Exam 3 Flashcards
Autonomy
Respecting the rights of others to make their own decisions (e.g., acknowledging the patient’s right to refuse medication supports autonomy).
Beneficence
The duty to act to benefit or promote the health and well-being of others (e.g., spending extra time to help calm an anxious patient).
Justice
The duty to distribute resources or care equally, regardless of personal attributes (e.g., an intensive care unit [ICU] nurse devotes equal attention to someone who has attempted suicide as to someone who suffered a brain aneurysm).
Fidelity
Maintaining loyalty and commitment to the patient and doing no wrong to the patient (e.g., maintaining expertise in nursing skill through continuing nurse education).
Veracity
The duty to communicate truthfully (e.g., describing the purpose and side effects of psychotropic medications in a truthful and non-misleading way)
4 fundamental guidelines for MH Hospitalization
o Neither voluntary nor involuntary determines patient’s ability to make informed decisions about personal healthcare.
o Mental illness present
o The illness and its symptoms will result in an immediate crisis situation and other less-restrictive alternatives (i.e., outpatient care) are inadequate or unavailable.
o There is a reasonable expectation that the hospitalization and treatment will improve the presenting problems
Nonmaleficence
Doing no harm to the patient (e.g., protecting confidential information about a patient)
Voluntary Admissions
How to be admitted?
How to be released?
-apply in writing for admission
-individual can leave AMA (reevaluation can be done and make admission involuntary though)
Involuntary Admissions 4 criteria
- Diagnosed with mental illness
- Danger to self or others
- Gravely disabled (unable to provide for basic necessities)
- In need of treatment and mental illness itself prevents voluntary help-seeking
Two arguments patients can make to be released from involuntary commitment
i. Writ of habeas corpus: “formal written order” to “free the person; the procedural mechanism used to challenge unlawful detention by the government; hospital immediately submits to court and court decides
ii. Least restrictive alternative doctrine: mandates that care take the least drastic action to achieve a specific purpose i.e outpatient less restrictive than inpatient
Involuntary admission process (5)
- Usually someone close to patient makes call to HCP, police, or mental health facility
- Formal application for admission is initiated
- Two physicians or combo of mental health professionals must certify that patient’s mental health status justifies detention and treatment
- Patient can get legal counsel and go to judge if they disagrees( arguments include writ of habeas corpus or least restrictive alternative doctrine)
- If not released by judge, patient can be kept 72 hours with formal hearing (For 3 days, patient gets basic care and learns about need for treatment)
Emergency Commitment
Who is it used for? (2)
What is the primary purpose?
Length?
o Used for people who 1) are so confused they cannot make decisions on their own or (2) are so ill they need emergency admission
Primary purpose: observation, diagnosis, and treatment of patients who have mental illness or pose a danger to themselves or others
Length: 24 to 96 hours depending on the state. A court hearing is held and a decision is made for discharge, voluntary admission, or involuntary commitment.
Unconditional release for Voluntary admission
What is it?
What if provider disagrees?
termination of legal patient-institution relationship by patient or provider
If provider disagrees, patient may be held 72 hours for involuntary admission or released AMA (against medical advice)
Conditional release
What does it require?
What 3 things are evaluated during the time?
How does it differ for voluntary vs involuntary admitted?
requires outpatient for specified period of time
During time, individual evaluated for follow-through on medication regimen, ability to meet basic needs, and ability to reintegrate into community
o Voluntary admitted who are conditionally released cannot be readmitted without involuntary commitment process
o Involuntarily admitted who are conditionally released can be readmitted involuntarily based on original order
Assisted outpatient treatment
What is it?
Who is it used for? (4)
How does it work?
Result of nonadherence?
court-ordered outpatient treatment; may occur post-discharge or straight from community to reduce or prevent relapse
- Used for those with hx of repeated hospitalizations, arrested for treatment nonadherence, Unlikely to participate in outpatient treatment and need treatment to prevent relapse; threat to self or others if relapse happens
-It is usually tied toward receipt of social welfare goods (disability benefits and housing) to improve adherence
-Nonadherence may lead to inpatient admission
6 patient rights in MH setting
- Right to treatment (most fundamental; right to quality care)
- Right to refuse treatment (even if involuntarily committed)
- Right to Informed Consent
- Rights of Psychiatric Advance Directives
- Rights on Restraints and Seclusion
- Right to Confidentiality
AMA discharge
When done?
What must patient do?
Why is it an ethical dilemma?
AMA release is if treatment seems beneficial but there is no compelling reason to seek an involuntary continuance of stay
Patient must sign a form indicating that they are leaving AMA. This form becomes part of the patient’s permanent record.
AMA is ethical dilemma because patient autonomy and right to refuse treatment clash with beneficence to protect patient
5 rights under right to treatment
i. The right to be free from excessive or unnecessary medication
ii. The right to privacy and dignity
iii. The right to the least restrictive environment
iv. The right to an attorney, clergy, and private care providers
v. The right to not be subjected to lobotomies, electroconvulsive treatments, and other treatments without fully informed consent
Right to refuse Psychopharmacological drugs
How does it work in emergencies?
How does it work in nonemergencies? (5 criteria)
i. In an emergency where harm to self or others may occur, institution can medicate person without a court order
ii. In nonemergencies, after a court hearing, person can be medicated if all the following are met:
1.Patient has serious mental illness
2. The person’s functioning is deteriorating and if the person is suffering or exhibiting threatening behavior
3. The benefits of treatment outweigh the harm
4. The person lacks the capacity to make a reasoned decision about the treatment
5. Less-restrictive services have been found inadequate
Informed Consent
What is it?
What does it require of the patient?
When is it needed?
What is nurse’s role?
it is when person has been provided basic info on problem, purpose of treatment, risks, benefits, alternatives to treatment; likelihood of success before accepting to do a procedure
- Requires patient to have capacity and competence to voluntarily accept
- Generally needed for surgery, ECT, and use of experimental drugs or procedures; may be required for all medications in some facilities (the more intrusive or risky the procedure; the greater need for informed consent)
- Nurse role is to provide education and witness signature; provider gets consent
Capacity
What is it?
When does it change?
Who decides if person has capacity?
Capacity: person’s ability to make an informed decision
- Fluid and can change rapidly
- Mental health providers may provide opinions about capacity.
Competency
What is it?
When does it change?
Who decides if person has competency?
If someone is incompetent, who makes their decisions?
Competency: legal term related to the degree of mental soundness a person has to make decisions or to carry out specific acts
a. Competent until they have been declared incompetent
b. If found incompetent through formal legal proceeding, patient may be appointed a legal guardian or representative who is responsible for giving or refusing consent for the patient while always considering the patient’s wishes.
i. Order of selection usually (1) spouse or partner, (2) adult children or grandchildren, (3) parents, (4) adult siblings, and (5) adult nieces and nephews -> court-appointed person if no one available
Psychiatric Advance Directives
What are they? When are they prepared?
6 things they may include
a way for patients with episode of severe mental illness to express treatment preferences; prepared while individual is well and identifies in detail their wishes and treatment choices
i. Designation of preferred physician and therapists
ii. Appointment of someone to make mental health treatment decisions
iii. Preferences regarding medications to take or not take
iv. Consent or lack of consent for ECT, medications, admission to MH hospital
v. Preferred facilities and unacceptable facilities
vi. Individuals who should not visit
Restraints
Definition
What to assess before restraints?
any mechanical or physical device that reduces movement of patient including side rails and holding
-assess for physical origins of violence such as drug interactions and side effects; temp elevation, hypoglycemia, hypoxia, electrolyte imbalances which can all cause behavioral disturbances
Seclusion
What is it?
What does it not include?
Who is it for?
confinement alone or in an area and preventing from leaving including if unlocked door but make threats about what happens if they leave
- Physical restraint in public room is not seclusion
- Reserved for violent, self-destructive
Timeout
is not seclusion; this is when patient chooses or accepts a suggestion to spend time alone in specific area for certain amount of time; can leave at any time
Chemical Restraints (and how do they compare to mechanical restraints)
medications or doses of medication not used for patient’s condition
Less restrictive than physical or mechanical but can impact patient’s ability to relate to environment
Restraints and least restrictive doctrine
5 less restrictive alternatives
What does CMS say about restraints in emergencies
i. In emergencies, CNS says less restrictive do not have to be used but need to be considered ineffective
ii. Least restrictive alternatives
1. Verbal intervention
2. Reducing stimulation
3. Actively listening
4. Providing diversion
5. Offering PRN medications
Documentation for Restraints and Seclusion (3 things included)
a. specific behaviors and mental state leading to restraint or seclusion
b. time the patient is placed in and released from restraint
c. 15–30-minute assessments for physical needs, safety (including protection from harm), and comfort
Orders for restraints and seclusion (4 notes)
- no PRN or standing orders for restraints
- renew every 4 hours (adults) for total of 24 hour (2 hours for children over 9-17; 1 hour for children under 9)
- After 24 hours, provider personally assesses the patient
- Restraint or seclusion is discontinued as soon as safer and calmer behavior begins and new order is required to reinstitute the intervention.
Confidentiality and Nurse-patient (3 tidbits)
- only patient can waive confidentiality (even in death)
- avoid conversations about patients in public places
- nurse does not have patient-nurse confidentiality like psychiatrists and attorneys (nurses must answer to the court)
4 exceptions to patient confidentiality (and what does failure to report lead to ?)
- Duty to warn (obligation to warn 3rd parties if they may be in danger from patient)
- Duty to protect (required to call and warn intended victim, victim family, or police to take necessary steps under the circumstances)- must assess and predict patient’s level of danger and identify who they are threatening
- Child Abuse (all nurses are mandatory reporters; some states allow anonymous reporting)
- Older Adult and Dependent/Disabled Adult Abuse (required by most states to report)
Failure to report suspected abuse, neglect, or exploitation may result in misdemeanor
7 interventions for seclusions and restraints
o Staff in constant (do not leave patient alone)
o Monitor vital signs
o Assess range of movement
o Observe blood flow in hands/feet
o Observe that restraint is not rubbing
o Provide for nutrition, hydration, and elimination
o Continuously assess the need seclusion or restraint
Negligence
most common unintentional tort involving failure to use ordinary care in any professional or personal situation when there is duty to do so
5 elements to prove malpractice (and what each entails)
- Duty of care established (nurse represents self as capable of caring for psychiatric patient and accepts employment)
- Breach of duty (nursing performance below standard of care which exposes patient to unreasonable risk of harm; can be commission or omission)
- Cause in Fact (Actual cause aka if nurse did not do what they did, would injury have occurred?)
- Proximate cause (Legal cause aka determined by whether event was foreseeable; If average reasonable nurse could foresee injury that would result from action or inaction, injury was foreseeable)
- Damages (Pain and suffering; Actual damages (loss of earning, medical expenses, property damage); Incidental damage (deprivation of benefits like normal relationships)
Delirium
What is it?
6 cardinal symptoms
progressive and reversible acute cognitive disturbance with an underlying physiological cause that impairs lower-level cognition and can lead to permanent cognitive decline if not addressed
- impaired attention (inability to direct, focus, sustain, or shift)
- abrupt onset with fluctuating periods of lucidity and disorganized thinking
- disorientation (to time and place; not usually person)
- anxiety, agitation
- poor memory
- altered perceptions (visual hallucinations and illusions; delusions)
Delirium
Onset
Causes/ Contributing Factors
Cognition (4)
Activity level (4)
Emotional state
Speech and language (4)
Prognosis
Onset: sudden and fluctuates throughout day
Causes/ Contributing Factors: underlying medical condition (UTI, substances, medications)
Cognition: impaired attention, memory deficit, disorientation, perceptual disturbances
Activity level: increased or decreased; restless; sundowning; reversed sleep-wake cycle
Emotional state: rapid swings (fearful, anxious, suspicious, aggressive; hallucinate or delusions)
Speech and language: rapid, inappropriate, incoherent, rambling
Prognosis: reversible with proper treatment
Dementia
Onset
Causes/ Contributing Factors (5)
Cognition (6)
Onset: slowly over months and years
Causes/ Contributing Factors: Alzheimer’s; vascular disease; HIV, chronic alcoholism; head trauma
Cognition: impaired memory, judgment, calculations, attention, abstract thinking, agnosia (inability to recognize things)
Dementia
Activity level (2)
Emotional state (2)
Speech and language (5)
Prognosis
Activity level: not altered; may have sundowning
Emotional state: flat (unresponsive in severe); agitation
Speech and language: incoherent, slow (difficulty finding the right word), inappropriate, rambling, repititious
Prognosis: not reversible; progressive
Depression
Onset
Causes/ Contributing Factors (5)
Cognition (3)
Activity level (3)
Emotional state (5)
Speech and language (3)
Prognosis
Onset: gradual with exacerbation during crisis or stress
Causes/ Contributing Factors: losses, loneliness, crisis, declining health, lifelong history
Cognition: difficulty concentrating, forgetfulness, inattention
Activity level: decreased (fatigue, lethargy); lack of motivation; poor sleep
Emotional state: extreme sadness, apathy, irritability, anxiety, paranoid ideation
Speech and language: slow, flat, low
Prognosis: reversible with proper treatment
Normal Aging vs Dementia
Normal Aging: Slight Forgetfulness (i.e sometimes forgetting names or appointments, but remembering them later)
What is the Alzheimer’s symptom?
Memory loss that disrupts daily life
Normal Aging vs Dementia
Normal Aging: Making occasional errors when balancing a checkbook
What is the Alzheimer’s symptom?
Challenges in planning or solving problems
Normal Aging vs Dementia
Normal Aging: Occasionally needing help to use the settings on a microwave or to record a television show
What is the Alzheimer’s symptom?
Difficulty completing familiar tasks
Normal Aging vs Dementia
Normal Aging: Forgetting the day of the week but figuring it out later
What is the Alzheimer’s symtom?
Confusion with time or place
Normal Aging vs Dementia
Normal Aging: Trouble understanding visual images or spatial relationships
What is the Alzheimer’s symtom?
Vision changes related to cataracts
Normal Aging vs Dementia
Normal Aging: Sometimes having difficulty finding the correct word
What is the Alzheimer’s symptom?
New problems with words in speaking or writing
Normal Aging vs Dementia
Normal Aging: Misplacing things from time to time and retracing steps to find them
What is the Alzheimer’s symptom?
Misplacing things and losing the ability to retrace steps
Normal Aging vs Dementia
Normal Aging: Making a bad decision once in a while
What is the Alzheimer’s symptom?
Decreased or poor judgment
Normal Aging vs Dementia
Normal Aging: Sometimes feeling weary of work, family, and social obligations
What is the Alzheimer’s symptom?
Withdrawal from social and work activities
Normal Aging vs Dementia
Normal Aging: Developing specific ways of doing things and becoming irritable when routine is disrupted
What is the Alzheimer’s symptom?
Changes in mood and personality
Mild Alzheimer’s 8 hallmark symptoms
- Difficulties retrieving correct words or names
- Trouble remembering recent conversations, material just read (family may notice memory lapses)
- Challenges in performing tasks in social or work settings (still able to work)
- Losing or misplacing a valuable object
- Increasing trouble with planning or organizing
- Apathy
- Depression
- Personality is intact
Moderate Alzheimer’s 8 hallmark symptoms
- Forget events or their personal history i.e be unable to recall their own address or telephone number or the high school/college from which they graduated
- Agnosia
- Behavior changes i.e become moody or withdrawn, especially in socially or mentally challenging situations
- Disorientation (confused about place and time)
- Need for help choosing proper clothing for the season or the occasion
- Wandering
- Change sleep patterns (may sleep during the day and becoming restless at night
- Paranoiac, agitated, and delusional or compulsive, for example, repetitive behavior like hand wringing
Severe Alzheimer’s 6 hallmark symptoms
- Require full-time, around-the-clock assistance with daily activities and personal care
- Lose awareness of recent experiences and of their surrounding
- Apraxia so they need repeated instructions and directions for simple tasks
- Experience changes in physical abilities, including urinary incontinence ability to walk, sit, and eventually swallow,
- Have increasing difficulty communicating and speaking (difficulty responding to environment)
- Become vulnerable to infections, especially pneumonia
Alzheimer’s and Symptoms
Confabulation (2)
Preservation
Agraphia
Confabulation: unconscious mechanism to protect ego involves creation of stories or answers in place of actual memories to maintain self-esteem; not lying b-c it is unconscious
Preservation: persistent repetition of word, phrase or gesture that continues after the original stimulus has stopped i.e repeatedly saying hello
Agraphia: early AD; diminished ability and eventual inability to read or write
Alzheimer’s and Symptoms
Aphasia
Apraxia
Agnosia
Aphasia: the loss of language ability; from difficulty finding right word to few words to babbling or mutism
Apraxia: loss of purposeful movement in the absence of motor or sensory impairment which results in the inability to perform familiar and purposeful tasks.
-For example, in apraxia of dressing, the person is unable to put clothes on properly (e.g., putting arms in trousers).
Agnosia: loss of sensory ability to recognize familiar objects, sounds, sights (can be auditory, visual or tactile)
Alzheimer’s and Symptoms
Hyperorality
Sundowning, or sundown syndrome
Memory impairment
Hyperorality: the tendency to put everything in the mouth and to taste and chew.
Sundowning, or sundown syndrome: tendency for an individual’s mood to deteriorate and agitation increase in the later part of the day, with the fading of light, or at night.
Memory impairment: initial difficulty remembering recent events -> deterioration of recent and remote memory.
9 Interventions around comfort and anxiety for Delirium
- Provide optimistic but realistic reassurance.
- Provide patient with information about what is happening and what can be expected.
- Accept patient’s perceptions or interpretation of reality and respond to the theme or feeling tone.
- Approach patient slowly and from the front and address patient by name.
- Always introduce self to patient when approaching.
- Communicate with simple, direct, and descriptive statements.
- Limit decision making if aggravates delirium
- Encourage significant others to remain with patient.
- Provide a consistent physical environment, daily routine, and caregivers.
5 Interventions around safety for Delirium
- Administer prn (as needed) medications for anxiety or agitation with caution.
- Physical restraints may increase symptoms and should be avoided if possible.
- Never leave a patient in acute delirium alone (family can watch)
- Maintain a well-lit, hazard-free, low-stimulation environment
- Encourage use of aids that increase sensory input (e.g., eyeglasses, hearing aids, and dentures).
3 Interventions around Orientation for Delirium
- Monitor neurological status on an ongoing basis
- Avoid frustrating the patient by quizzing with orientation questions that cannot be answered.
- Use environmental cues (e.g., signs, pictures, clocks, calendars, and color coding of environment) to stimulate memory, reorient, and promote appropriate behavior.
4 basic Interventions for Alzheimer’s Disease
- Provide emotional support to patient and family: Ascertain what is important to these patients, their values and beliefs, as well as their life histories. (unconditional positive regard is key)
- support caregivers: Include family members in planning, providing, and evaluating care
- assess and facilitate self - care: Identify usual patterns of behavior for such activities as sleep (provide rest periods), medication use, elimination, food intake, self-care
- Provide finger foods to maintain nutrition for patient who will not sit and eat.
7 interventions for comfort care and anxiety management in Alzheimer’s
- Introduce self and address patient by name when initiating interaction and speak slowly.
- Give one simple direction at a time in a respectful tone of voice.
- Use distraction, rather than confrontation, to manage behavior.
- Provide consistent caregivers, physical environment, and daily routine. (Limit number of choices patient must make so as not to cause anxiety.)
- Select television or radio programs based on cognitive processing abilities and interests.
- Place patient’s name in large block letters in room and on clothing, as needed.
- Use symbols, rather than written signs, to assist patient in locating room, bathroom, or other area.
What is the rationale for the following intervention for Dementia?
Gradually restrict use of motor vehicles
As judgment becomes impaired, the person may be dangerous to self and others.
What is the rationale for the following intervention for Dementia?
Minimize sensory stimulation.
Decreases sensory overload, which can increase anxiety and confusion.
What is the rationale for the following intervention for Dementia ?
If the person becomes verbally upset, listen and be supportive, allowing the person to be upset. Gradually try to redirect and change the topic.
Goal is to prevent escalation of anger. When attention span is short, the person can be distracted to more productive topics and activities.
What is the rationale for the following intervention for Dementia?
Label all rooms and drawers. Label often-used objects (e.g., hairbrushes and toothbrushes)
May keep the person from wandering into other people’s rooms. Increases environmental clues to familiar objects.
