Module 4 - Introduction to Psych Nursing Flashcards
Mental Health
WHO: STATE OF WELLBEING in which the individual realizes his or her own abilities, can cope with life’s normal stressors, can work productively and can make a contribution to society
Mental Health is the successful performance of what 4 mental functions
- Results in Productivity
- Fulfilling Relationships
- Ability to adapt to change
- Ability to cope with adversity, life’s events
Mental health provides the capacity for what?
rational thinking
learning
emotional growth
resilience
self esteem
Elements of Mental Health
- self governance ability to act independently, dependently, or interdependently without losing autonomy
- progress toward growth or self realization
- tolerance of the unknown - coping ability
- reality orientation
- master of environment
- stress management
*some degree of variance exists but inability leads to mental illness
3 Areas that Influence/Drive Mental Health
Biologic Influences
Psychological Influences
Sociocultural Influence
Examples of Biologic Influence of Mental Health
prenatal, perinatal, and neonatal events
physical health status
nutrition
history of injuries
neuroanatomy
physiology
Examples of Psychological Influence of Mental health
Interactions
intelligence quotient
self concept
skills
creativity
emotional developmental level
Mental Disorders
APA: Clinically significant disturbances in cognition, emotional regulation, or behavior that reflects a dysfunction in the physiological, biological, or developmental processes underlying mental dysfunction.
They are usually associated with distress or impaired functioning.
How can mental health be viewed?
as an illness continuum
it can be viewed on end points of a continuum with movement back and forth during life (like a pendulum swinging back and forth)
What are the 4 levels of Mental Health?
Physical
Personal
Interpersonal
Societal
*All four of these impact your mental health on a continuum)
Can mental health and illness be used interchangeably?
NO they cannot be defined completely in terms of one another
Individuals and families are complex
Incidence and Prevalence of Mental Illness is ____
non-discriminatory (can happen to anyone at any time)
At any given time how many Americans could be diagnosed with mental illness 18 yo and older?
1 in 4 Adults
26% of 18+
57.7 Million Americans
How many with mental illness will never seek treatment?
1/2
Dual Diagnosis
A diagnosed mental disorder co-occurring with substance abuse problems
15% of adults with MI have this
___% of homeless people have schizophrenia or bipolar disorder
25%
___ is the most often missed and under diagnosed mental health problem
depression
What group has the highest depression leading to suicide rates?
People 65+
What is the etiology for Mental illness?
IT is largely identified, and it is believed to be caused by complex interactions among genetics and environmental influences
A combination of biological and environmental factors with exact definitions unknown
What is the one common thread of mental illness etiology?
Many mental illnesses are undefined/we largely do not know the precise causes - individual aspects can play a big role in MI
The experience and consequences of Mental Illness are …
much more complicated than a list of symptoms and diagnosis
___ ___ of mental illness are elusive
precise definitions
___ in and of itself is not sufficient to produce a mental illness
Stress
What are the 2 main diagnostic tools for classifying Mental Illness?
ICD-10 (WHO)
DSM-5 (APA)
ICD-10
WHO’s Classification of Mental and Behavioral Disorders, ICD-10 international diagnostic standard for general epidemiological and many health management purposes monitoring and analysis of the general health of a population and the incidence and prevalence of diseases.
DSM-V
APA developed Diagnostic and Statistical Manual of Mental Disorders ( DSM ) multi-axial classification system groups disorders by symptom clusters and differentiates between normality and psychopathology based on duration and severity of symptoms.
In 2015, the DSM V…
moved away from the multi-axial system to a more unified approach aimed at improving diagnostic care
5 Axis of DSM
Axis I - Clinical Disorder
Axis II - Personality Disorders and Mental Retardation
Axis III - General Medical Conditions
Axis IV - Psychosocial and Environmental Problems
Axis V - GAF - Global Assessment Scale # system meaning current functioning/highest level of functioning in the past year
Each disorder has ___ that describes behaviors, symptoms, or signs; duration and other qualifiers, the ___ do NOT determine ___.
each disorder has criteria that describes behaviors, symptoms, or signs; duration and other qualifiers, the criteria do NOT determine diagnosis
Many clients have ___ dx on the first 3 axes
1+
Axis I Criteria
Includes most of the psychiatric disorders EXCEPT personality disorders and issues of developmental disorders
If a person has more than 1 axis I disorder, list them all with the chief complaint listed first
Axis II Criteria
Personality Disorders
Intellectual Developmental Disorder
Other Prominent Maladaptive and Defense Mechanisms
Axis III Criteria
General medical conditions that may be relevant to understanding and/or managing the mental disorder
Does NOT include mental disorders that are thought to be a direct cause for a mental disorder - those are coded on Axis I
Axis IV Criteria
Problems with Primary Support Group
Problems r/t Social Environment
Educational, Occupational, Housing or Economic Problems
Problems w/ access to health care services
Problems w/ legal system
Axis V Criteria
Clinician makes a judgment about a person’s overall level of functioning
GAF Scale: 0-100
The lower the number, the lower the level of function
What are some of the Limits of the DSM System?
- Categories are descriptions, not explanations and labeling - can cause tautology
- Divides normal and abnormal
- clients can suffer from the same disorder and manifestations, but personal experience differs for each client
- inflexibility of duration
- criterion utilized for adults and children
- cultural discrepancies
Tautology
Focusing on someone’s label
avoid it
a nurse must avoid expecting a persons behavior based on a diagnostic label
What changes were made to the DSM multi axial system?
A new approach the APA moved to with a single axis rather than multiple axis approach
The previous approach created an arbitrary hierarchy of mental disorders between the first two axes. It also implied a separation of mental disorders from physical disorders, when in fact mental disorders are physical disorders.
This current approach still uses all of the same mental, physical and social considerations as the multi-axial system but does it in a more unified manner aimed at improving diagnosis and care, informing new research and allowing for global information sharing.
DSM Single Axis Approach
First 3 Axis were combined containing all mental and other medical diagnoses - allowing for removal of artificial distinctions among conditions, benefitting both clinical practice and research use
Axis IV still represents contributing stressors, but now uses ICD codes which allow providers to better indicate other problems like relationship problems, that need clinical attention
GAF of Axis V is no longer used d/t lack of clarity and was replaced by the WHO disability assessment schedule - this change brings the DSM into better alignment with other medical disciplines
Parity of the DSM Single Axis Approach?
It is a term meaning that mental disorders are now on the same level of physical disorders
What does the WHO Disability Assessment Schedule do?
Measures disorders and their associated disabilities which are shown as conceptually distinct and are assessed separately
What is the HP2020 goal for mental health?
Improve mental health through prevention and by ensuring access to appropriate quality mental health services
Key: TREAT VIA PREVENTION
In what ways can a nurse prevent and treat mental health issues?
Health promotion and illness prevention
Attention to medically underserved populations (Advocate)
Involvement of managed care in behavioral health
Quality management, including client outcomes
Expanded practice of advanced clinical providers PNP
Community based primary care
Influence of consumer and family advocacy (educate family too)
Decreased benefits for Medicare, Medicaid, disability programs
What are some of the Issues related to Mental Health treatment?
Failure to Seek Treatment
Cost (Inpatient care and medications)
Stigma
Revolving Door Treatment
Lack of Parity
Limited Access to Care (inadequate, inappropriate, no care, difficulties for families to determine appropriate care)
How many people fail to seek mental illness treatment, what does it cause, and why does it happen?
2/3 fail to seek it
It leads to increase expenses r/t loss productivity, increase in criminal justice system and social service costs
It can be due to a variety of factors such as the area they live, a long waiting list, etc
What is the Stigma behind mental health treatment?
There are misconceptions, discrimination, and stereotyping occurring which leads to people not seeking help
Revolving Door Treatment
A person going in and out of a hospital as they have troubles with medicine compliance and sometimes insurance companies will discharge them early before they are ready
Decreased length of stay, managed care mandates, deinstitutionalization, lack of community supports can all lead to this
Deinstitutionalization
Trying to keep people out of mental hospitals
It is a good thing because we want them to be able to leave, but they still need services to make sure they can deal with long term issues
What is the parity like with mental health treatments?
Inequalities: of coverage or what’s most effective versus what is actually received
ex: We can talk about diabetes casually but not depression
Goals for Improving Mental Health Care
Increase the number of Mental Health Professionals caring for children and adolescents
Expand Mental Health Services
Cultural understanding
Improve understanding
Redesign rehabilitation services to meet client needs- social, physical, cultural needs
Integration and collaboration in services
Reintegration into Society- family involvement, employment, continued education, social and recreational activities, community participation
Legislation to improve coverage
Culturally competent care
Medication Adherence
Self-Help and Advocacy
National Alliance for the Mentally Ill
Psychiatric Advanced Directives- treatment wishes during stable periods
What is a huge issue with mental health client populations?
Medication Compliance
What is crucial to medication compliance?
EDUCATION - on the medication and the side effects
What does a nurse do in Psychiatric Nursing
Work with individuals and families who have psychiatric problems and disorders, such as depression, schizophrenia, bipolar disorder, psychosis or dementia.
What sort of tasks might a nurse do in psychiatric nursing?
Assess mental health and physical needs and provide interventions based on individual needs
Develop and evaluate nursing care plans to ensure positive outcomes
Crisis intervention and counseling
Help patients regain or improve their coping abilities
Manage and work with a team to ensure and enhance the therapeutic environment
Assist patients with self-care activities
Administer and monitor treatment regimens
What roles does a Psychiatric Nurse have?
Participation in the interdisciplinary mental health team
Advocacy
Health promotion and maintenance
Case management
Screening
Milieu therapy
Health teaching
Psychobiologic interventions
Why is Case management so important?
A person can be stable but they may have issues with housing and pay so case managers and communication with them is very important
What is a highly critical role of the nurse in psych nursing?
to advocate for the patient
Milieu Therapy
Therapy where patients can practice life skills in a safe controlled environment where healthcare professionals can help with interactions and actions (unlike in the community where they cannot help)
What are some important Qualities a Psychiatric Nurse should have?
- Therapeutic Use of Self (forming a trusting relationship providing comfort, safety, and acceptance)
- Genuineness and Warmth (openness, realness, lack of defenses)
- Empathy
- Leadership (empower, direct, and manage care)
- Acceptance (suggests neither approval nor disapproval but tolerance and appreciation of the client - know how to care for everyone even someone who did a heinous crime)
- Maturity and Self Awareness (major role in nurses ability to tolerate differences)
Empathy
Ability to “walk a mile in a clients shoes”
Crucial to therapeutic relationship
Where should you never be with a psych patient?
Alone in an isolated spot
Alert staff to your whereabouts at all times
Always have a __ __ in psych nursing, never put yourself in a position where …
Always have an exit plan, do not put yourself in a position where your back if to a closed in area
Avoid what when caring for psych patients?
provocative clothing and having too much skin exposed
What topics of discussion should be avoided and why unless you have experience in managing them?
- Religion
- Politics
- Sexual Topics
Psychotic patients generally experience delusional themes in these three areas
Avoid wearing what when working with psych patients?
Necklaces or other items that can be used as a weapon to strangle
Do not wear loop earrings
Safety comes first in psych nursing, always …
listen to your gut or primary instinct
What are some differences in the nursing process for psych nursing?
- Observations are extremely important. This should be the manner and focus of the nurses’ observations
- The particulars of interviewing during data collection
- The types of interventions sued for identified problems
What is a crucial thing to have as a nurse that can impact the nursing process?
A therapeutic nurse client relationship where you have self awareness in order to reduce barriers to effective data collection and assessment
What can impact your self awareness?
Personal feelings, values, beliefs, perceptions, communication skills, developmental stage of the client, spirituality, and religion all may interfere with accurate data collection
What are some components of the psych physical examination?
Review of systems
Diagnostic testing
Vital signs
Neurological status
Changes in sleep patterns, appetite, libido, concentration
Elimination
Activity & exercise
Hydration
Self-care
What are some components of the psych mental status examination?
General appearance
Orientation
Mood and affect
Quality of speech
Thought process
Cognitive Intellectual Performance
Insight & Judgement
What are some psychosocial components of a psych nursing assessment?
Recent stressors
Strengths
Current medications
History or psychiatric treatment
Substance abuse history
Quality of support systems
Family definition of problem
Behavior
Self-concept
Body image
Self- esteem
Personal identity
Suicidal/homicidal ideation (Safety is critical)
Coping patterns
Spiritual and cultural needs
Legal and occupational history
Economic status
Quality of life
What area of examination may be most important?
Mental Status Exam
Affect
capacity to vary outward emotional expressions (like the weather)
Mood
prominent and overall emotional state expressed (like a season)
How do mood and affect compare?
Mood is more consistent like a season while affect is more changing per day
Insight
Awareness of a problem going on
should a patient have this they will be more likely to comply and assist, but if they are not they are more likely to take risks or be noncompliant to a care plan
What are some Life Span Considerations for Children and Adolescents in the psych nursing field?
Growth and development stage
Family dynamics - parental involvement and permission
Parenting styles
What are some life span considerations for older adults in the psych nursing field?
AVOID AGEISM
developmental stage
determine how to address them (e.g. surname)
Psych Nursing Diagnosis
Analyze assessment data to determine diagnoses
DIAGNOSIS DRIVES CARE
Do it according to NANDA classification system
Outcome Identification Care Plan Goals in Psych Nursing
psych nurse identifies expected outcomes that are individualized to the client and measurable
Update constantly as things always are changing
What is planning like for a psych nurse?
the psych nurse develops a plan of care that prescribes interventions to attain expected outcomes.
Safety needs often a priority
patient involvement is critical once they are well enough or stable enough to be involved
Types of nursing Interventions
Biologic
Psychological
Social
Examples of Biologic Nursing Interventions
Promote self care
Encourage physical activity
Sleep intervention
Encourage proper nutrition
Relaxation techniques
Medication management
Examples of Psychosocial Nursing Interventions
Cognitive interventions
Counseling
Conflict resolution
Bibliotherapy
Reminiscence
Behavior therapy
Psychoeducation
Examples of Social Nursing Interventions
Milieu therapy
Containment
Validation
Structured interventions
Open communication
Patient Safety
Bibliotherapy
Use of literature to help people cope with emotional problems, mental illness, or change their lives back
Also can be used to produce effective change and promote personality growth and development
What is Evaluation like in Psych Nursing?
Psychiatric nurse evaluates the clients progress in attaining expected outcomes
it is a dynamic process that changes as the clients condition changes
What are the key components of documentation?
- Becomes a part of the clients permanent record
- Objective and Subjective data is documented
- Written documentation should be clear and legible
- nurses should avoid inferences or judgments
- nurses should use concrete and specific terms
__ determines what is “right” or “wrong” within a society
legislation
__ ultimately preps you and protects the client
Knowledge (of law, of practice, etc)
Malpractice
a tort action that a consumer plaintiff brings against a professional defendant when the plaintiff believes the professional injured him or her within the consumer-professional relationship
Common Liability Issues
Protection of clients
Defamation of character (Libel and Slander)
Supervisory liability
Short-staffing issues
Libel
published false statements
Slander
spoken false statements
What are short staffing issues ?
there is always a call in or staffing issue occurring that can lead to safety issues
What is one of the best ways to prevent safety risks?
Be a part of a team and have teamwork with the psych nurses
What are the guideline recommendations for avoiding liability from more important to least?
(All are still extremely important though)+
- Always put the client’s rights and welfare first
- Comply with the rules and regulations in the hospital’s or agency’s policy manual
- Practice within the scope of the state’s nurse practice act
- Maintain current understanding and knowledge of established practice standards
- Keep accurate, concise, and timely nursing records
Basic Rights of Psychiatric Clients
Appropriate treatment
Individualized plan of care
Ongoing participation in treatment
Right to refuse treatment, except in emergency situation
Decision making around experimental treatment
Freedom from restraint or seclusion except during emergency situation with written provider order
Humane treatment environment
Confidentiality of records
Right to access records
Access to visitors, telephonic and mail communications
Access to these rights
Right to assert grievance if rights are infringed upon
Right to access protection, service, and a qualified advocate in order to understand one’s rights
Right to assert these rights without reprisal
Right to referral to other providers upon discharge
Always use the least ___ treatments
restrictive
Informed Consent
consent that patient gives to provider after receiving sufficient information allowing the patient to understand a procedure
What sort of sufficient information needs to be given to a client to get informed consent?
Benefits/ Costs
Way procedure will be administered
Prognosis
Side effects/ Risks
Possible consequences of refusing treatment
Other alternatives
What is a psych special consideration regarding consent?
Many psych clients are unable to give informed consent due to symptoms and need substituted consent
Substituted Consetn
situation that comes into play if competency is a problem
it is obtained in competency issue cases from a healthcare proxy, guardian, or next of kin
Confidentiality in Psych Nursing
Preservation of confidentiality is especially important for Mental illness clients
It can carry stigma
HIPPA, responsible record keeping, and the client’s employer are all important factors here
What are the exceptions to psychiatric confidentiality?
- Duty to warn and protect third parties
- child and elder abuse reporting statues
What are the 4 most important Legal Rights of the Psych Patient?
- Right to Treatment
- Right to treatment in the LEAST RESTRICTIVE ENVIRONMENT
- Right to refuse Treatment
- Right to Aftercare
Types of Hospital Psych Admissions
Voluntary
Involuntary
Voluntary Admission
paperwork signed by the patient for admission
for the competent patient
In NYS they cant just check out tho, need doctor permission
Involuntary Admission
“Commitment”
Code 939
Have to consider the 3 main things to do this involuntarily and they must not be competent or have questionable competency
3 Big things to evaluate in order to Commit/Involuntarily Admit someone?
- Danger to Self
- Danger to Others
- Inability to care for self
What are some procedures that can allow for involuntary admissions?
Judicial
Administrative
Agencies
What nature, purpose and reasoning can lead to involuntary admission?
Emergency
Observation or Temporary Stay
Long Term or Formal Outpatient care
What is the steps for involuntary admission?
Petition –> Examination –> Determination by Medical, Court, or Administration –> 2 possible outcomes
Outcome 1: Release
Outcome 2: Hospitalization -> 3 Paths:
(1) Emergency - to control an immediate threat to self or others
(2) Short Term - for diagnosis and short term therapy
(3) Long Term - for treatment until determined ready for discharge
Ethics
the study of philosophical beliefs about what is considered right or wrong in a society
Ethical Dilemma
situation that requires a choice between morally conflicting alternatives
Bioethics
used in relation to ethical dilemmas surrounding client care
5 Principles of Bioethics
- Beneficence
- Autonomy
- Justice
- Fidelity (nonmalficence)
- Veracity
Beneficence
the duty to promote good
Autonomy
the right to make one’s own decisions and respect for the rights of others to make their own decisions
Justice
treating others fairly and equally
Fidelity
nonmaleficence
maintaining loyalty commitment; doing no wrong to a client
Veracity
One’s duty to always tell the truth
Exception to Veracity Principle
when the truth would be knowingly harmful to a client
Resources for Guidelines in Ethical Dilemmas
Nurse practice acts
Hospital and organizational polices
Patient bill of rights
Code of Ethics for Nurses with Interpretive Statements of the American Nurses Association
Standards of Care from the Scope and Standards of Psychiatric-Mental Heath Nursing Practice
Nurses must ___ ___ in institutional or community settings
protect themselves
Are employers held responsible for employee injuries caused by violent client behavior?
Not usually
This is because nurses have placed themselves knowingly in the range of danger by agreeing to acre for unpredictable clients
Good judgment means…
not placing oneself in a potentially violent situation!!!
It is important to KNOW ___ ___ while working
YOU ENVIRONMENT
