENT OF SUICIDE RISK
-depressive disorders are most commonly occurring mental disorders, but not always treated in psych setting
-coordinated ongoing interactions among team, patient, and family, are needed
-collaboration between PCP and mental health specialist is key to achieve remission of symptoms and physical well-being
cognitive and interpersonal therapies for depressive disorders
-short term cognitive and interpersonal therapies may be as effective as pharmacotherapy in milder depressions
-CBT is an effective strategy for preventing relapse in patients who have had only a partial response to pharmacotherapy alone
-CBT is implemented in individual or group therapy by a trained clinician
psychosocial assessment for DDs
mood and affect
thought process and content
cognition
memory
attention
coping skills
developmental history
family psychiatric history
patterns of relationships
quality of support system
education
work history
impact of physical or sexual abuse on interpersonal function
anhedonia
mood and affect of DDs
sustained period of feeling depressed, sad, or hopeless, and may experience anhedonia (loss of interest or pleasure)
-patient may report not caring anymore, or not feeling any enjoyment in activities that were previously considered pleasurable
-decreased libido and sexual function
-irritability and anger are s/sx, especially in those who deny being depressed
thought content of DDs
-often unrealistic negative evaluation of their worth or have guilty preoccupations or ruminations about minor past failings
-often misinterpret neutral or trivial day to day events as evidence of personal defects
-may also have an exaggerated sense of responsibility for untoward events, resulting in feeling hopeless, helpless, worthless, and powerless
-possible disorganized though processes, and perceptual disturbances should be assessed
cognition and memory in DDs
-many with depression report an impaired ability to think, concentrate, or make decisions
-may appear easily distracted or complain of memory difficulties
-in older adults, memory difficulties may be the chief complaint and may be mistaken for mistaken for early signs of dementia
-when depression is fully treated, memory problem often improves or fully resolves
social nursing assessment of DDs
-developmental hx
-family psychiatric hx
-patterns of relationships
-quality of support system
-education, work history
-impact of physical or sexual abuse on interpersonal function
-spiritual dimension and religious background
biologic nursing interventions for DDs
-re-establish normal sleep patterns, healthy nutrition, encourage activity, and exercise
-administering and monitoring antidepressant therapy: SSRIs, SNRIs, tricyclic antidepressants, MAOIs, others
antidepressant therapy BBW
increased risk for suicide in children, adolescents, and young adults ages 18-24
SSRIs
selective serotonin reuptake inhibitors
-inhibit reuptake of serotonin
-common SE: headache, anxiety, insomnia, transient NVD, sedation, constipation, dry mouth, tremors, blurred vision, muscle weakness
examples: fluoxetine (prozac), sertraline (zoloft), paroxetine (paxil), citalopram, escitalopram (lexapro), fluvoxamine
SNRIs
serotonin and norepinephrine reuptake inhibitors
-prevent reuptake of serotonin and norepinephrine
-side effects: similar to SSRIs, and increased BP
examples: duloxetine (cymbalta), levomilnacipran, venlafaxine, desvenlafaxine (pristiq xr)
TCAs
tricyclic antidepressants
-act on variety of neurotransmitters, including norepinephrine and serotonin
-more serious SE! sedation, anticholingergic side effects, orthostatic hypotension
-other SE: tremors, restlessness, insomnia, NA, confusion, pedal edema, HA, seizures, blood dyscarias, possibly cardiotoxicity
-dangerous in even of overdose: 3-5 times the dose is lethal! crucial to screen for SI
examples: amitriptyline, amoxapine, desipramine, doxepin, imipramine, clomipramine.
MAOIs
monoamine oxidase inhibitors
-inhibit MAO, an enzyme that breaks down serotonin, norepinephrine, and other neurotransmitters
-potentially dangerous interaction (HTN crisis!) with tyramine-rich foods and certain meds
-sides of food-drug interaction include severe HA, palpitations, stiff/sore neck, NV, sweating, HTN, stroke, possibly death
-SE: dizzy, HA, insomnia, dry mouth, blurred vision, constipation, nausea, peripheral edema, urinary hesitancy, muscle weakness, forgetfulness, weight gain, orthostatic hypotension, sexual dysfunction
many interactions! need 2 weeks to leave system
tyramine rich foods= pepperoni, salami, fermented foods, like veggies and meets, citrus, freshly baked breads, nuts, aged cheese, wine, kombucha
examples: isocarboxazid, phenelzine, tranylcypromise, selegiline.
nursing interventions for MAOIs side effects
-sugarless gum, lozenges, fluids
-take med with food
-balanced diet and exercise
-maintain fluid balance/increase hydration
-sit and stand slowly
-no alcohol or drugs
-frequent bathing, light weight clothing
serotonin syndrome
a potentially serious side effect!
-caused by drug induced excess of intrasynaptic serotonin
-s/sx: change in mental status, agitation, ataxia, myoclonus, hyperreflexia, fever, shivering, diaphoresis, diarrhea
-Tx: determine and discontinue offending substance, and if mild-lorazepam for agitation, and moderate to severe- possible hospitalization for cardiac monitoring, IVF, sedation, cooling blankets, antipyretics, nitroprusside for HTN and tachy
psychological nursing interventions for DDs
-therapeutic relationship
-cognitive interventions: thought stopping and positive self talk
-behavior therapy: activity scheduling, social skills training, problem solving
-interpersonal therapy
-family and marital therapy
-group interventions, support groups, teaching groups
social nursing interventions for DDs
-milieu therapy
-safety: for increased risk of self-harm with feeling better and having increased energy
-family education and support, consumer-oriented support groups
-organizations: depression and bipolar support network, national alliance on mental illness, mental health association and recovery inc.
suicidal behavior and recognizing signs
-SI
-require immediate mental health assessment regarding the depth of thoughts and intentions: passive or active, seriousness depending on frequency, intensity, and lethality
-initially assessed, and then reassessed throughout the course of treatment
suicidal behavior: risk factors
significant triggers:
-lack of availability and inadequacy of social supports
-family violence, including physical or sexual abuse
-history of SI or suicidal behavior
-presence of psychosis or substance use or abuse
-decreased ability to control suicidal impulses
-psychological stress and previously diagnosed psych disorders are chief risk factors for veterans
suicide
-one of the major health problems in the US, with several health goals of healthy people 2020 addressing it
-most are associated with mental illness, depression being the most common
-rates have steadily increased in the past 20 years, with a 35% increase in the total suicide rate from 1999 to 2018
-suicide is so rejected in contemporary society that people with strong suicidal thoughts dont seek treatement for fear of being stigmatied by others
suicidality
all suicide-related behaviors and thoughts of completing or attempting suicide and suicidal ideation
suicidal ideation
thinking about and planning one’s own death
suicide attempt
nonfatal, self inflicted destructive act with explicit or implicit intent to die
parasuicide
voluntary, apparent attempt at suicide, commonly called a suicidal gesture, in which the aim is NOT DEATH.
lethality
the probability that a person will successfully complete suicide
-determined by seriousness of the person’s intent and the likelihood that the planned of death will succeed
-a plan to use an accessible firearm to commit suicide has greater lethality than a suicide plan that involves superficial cuts of the wrist.
suicide epidemiology
-10th leading cause of death
-occurs every 11 minutes in the US
-mountain range has highest rates
-can be disguised as accidents or homicides
-can occur across lifespan
risk factors for suicide
-mental illness: mood disorders associated with high risk. substance use and personality disorders found to influence suicide risk. auditory hallucinations increase risk. substance abuse increases likelihood of SI.
-medical illness
-psychological: internal distress, low self-esteem, interpersonal distress, child: social isolation primary risk factor: leads to despair and can be caused by family discord, neglect, abuse, other suicides, and divorce.
-gender: males > females for suicide completion
-sexuality: increased risk among LGBT community
-racial and ethnic variations: higher rate among whites and American indian/alaska natives
biologic theories of suicidal behavior
-depression: those who complete suicide often have extremely low levels of the neurotransmitter serotonin
-severe childhood trauma
-genetic factors: suicide runs in families. first degree relative suicide is highly predictive of a serious attempt. also appears to be a gene/environment connection between early childhood sexual abuse and suicidality. early childhood adverse experiences appear to lead to genetic changes that modify expression of neurologic system, impacting development
psychological theories of suicidal behavior
-cognitive theories: cognitive triad= 1. hopelessness, 2. helplessness, and 3. worthlessness
-Beck first identified this as integral to experience of depression.
-those who are hopeless are more likely to consider suicide than those who are depressed but hopeful about the future. lack of positive thoughts about the future is more likely to predict suicidal behavior than negative thoughts even though both contribute to hopelessness.
social theories of suicidal behavior
-social distress: lack of social connection
-suicide contagion: social exposure to suicide-seems to work through. modeling and is more likely to occur when the individual contemplating suicide is of the same age, gender, and background as the person who died. can be prompted by the suicide of a friend, an acquaintance, online social networking, or idolized celebrity. for celebrities, the number of “copycat suicides” is proportional to the amount, duration, and prominence of media coverage.
-economic disadvantage: poverty, unemployment, low income
family response to suicide
-devastating
-survivors with increased grief, anxiety, depression, guilt, shame, self-blame, and family dysfunction
-recovery is an ongoing task
-one suicide estimate6 survivors significantly impacted by the loss
protective factors from suicide
-CDC identifies: effective clinical care for mental, physical, and substance abuse disorders; family and community support/connectedness; support from ongoing medical and mental health care relationships; cultural and religious beliefs that discourage suicide and support instincts for self-preservation.
-family and friends, faith or religion, community
-precautions include 1-1, no tubes or sharp objects in room, q15 wellness checks
interdisciplinary treatment for suicide
-previous attempt is greatest predictor of future attempt.
-risk assessment: identification of suicidal ideation, elicitation of a plan, determination of the severity of ideation, evaluation of availability of means
warning signs for suicide
ISPATHWARM
-I: ideation= talking about death, dying, suicide
-S: substance abuse
-P: purposelessness
-A: anxiety
-T: trapped= feeling there is no way out
-H: hopelessness
-W: withdrawal
-A: anger, rage
-R: recklessness
-M: mood change
suicide prevention
-priority care for psych emergency: provide for safety while initiating the least restrictive care possible
-if risk is imminent: reconnect patient to others and instill hope, restore emotional stability and reduce suicidal behavior, ensure safety! focus on management of suicidal impulses and development of protective strategies, create a list of resources
inpatient care and nursing management of a suicidal patient
-help pt feel secure and hopeful
-continuous or intermittent observation
-remove dangerous objets
-help pt describe feelings and identify ways to manage safety needs
biologic nursing interventions for a suicidal patient
-physical care of self-inflicted injury: those who have survived an attempt often need physical care of their self-inflicted injury
-medication management: focuses on treating the underlying psych disorder. clozapine is an approved med for suicide risk in individuals with schizophrenia.
-electroconvulsive therapy: (ECT) used in both inpatient and outpatient to alleviate severe depression, especially in those who may not tolerate conventional pharmacotherapy well. among several strategies used to decrease suicidal behavior over the long term.
psychological nursing interventions for a suicidal patient
-challenging the suicidal mindset: distraction, validation, management of emotional distress, exploration of alternative solutions
-developing new coping strategies: crisis management, generate solutions, engage in effective interpersonal interactions, maintain hope
-psychoeducation: suicide prevention
CTS= commitment to treatment statement: pt agrees to engage in treatment, try new approaches, and access emergency services if needed.
social nursing interventions for a suicidal patient
-social skills training: poor social skills may interfere with pt’s ability to engage others. assess pt social capability early in treatment and make necessary provisions for social skills training. interpersonal relationship with the nurse is an ideal place to begin shaping social behaviors that will help pt establish a social network that will sustain them during periods of discouragement or crisis.
-developing support networks, like recovery groups, drop-in centers, self-help groups to help the pt become connected to others.
-stigma reduction
continuum of care for a suicidal patient
-pt cannot be released to home until a workable plan of care is in place
-pt’s outpatient environment should be made as safe as possible before discharge
-nurse must share care plan with family members so they can remove objects in the pt’ s environment that could be used to engage in self-harm
-nurse should explain this measure to the pt to reinforce their sense of self-control. important to be reasonable in deciding what to remove from environment.
-care plan includes scheduling an appointment for outpatient tx, providing for continuing somatic tx until the first outpatient tx visit, providing for access to emergency psych care, and arranging structure and safety in pt environment.
documentation and reporting for a suicidal patient
-nurse must thoroughly document encounters with patients who are suicidal. this action is for the patient’s ongoing treatment and the nurse’s protection.
-lawsuits for malpractice in psych settings often involve completed suicides. medical record must reflect that nurse took every reasonable action to provide for the pt’s safety.
-nurse should document the presence of absence of suicidal thoughts, intent, plan, and available means to illustrate the pt’s current and ongoing suicide risk. if the pt denies any suicidal ideation, it is important that this is documented.
-documentation must include any use of drugs, alcohol, or prescription meds by the pt during 6 hours before the assessment
-should reflect level of pt’s judgment and ability to be a partner in tx
