Exam 2 Flashcards
beneficence
the duty to act to benefit or promote the good of others
autonomy
respecting the rights of others to make their own decisions
justice
the duty to distribute resources and care equally regardless of personal attributes
fidelity
maintaining loyalty and commitment to the patient and doing no wrong to the patient
veracity
due process
the government must follow fair procedures before depriving someone of “life, liberty, or property”
least restrictive alternative doctrine
mandates that least drastic means be taken to achieve a specific purpose
writ of habeas corpus
formal written request to “deliver the body”; have to present the information
humphrey vs cady 1972
involuntary civil commitment to mental hospital is a massive curtailment of liberty and requires due process protections
olmsted vs L.C. (1999): US supreme court
pt with mental health illness are to be placed in less restrictive community settings rather than in institutions
in order for a patient to be admitted to the hospital…
illness must present an immediate crisis; expectation exists that hospitalization and treatment will improve the immediate problem
different types of admissions
voluntary, involuntary (commitment)
in order for a pt to be involuntarily admitted…
specified number of physicians must certify that the persons mental health status justifies detention and treatment
types of involuntary hospitalization
emergency hospitalization, observational/temporary hospitalization, long-term or formal commitment, outpatient commitment (ex. substance abuse rehabs)
2 types of discharges from hospital
conditional release- outpatient treatment usually required; unconditional release- discharge (seen with discharge to a shelter)
patients right to treatment
1964 hospitalization of the mentally ill act- medical/psychiatric care and treatment must be provided to everyone admitted to a public hospital; treatment must be humane environment, qualified and sufficient staff to provide adequate care, and individualized plan of care
patients right to refuse
patients have the right to withhold consent, right to withdraw at any time, right to retract consent; exception is if pt is committed
patients right to informed consent
an adult with sound mind has a right to determine what shall be done with his or her own body
implied consent
clinician approaches pt with medication and pt indicates willingness to receive med, implied consent has occurred; state psychiatric hospitals generally require informed consent for every medication given
general rule for implied consent
the more intrusive or risky the procedure, the higher the likelihood informed consent must be obtained
steps nurses must take if they suspect negligence or illegal activity on pert of professional colleague or peer
nurses suspect negligence in a peer -> nurses have legal duty to report risks of harm to pt (communicate risks to person directly involved) -> evidence should be clearly documented before making accusations -> if behavior continues then the nurses are obligated to report behavior to supervisors -> if danger persists report to next level of authority such as board of nursing
pt rights after death, pt tests positive for HIV, or if pt emloyer states “need to know”
right to privacy continues after death; privilege does not apply in cases where healthcare provider has duty to report past present or future criminal activity; any release of info to 3rd part without pt expressed consent is breach of confidentiality
situations where healthcare professionals have duty to break confidentiality
duty to warn/protect 3rd parties (ex. pt expressed homicidal ideations)
nursing implications in jurisdictions that have adopted Tarasoff doctrine
duty to warn 3rd parties is applied to advanced practice registered nurses and psychiatric mental health nurses; staff nurses and members of mental health team should report threats of harm; failure to report and record relevant info from police and relatives may result in pt old records being deemed negligent
patient rights regarding restraint and seclusion
all pt have right to be free from physical or mental abuse and corporal punishment; all pt have right to be free from restrain or seclusion as means of coercion discipline convenience or staff retaliation; restraint or seclusion can only be imposed to ensure immediate physical safety of pt or staff and must be discontinued as early as possible
documentation and charting
must contain factual information only (ex. pt appears to be agitated); provides accurate and complete info about the care and treatment of pt; gives healthcare personnel means of communicating with each other; allows for continuity of care; used by facility for medical records; used as evidence; only staff that has a need to known shall have access to chart
the nursing process is a…
6 step problem-solving care approach; facilitates care that is appropriate, safe, culturally competent, developmentally relevant, high-quality; creates the foundation for standards of practice
nursing process steps
assessment, nursing diagnosis, outcome identification, planning, implementation, evaluation
role of standards of practive
provide criteria for certification, legal definition of nursing, NCLEX, 6 standards of practice (aka nursing process)
standard 1- assessment
collect data perinent to consumer; evidence based/holistic ass. technique; primary source is pt; abides HIPAA; documentation is retrievable
assessment considerations
age and language barrier
psychiatric RN goals of assessment
establish rapport, understand current problem/chief complaint, review physical status and obtain baseline vitals, assess for risk factors of pt or others, perform mental health exam., assess psychosocial status, identify mutual goals for treatment, form plan that prioritizes pt needs, document in retrievable format
how to gather data
review of systems, lab data, MSE, psychosocial assessment, spiritual/religious assessment, cultural/social assessment, self-awareness assessment, validating assessment
conducting MSE
fundamental overall pt assessment; purpose is to eval. current cognitive function, aids in collecting/organizing objective data; observes behavior, verbal/nonverbal communications, speech, cognitive ability, lifestyle, strength of resources
overview of what MSE consists of
personal info, appearance, behavior, speech, affect and mood, thought, perceptual disturbances, cognition
why does psychosocial assessment include spiritual and religion
they can influence how people solve their own problems in life; it cand influence health and illness; being aware can decrease stigmatization stereotyping and labeling
info psychosocial assessment obtains
Chief complaint, HX of violent SI or self-mutilating behaviors, alcohol/substance abuse, family psych HX, personal psych treatment (meds/therapy), life stressors and coping mechanisms, quality of ADLs, personal background, social background, weakness strengths and goals for treatment, racial ethnic and cultural beliefs/practices, spiritual beliefs/religious practices
standard 2- diagnosis
formulating nursing diagnosis; can be standard, risk, or health promotion diagnoses
standard nursing diagnosis
the problem (unmet need), the etiology (probable cause), the supporting data (s/s)
nursing risk diagnosis
high probability of a future negative event for a vulnerable individual
health promotion diagnosis
willingness to enhance specific health behaviors
standard 3- outcome
psychiatriic mental health RN identifies expected outcomes and consumers goals based on consumer and or situation
nursing standard outcome criteria
reflect maximal patient health that can be realistically achieved through evidence-based interventions; provides direction for continuity of care; patient-centered and culturally appropriate; must be variable and measurable; must reflect pt actual state; must include a set time for achievement, must be specific, and must be short
outcome plan should be…
safe, evidence-based, realistic, compatible with other therapies
standard 4- planning
psychiatric mental health RN develops plan that prescribes strategies and alternatives to assist consumer in attaining expected outcomes
standard 5- implementation
psychiatric mental health RN implements identified plan; standard 5A- coordination of care, standard 5B- health teaching/promotion, standard 5E- pharmacological/biological/integrative therapies, standard 5F- milieu therapy, standard 5G- therapeutic relationship and counseling
standard 6- valuation
psychiatric mental health RN enhances progress toward attainment of expected outcomes; enables revisions to outcomes diagnoses and interventions
“standard 7”- documenting
consists of: evaluation of stated outcomes, all changes in pt condition, record of informed consents, medication rxn, symptoms/concerns, untoward incidents, patient progress, nonadherence
ACE’s
adverse childhood experiences- sensitize people to stress in later life
different examples of ACEs
psychological, physical, or sexual abuse; violence against a parent; living with those who abuse substances, are mentaly ill, or were ever incarcerated
fight or flight response
part of sympathetic nervous system (which is part of autonomic nervous system); body prepares for a situation that is perceived as a threat; increase in BP, increase in HR, increase in RR, increase in cardiac output, increase glucose in bloodstream, senses become sharper, lungs expand more, blood shunted from GI tract
general adaption syndrome stage 1
alarm or acute stress stage: activates SNS and epi is pumped into blood to initiate response; HPA axis activated to stay on alert and maintain the response by production of cortisol to increase blood glucose and muscle endurance
general adaption syndrome stage 2
resistance or adaption stage: sustained and optimal resistance to the stressor; recovery; repair, and renewal may occur
general adaption syndrome stage 3
exhaustion stage: resources are depleted; the stress may become chronic; long term exposure to cortisol can result in vulnerability to stress-related illness (anxiety, depression, etc.)
bad stress aka distress
negative draining energy that results in anxiety, depression, confusion, helplessness, hopelessness, and fatigue (ex. catastrophic thinking)
good stress aka eustress
normal physiological positive energy that motivates individuals and results in positive feelings and purposeful movement (ex. exercise, childbirth)
immune system and the stress responses
there is an interaction between the nervous system and the immune system during alarm or stage of GAS; the stress response negatively affects the bodys ability to produce protective factors
mediators of the stress response
stressors, perception, individual temperament, social support, culture, spirituality/religion
mediator to stress response- stressors
can be physiological like trauma, infection, hunger, or pain; or it can be psychological like divorce, loss of job, death in the family
mediator to stress response- perceptions
how stress is perceived is affected by factors like age, gender, culture, experience, lifestyle
mediator to stress response- temperament
unique personality with different strengths and vulnerabilities (ex. coping strategies, childhood, personal outlook)
mediator to stress response- social support
strong support like support groups and significant others; shared identity with others; social support lowers mortality rates; lack of social companions increases rate of illness and early death risk
mediator to stress response- culture
some cultures experience and describe stress more physically (like asian/african/central american view as somatic/physiological)
mediator to stress response- spirituality and religion
can be protective to stress
nursing management of stress responses
measuring stress through social readjustment rating scale- measures level of positive and negative stressful events over 1 year period, recent life changes questionnaire- change is equated with stress, perceived stress scale- 10 item; assessing coping styles
the 4coping styles
health-sustaining habits- med compliance, diet, relaxation; life satisfaction- work, family, hobbies; social supports; effective and healthy responses to stress
how to manage stress through relaxation techniques
biofeedback, deep breathing, guided imagery, progressive relaxation, meditation, mindfulness, physical exercise, cognitive reframing, journaling, humor
managing stress via biofeedback
provides immediate and exact info such as muscle activity, brain waves, skin temp., HR, BP (ex. smart watches and exercise trackers)
managing stress via deep breathing
deep breath through nose, expand abdomen, hold for 3 seconds, exhale slowly through mouth; focus on belly expansion and repeat for 2-5 minutes
managing stress via guided imagery
taught to focus on pleasant images to replace negative emotions or stress
managing stress via progressive relaxation
deliberately tense muscle groups as tightly as possible for 8 seconds and then release
managing stress via meditation
train mind to develop greater calm; use calm to bring insight into experience
managing stress via mindfulness
STOP- Stop what you are doing; Take a deep breath; Observe thoughts, feelings, and emotions; Proceed with something that is important to you
managing stress via physical exercise
even those who are vulnerable to depression physical exercise reduces incidence; minimum of 3 hours a week reduces risk of depression and type of workout does not matter; adding extra 30 minutes decreases by another 17%
managing stress via cognitive reframing
change perception of stress by reassessing situation and replacing the irrational belief; ask self: what positive things can i get out of this situation? what did i learn? what would i do differently? what is the worse that can happen?
managing stress via journaing
helps identify triggers
managing stress via humor
helpful cognitive approach; can reduce intensity
mood
pervasive and sustained emotion that may have a major influence on a persons perception of the world
affect
the emotional reaction associated with an experience
bipolar spectrum disorders
conditions that include bipolar disorder and other types of mental conditions that can involve depression or mood swings; chronic, recurrent, life threatening illnesses; exist on range of symptoms on continuum
4 categories of bipolar disorders
bipolar I disorder, bipolar II disorder, cyclothymic disorder, rapid-cycling bipolar disorder
bipolar episodes consist of
mania, hypomania, depressive
bipolar I mood swings
begins at euthymia then up to mania and then down to depression then back to euthymia; more time in depression
bipolar II mood swings
begins at euthymia then goes up to hypomania and then down to depression then back to euthymia; much more time in depression
cyclothymia mood swings
begins at euthymia then goes up to hypomania then down almost to depression, then back up to hypomania then back to euthymia; appears to spend equal duration at hypomania and near-depression
unipolar depression
affects women more often and appears later in life; sleep disturbances, loss of appetite; depression may be agitated; physical symptoms can be seen
bipolar depression
less likely to be female and report symptoms of diminished interest; increased risk of earlier onset and more total episodes over time; change in appetite, psychomotor retardation, higher risk of substance use and suicide, psychosis, cognitive symptoms
predisposing factors of developing BSDs
risk factors involve complex interaction of poorly understood environmental, genetic, neurochemical factors; biological findings- genetic, neurobiological, neuroendocrine, neuroanatomical factors; environemntal and psychological influences; cultural considerations; lifespan issues
clinical manifestation of delirious mania
rapid onset of delirium, plus mania, may see psychosis in addition
clinical manifestation of mania
hyperactivity; manipulative, fault finding, profane, adept at exploiting others vulnerabilities; sleep less; nonstop physical activity with lack of sleep and lack of food can lead to exhaustion and even death
clinical manifestations of hypomania
s/s similar to mania but less extreme
those who are diagnosed with BSDs show behaviors, speech, and thought patterns of…
paranoid delusions, grandiosity, sensory perceptions, pressured speech, flight of idea, circumstantial speech, rate/rhythm of speech can be rapid and verbose, content of speech often sexually explicit, clang associations
cognitive functioning related to BSDs
1/3 of pt display significant and persistent cognitive difficulties; prevention strategies include effective pharmacotherapy and psychoeducation programs, treating subclinical depressive symptoms, control comorbidities, implement cognitive or functional remediation, promote healthy habits, aerobic physical exercise
examples of BSDs diagnoses
sleep-impaired, manic state/impaired neurological status/excessive, impaired cognition, impulse control impaired, interactive behavior impaired, anger control impaired, medication regimen non-adherence
goal of phase I (acute mania)
prevent injury and maintain safety (measurable and realistic)
goal of phase II and Phase III (continuation and maintenance phases)
continue resolution of problematic symptoms, prevent elapse and limit severity/duration of future episodes
planning of acute mania phase
focused on physiological stability of pt while maintaining safety
planning of continuation/maintenance phase
focuses on maintaining adherence with the medication regiment and preventing relapse
evidence-based practice interventions for BSDs
milieu therapy, seclusion, pharmacological and biological therapies- bipolar medications, anticonvulsant drugs, anxiolytics, 2nd gen antipsychotics, ECT
bipolar medications
aka mood stabilizers: lithium
anticonvulsant drugs for BSDs
valproic acid, carbamazepine (tegretol), lamotrigine (lamictal)
anxiolytic drugs for BSDs
clonazepam (klonopin), lorazepam (ativan)
safety and physiological needs of pt in acute phase of mania
structure in safe milieu, nutrition, sleep/rest, hygiene, eliminations
communicating with pt in acute phase of mania
firm and calm approach, short and concise statements, remain neutral (no power struggle), consistent in your approach, frequent staff meetings, decide on limits for pt with staff and state to pt, redirect energy into appropriate and constructive channels, distraction as a tool to de-escalate
ideal therapeutic milieu
atmosphere with decreased stimulation, space for solitary or noncompetetive activities, staff observation and intervention, private rooms for pt when possible so pt can return when beginning to get agitated
when a pt begins to escalate staff should…
de-escalate, sedating meds, seclusion
lithium therapy
tends to require 3-6 weeks for observation of full therapeutic response; needs monitoring of serum levels due to narrow therapeutic range and toxic range
expected side effects of lithium
fine hand tremor, polyuria, mild thirst, mild nausea, general discomfort, weight gain, sedation, acne, cognitive problems, hair loss
signs of early lithium toxicity
less than 1.5mEq/L; increased N/V/D, increased thirst and polyuria, slurred speech, muscle weakness
interventions for early lithium toxicity
hold medication, measure serum lithium levels, re-evaluate dosage
signs of advanced lithium toxicity
1.5-2 mEq/L; coarse hand tremor, persistent GI upset, mental confusion, muscle hyperirritability, electroencephalographic changes, incoordination
advanced lithium toxicity interventions
hold medication, obtain serum level, re-evaluate dosage, treat more serious symptoms
signs of severe lithium toxicity
2-2.5 mEq/L; ataxia, serious EEG changes, blurry vision, clonic movements, large urine output (dilute), tinnitus, seizures, stupor, severe hypotension, coma, death secondary to pulmonary complications
interventions for severe lithium toxicity
stop drug and facilitate excretion; if alert give emetic (vomit), gastric lavage, treat with urea mannitol and aminophylline to hasten excretion; no known antidote for lithium poisoning
what is likely to occur to pt taking lithium carbonate with low sodium levels?
lithium toxicity; low sodium levels increase effect of lithium toxicity
antiepilectics as mod stabilizers for treatment of BSDs
carbamazepine (tegretol)- treats manic episodes, especially mixed type; valproic acid- first-line treatment for manic episodes, mixed episodes and rapid cycling; lamotrigine (lamictal)- treatment of bipolar depression, less evidence for treating mania; other anticonvulsants- topiramate, oxycarbazepine
antipsychotic meds used for treating BSDs
first line for acute mania- olanzapine, quetiapine, aripiprazole, risperidone, paliperidone, ziprasidone, asenapine; first line treatment of bipolar depression- quetiapine monotherapy, olanzapine and fluoxetine combo, lurasidone for acute episode of bipolar depression; prevention of relapse of mania and depression- olanzapine and quetiapine monotherapy, olanzapine and quetiapine as adjunctive meds to lithium or valproate
