study guide exam 1 Flashcards
what are the 4 lobes of the brain
frontal, parietal, occipital, temporal
what are the 4 parts of the limbic system
hippocampus, amygdala, anterior thalamus, hypothalamus
describe the frontal lobe
executive function and personality
- maintains & focuses attention, organize thinking, speech & motor activities
- weights consequences , set goals, modulates emotions, integrates ideas, emotions & perceptions
describe the parietal lobe
body sensations, maintains focused attention
- motor activités - attention & perception of spatial relations
- processes sensory impulses from thalamus
describe the occipital lobe
vision and visual memory
- reading, language formation, reception of vestibular, acoustic and tactile stimulus (hearing)
describe the temporal lobe
processing of auditory stimuli, emotion, learning, and memory circuits
- gives emotional tone to memories. is involved in making moral judgements, registers acts of aggression
- “warm memory”
describe the limbic system (LOBE)
- paleomammalian brain
- response for emotions, behaviors, LTM, olfaction (smell)
function of hippocampus
LTM for recall, learning, sensory integration
function of amygdala
reward, fear, anxiety, anger, emotion, social behavior, impulsive gut responses
- ex: addiction (no processing)
function of anterior thalamus
relays sensory & motor signals to cerebral cortex along with regulating of consciousness, sleep, and alertness
- ex: insomnia, wake up throughout the night
function of hypothalamus
regulates homeostasis, hunger, thirst, temperature, body functions, corticosteroid production
5 neurotransmitters learned DANGS
dopamine
norepinephrine
GABA
acetylcholine
serotonin
describe acetylcholine
- derived from coenzyme A
- widely distributed in: cortex
- plays a role in: learning, memory, movement
- implication in nicotine dependence
- contributes to excessive arousal of thought with use of cocaine & amphetamines
- tip: feeds addiction
describe GABA (NT Gamma-Amino butyric acid)
- inhibitory NT widely distributed throughout: nervous system
- responsible for: slowing activity of nerve cell
- inhibitory effect involved in: anxiety, agitation, seizures
- involved in sedative effects of benzodiazepines, barbiturates, and ETOH (alcohol)
- helps with relaxation, sleep, slows body and brain down
- tip: calms anxiety
describe glutamate (NT GLU)
- derived from proteins in the diet
- excitatory NT found throughout the brain
- important in learning
- triggered w/ hallucinogens (PCP- acid, LSD, extra psychotic effects)
describe norepinephrine (NT NE)
- derived from tyrosine (amino acid)
- projects broadly throughout the brain
- responsible for arousal & response to stress
- most likely activated in ADHD & anxieties (too much NE)
- cocaine & amphetamines affect the transmission of NE & contribute to the stimulating & pleasurable effects of these drugs
- TIP: fight/flight, energy, appetite, BMR, socializing
describe serotonin (NT 5HT)
- derived from tryptophan (amino acid) (milk, turkey)
- initiates in midbrain & broadly projects throughout the cortex, hypothalamus and limbic system
- receptors found in brain, gut, platelets, and spinal cord
- path most likely involved in pain, movement, sleep, appetite, anxiety, depressive mood mental health disturbances
- tip: LSD & ecstasy have their primary effects in the serotonin pathways. Cocaine, amphetamines, ETOH & nicotine also affect serotonin transmission. SSRIs cause GI upset r/t receptors
- plays a role in sleep regulation, hunger, pain perception, aggression and sexual behavior
describe NT dopamine (DA)
- derived from tyrosine (amino acid)
- projects to amygdala, nucleus accumbens (deep midbrain), through limbic system * many paths
- involved in movement, learning, pleasure, motivation
- 4 pathways: mesolimbic, mesocoritcal, basal ganglia, pituitary, thalamus
- pleasure, socializing, food seeking, reward, addiction
describe mesolimbic path for DA
reward path activated by most drugs of abuse
- path most likely activated in mania, psychosis, schizophrenias (increase DA = flat affect, poverty though/emotion, triggered hallucinations)
- all antipsychotics work by decreasing DA in this path
describe mesocortical path
mediates cognitive and affective sx.
- path is considered one of executive function
- most likely to be activated in depression, catatonia, decreased attention, concentration, mania, schizophrenia
- decreased DA = negative sx.
- antagonist antipsychotics work by decreasing dopamine
describe basal ganglia path
extrapyrimidal system
- path is prominent for motor control
- most likely path activated in Parkinson’s, EPS, movement disorders, coreas
- antagonist antipsychotics work by decreasing DA (but path is also saturated w/ ACH)
- when DA drops = ACH increase which can cause EPS (akathisia, dystonia, TD or peudoparkinsonism)
describe pituitary path
projects from hypothalamus to anterior pituitary
- path considered sexual dysfunction, weight gain, hyperprolactinemia (increase lactation/ breast enlargement in men)
- all antagonist antipsychotics work by decreasing DA
- when DA drops = release of prolactin -> breast enlargement, galatorhea (breast milk secretion) or amenorrhea
NT DA and mental health correlation
- increase DA = schizophrenia, mania, psychosis, + sx.
- decrease DA = depression, Parkinson’s disease
- responsible for: pleasure, socializing, food seeking, reward, addiction
NT NE and mental health correlation
- increase NE: arousal, mania, anxiety states, schizophrenia
- decrease NE: depression
- responsible for: fight/flight, energy, appetite, BMR, socializing
NT GABA and mental health correlation
- increase GABA: reduced anxiety
- decreased GABA: anxiety disorders, schizophrenia
- responsible for: inhibitory NT, emotional balance, sleep
NT ACH and mental health correlation
- increase ACH: depression
- decrease ACH: Parkinson’s disease, Alzheimer’s disease, Huntington chorea
- responsible for: memory
NT 5HT and mental health correlation (serotonin)
- decrease 5HT: depression, worthlessness, suicidal ideation, appetite, sleep
- increase 5HT: anxiety states, expansive irritable mood, grandiosity, agitation (bipolar)
- responsible for: sleep regulation, hunger, pain perception, aggression and sexual behavior
describe activities of neurons
- conduction along neuron involves inward movement of sodium ions followed by outward movement of potassium ions
- when current reaches end of the cell, neurotransmitter is released
- the neurotransmitter crosses the synapse and attaches to a receptor on the post synaptic cell
- attachment of neurotransmitter to receptor either stimulates or inhibits postsynaptic cell
describe cellular reuptake
- once receptor reaches postsynaptic cell and exerts its influence, it separates from receptor and gets destroyed by enzyme starting with the NT name and ending was -ase
- 1/2 ways NT can be destroyed
- meaning: NT taken back into presynaptic cell from which they were originally released and either reused or destroyed by intracellular enzymes
describe voluntary admission to psychiatric units
- client seeks admission through written application
- has the right to demand release (usually) -> provider says no, pt. cannot leave (liability)
- has the right to demand release
- staff may detain if the client is at risk
- client may refuse meds & treatment
- may be restrained, secluded or given “prn” medications against their will if a danger to self or others
describe involuntary admissions to psychiatric units
- admission made without consent
- made if client is a danger to self or others; not able to meet own basic needs; judgement is so impaired that does not understand need for treatment, and has a diagnosed mental illness
describe involuntary commitment procedure
1) petition by concerned individual
2) cert #1: attests to code def. of MI, done by MD or PhD, within 72 hours
3) cert #2: done within 24 hours of 1st, by MD
—if patient disagrees—
4) court docket within 7 days
5) pt. seen by psychological lawyer, case reviewed
6) probate court: judge hears evidence and rules
7) client has right to trial (w/ jury if desired) and be represented by an attorney (court appointed if needed)
8) testimony from petitioner, MD, or PhD, patient given
9) judgement based on testimony and least restrictive setting treatment option (outpatient privileges)
10) if committed, client must take medications
11) may be discharged earlier than ruling based on MD assessment
what are the rights of a hospitalized patient
- to be treated with dignity
- to be involved with treatment planning
- to refuse treatment
- to leave the hospital
- to have legal representation
- to have private conversations, use of phone
- confidentiality (be mindful to patients, ask if comfortable)
inpatient vs. community setting
—–inpatient——
- locked unit
- staff set boundaries
- regular food, housekeeping, security services
- medication encouraged
- milieu (wandering around nurses station)
- health care team support
——CMH—–
- locked apartment
- client set boudandaries
- erratic food, housekeeping, security services
- client may be noncompliant (up to pt.)
- social isolation (or opposite)
- limited support (need education)
inpatient vs. community goals
——inpatient——
- client symptoms will be stabilized
- client will return to community
—–CMH—-
- client will maintain stability in the comunity
- client will participate as active member of treatment team
- client will demonstrate improved ability to function
inpatient vs. community interventions
—–inpatient——
- enforced by seclusion and restraint
- development short term therapeutic relationship
—–CMH——-
- access negotiated with client or gained through family, police, or landlord
- maintain long term relationship
inpatient vs. community medication/socialization activities
—inpatient—-
- supervised, even court-ordered
- socialization: provided and required
—–CMH——
- negotiate consent for and adherence to taking medication
- assist client to identify and use community resources (self-governed activities, integrate into community)
inpatient vs. community self care, nutrition, health care activities
—-inpatient—-
- assist self care, nutrition
- health assessment and intervention prn
——CMH—–
- negotiate meaning of adequate self care, nutrition, and health care with client and social support system
- assist client in assessing for needed community services (DHS, rides -> provider)
inpatient vs. community sociocultural context
—inpatient—-
- develop plan of care that attends sociocultural context of individual
—-CMH—–
- work with client and support system to plan and implement care consistent with sociocultural belief system and context
- want family to be involved
what is anxiety vs. fear
anxiety: reaction to an unspecified danger
fear: reaction to a specific danger
physical sx. associated w/ anxiety
- palpitations
- sweating
- trembling
- SOB
- feelings of choking
- chest pain/discomfort
- nausea
- feeling dizzy
- unsteady
- chills or heat sensations
- paresthesias (N/T)
- feelings of detachment
- fear of losing control
- fear of going “crazy”
- fear of dying
substances inducing anxiety 8
- alcohol
- caffeine
- cannabis
- hallucinogens
- inhalants
- opioids
- amphetamines
- cocaine
4 stages of anxiety
mild, moderate, severe, panic
mild anxiety
- perceptual field heightened
- grasp what is happening
- identifies disturbing things
- can work toward a goal
- examine alternatives
- experiences slight discomfort
- restlessness, irritability
- mild tension reliving behaviors
moderate anxiety
- perceptual field narrows
- selective inattention
- needs to have things pointed out
- problem solving ability moderately impaired
- benefits from guidance
- shaky voice, concentration difficult
- SNS symptoms
- somatic complaints
severe anxiety
- perceptual field greatly reduced
- attention scattered
- self absorbed
- can’t attend events or see connections
- perceptions distorted
- feelings of dread/doom
- SNS symptoms
- confusion, purposeless activity
panic level anxiety
- unable to focus on environment
- terror, emotional paralysis
- hallucinations/delusions
- muteness, severe withdrawal
- immobility or extreme agitation, severe shakiness
- disorganized, irrational thinking
- unintelligible speech
- sleeplessness
interventions: mild to moderate anxiety
- help identify anxiety & antecedents to anxiety
- anticipate anxiety provoking situations
- demonstrate interest
- encourage talk about feelings and concerns
- keep communication open
- use clarification to understand
- encourage problem solving
- use role playing, modeling
- explore behaviors use in past
- provide outlets for excess energy
interventions: severe to panic anxiety
- maintain calm manner
- remain with client
- minimize environmental stimuli
- use clear, simple statements and repetition
- low pitched voice, speak slowly
- reinforce reality if distortions occur
- listen for themes
- meet physical and safety need
- set verbal limits/physical limits
- assess need for medication or seclusion
defenses against anxiety (defense mechanisms)
- automatic coping styles, most people use a variety
- protect and manage conflict & lower anxiety
- blocks feelings, memories
- are relatively unconscious, not always apparent
- are reversible
- are adaptive as well as maladaptive
- consider frequency, intensity, duration of use
criteria for OCD
- obsession
- compulsion
- rules rigidly applied (cleaning, ordering, counting, checking, repeating words silently)
- person knows obsessive/compulsion are excessive & unreasonable
- cause increased distress & is time consuming (more than 1/hour day)
describe obsession
persistent unwanted thoughts, urges, intrusive (taboo, aggressive, sexual, religious, harm)
describe compulsions
repetitive behaviors or mental acts; driven to perform in response to an obsession
OCD intervention
- anticipate needs, esp. for information
- focus on clients rather than on rituals
- monitor nutrition/sleep; encourage meals/rest
- avoid hurrying client
- do not arbitrarily forbid rituals; give positive reinforcement for non-ritualistic activity
- psychoeducation: medication, interrupting obsessive thoughts
criteria for PTSD
- person witnessed or experienced a life threatening event (learned that the event occurred to close friends or family)
- event is persistently re-experienced
- avoidance of stimuli associated with trauma
- persistent symptoms of arousal
- begin within the first 3 months after trauma or delayed by months or years. increased suicide risk
- can occur in children, duration more than one month
ex. of person witnessed or experienced a life threatening event
- death to self or others
- violence
- sexual assault
- horror
ex. of event is persistently re-experienced
- images
- dreams
- flashbacks
- distressing memories
- psychological distress
persistent symptoms of arousal ex.
- insomnia
- irritability
- angry
- outbursts
- difficulty concentrating
- alt. in mood
- amnesia
- reckless or self-destructive behavior
- problems with concentration
- exaggerated startle response
- sleep
PTSD interventions
- assess type of trauma, immediate action -> later coping
- early intervention is key
- assess pre and post trauma functioning, including drug and ETOH use
- explore shattered assumptions
- promote discussion of possible meanings of event (individual or group therapy), meds of anxiety/depression, anxiety reduction techniques
- suggest that client not responsible for event, but is responsible for coping
- identify social support and encourage us of support group
OCD interventions
- anticipate needs, esp. for information
- focus on client rather than on rituals
- monitor nutrition/sleep; encourage meals/rest
- avoid hurrying client
- do not arbitrarily forbid rituals; give positive reinforcement for non-ritualistic activity
- psychoeducation: meds, interrupting obsessive thoughts
criteria of phobia
- irrational fear or an object of situation that persists although the person recognizes it as unreasonable
- anxiety is severe if the object of situation is encountered
- types include: agoraphobia, social phobia, specific phobias
phobia intervention
- determine type of phobia & onset
- explain anxiety ds.
- have client list consequences of contacting feared object
- identify therapies for phobias
- systematic desensitization
- teaching relaxation techniques - deep breathing, progressive muscle relaxation, meditation, visual imagery
- model unafraid behavior - therapist is active, coach
medications for anxiety disorder
- anxiolytics drugs: benzodiazepines (valium, xanax, Ativan, klonopin, etc.)
describe anxiolytics (use
useful on short term basis if anxiety is moderate to severe
describe anxiolytics (side effects)
sedation, decreased cognitive function, ataxia, dependence and addiction may develop
describe anxiolytics (teaching)
- avoid liquor
- caffeine
- pregnancy
- breast feeding: may cause withdrawal if used for 3 months or more
- DO NOT STOP ABRUPTLY: reduces the ability handle machinery - very important
medication for depression
tricyclics drugs: antidepressant medications
tricyclic use
used to prevent panic attacks, phobias, PTSD
tricyclic drugs
anafranil (good for OCD) (elavil), tofranil, pamelor
describe SSRIs
selective serotonin reuptake inhibitors
SSRI use
treat OCD, panic, agoraphobia, GAD (generalized anxiety ds.)
- inhibits reuptake of serotonin so that more serotonin is available “feel good hormone”
SSRI drug
buspar: non benzo anti anxiety medication
- 2-4 weeks to work, not addicting, good for long term
interventions for dealing with anxiety
- assess level first
- if moderate: stay with client, decrease stimulation, determine trigger if possible, try talking to patient if possible, journaling, exercising, thought stopping, CBT
- if severe to panic: use slow simple communication, quiet, non stimulating safe environment, deep breathing, visualization, progressive muscle relaxation, meds PRN!!
- monitor own feelings
antidepressants SSRIs
- citalopram (celexa)
- escitalopram (lexapro)
- fluoxetine (prozac)
- paroxetine (Paxil)
- sertraline (Zoloft)
anti anxiety agents: benzodiazepines
- alprazolam (xanax)
- diazepam (valium)
- lorazepam (Ativan)
serotonin partial agonists
buspirone (BuSpar)
other classes: beta blocker, antihistamine
beta blocker: propranolol (inderal)
antihistamine: duphrenhydramine (Benadryl)
SNRI’s meds
duloxetine (Cymbalta)
venlafaxine (effexor)
tricyclics meds
amitriptyline (evail)
clomipramine (anafranil)
imipramine (tofranil)
what is mental health
successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and ability to cope with challenges
what is mental disorders
health conditions characterized by alterations in thinking, mood, and or behavior associated with distress and or impaired functioning
what is mental illness
refers to all diagnosable mental disorders
some attributes of mental health
- accurate appraisal of reality
- ability to experience joy
- ability to take responsibility for own actions
- ability to control own behavior
- think clearly
- relate to others
- ability to work and be productive
- ability to play and laugh
mild characteristics of mental health (2)
- daily joys and sorrows
- manageable anxiety levels inherent in living - not w/o s/sx but coping and functional ADLs
moderate to severe characteristics of mental health
- anxiety ds.
- personality ds.
- eating ds. - marked distress
- notable s/sx with moderate impairment in function and ADLs
severe to psychosis characteristics of mental health
- depressive & bipolar ds.
- schizophrenia ds.
- cognitive ds.
- severe/chronic s/sx resulting in impairment in quality of life, unable to manage ADLs or societal role successfully
culture and diversity
what does a group accent as normal? varies amongst cultures and groups
what is the DSM V
diagnostic and statistical manual (5th edition)
- provides specific criteria for the diagnosis of 157 mental disorders (20ch.)
- classifies ds., useful in clinical, research, and teaching
- environmental problems listed as codes
- global functioning measured by WHO disability assessment
- provides uniformity across practice settings
- available online through WSU library system
ex. of DSM 5 disorders
- autism spectrum disorder: autistic DO, Rhett’s DO, aspergers DO
- major neurocoginitive ds: dementia, Alzheimer’s type
- alcohol use ds: alcohol intoxication
- schizophrenia: no changes
- mood ds: bipolar, MDD, no changes
- anxiety ds: panic, PTSD, GAD, phobia, no changes
what is stress
state produced by a change in the environment perceived as threatening, challenging, or damaging to well being
what does stress produce
biochemical, physiological, cognitive and behavior changes directed at adjusting to the effects of the stress
________ & ________ are central to psychiatric ds. and provision of mental health care
stress; our responses
early life exposure to stressful events related to greater incidence of?
all mental illnesses as adults (ETOH, drug dependence, eating disorders, PTSD, suicidal behaviors
what does the stress-diathesis model state
- genetic combinations
- emotional and psychiatric disorders arise form interaction of negative life events with pre-existing vulnerabilities
what are the 4 types of stressors
- environment
- social
- demanding
- life events
what is the general adaptation syndrome
- perception of threat
- 3 stages: alarm, resistance, exhaustion
what is the alarm stage of general adaptation syndrome
- acute, brief, adaptive (fight or flight); sympathetic
- hypothalamus -> adrenals -> catecholamine adrenalin (increases HR, RR, BP for strength/speed, pupils dilate, blood diverted away from GI tract and kidneys)
- adrenal cortex -> corticosteroids (muscle endurance. stamina)
- endorphins released to create sense of pain and injury
what is the resistance state of general adaptation syndrome
- AKA adaptation, sustained and optimal resistance to stressor occurs
what is the exhaustion stage of general adaptation syndrome
- when attempts to resist fail, resources are depleted, stress may become chronic -> wide array of physical/psychological sx. even death may occur
distress
negative draining energy - anxiety, depression, confusion, helplessness, hopelessness. fatigue
eustress
positive, beneficial energy, motivates and results in feelings of happiness, purpose, etc.
what is stress on males
fight or flight
what is stress on females
- tending and befriending
- protection of young
- reliance on social network for support
- more sensitive to corticotropin - reading factor (peptide hormone release in response to stress)
there is a strong relationship between
stressful life events and depression
what are the 4 phases of interpersonal process
orientation: getting to know patient, building rapport and trust
identification: main problem?
working: interventions, teaching, counseling
resolution: problems resolved, no longer in range of hurting themselves or others
nursing role in mental health
- focus is on client
- nurse is participant observer
- nurse has awareness of role
- nursing is investigative
- nurses use theory
- developed processed recording
agonists drug vs neurotransmitter
mimics the effects or neurotransmitters naturally found in the human brain by binding to and stimulating the receptor site
antagonists drug vs neurotransmitters
block neurotransmitters, thereby obstruct neurotransmitter’s action
what are the 3 types of defenses against anxiety
repression
displacement
rationalization
what is repression
stressful, painful proving memories are actively prevented from entering conscious thoughts, but patient still feels sad
-ex: patient has repressed memories of abuse/trauma as a child, difficult time forming relationships
what is displacement
taking out emotions onto safe object or person
what is rationalization
making excuses
what are defense mechanisms
temporary protection until patient can accept what’s happening
- blocks feelings and memories
- freud: “things are going on in the unconscious mind that birth defense mechanisms”
adaptive vs. maladaptive defense mechanisms
- adaptive: helps you by blocking overwhelming anxiety
- maladaptive: blocks reality from ever reaching consciousness
what is the mental status exam
part of the assessment in all areas of medicine
- analogous to the physical exam in general medicine and the purpose is to evaluate an individual’s current cognitive process
- aids in collecting and organizing objective information
what does the nurse observe in mental status exam
- patient’s physical behavior
- nonverbal communicatoin
- appearance
- speech patterns
- moods and affect
- thought content
- cognitive ability
- insight and judgement
what are the 4 therapies learned
short term, cognitive, behavioral therapy
what is short term therapy
- fewer than 10 sessions
- for relatively healthy and well function clients
- rapid, back and forth between client and therapist
- based on present problems
- goals is to help client understand and cope better
what is cognitive therapy
- active, directive, structure, and time limited
- based on theory that thoughts affect mood
- goal: identify, reality test, and correct distorted thinking to help mood and behavior
- client learns to question and challenge their thinking (ex; what is the evidence for this: am I overgeneralizing, catastrophizing, assuming worst case scenario)
what is behavioral therapy
- focus: learning more adaptive behavior
- applications: operant condition, modeling, systematic desensitization, aversion therapy, relaxation
- therapist: active and directive
what are neurotransmitters
chemical signals between the neurons (neurotransmitter) allow for communication between neurons
- neuromessenger
- released from axon terminal at presynaptic neuron on excitation
- crosses synapse to adjacent postsynaptic neuron, where it attaches to receptors on the neuron’s surface
- once attached to receptor and exerting its influence on postsynaptic cell, neurotransmitter separates from the receptor and is destroyed
how do neurotransmitters work
- neurons have the ability to communicate by conducting an electrical impulse from one end of the cell to another
- cellular membranes are electrically charged due to ions inside and outside cell
- communication between neurons occurs mainly through sodium (Na) and potassium (K) ions.
- resting state: unequal distribution of these two on the inside of the cell membrane and the outside. there are lots of positively charged potassium ions just inside the membrane and lots of sodium ions (along with some potassium ions) on the outside.
- intracellular space is more negative when compared with the extracellular space ions
what are the 2 ways neurotransmitters are destroyed
- specific neurotransmitters (acetylcholine) at post synaptic cell
- other neurotransmitters (norepinephrine) are taken back into presynaptic cell, from which they were originally released by a process called reuptake
- either reused or destroyed by intracellular enzymes
what is suicide
- 8th leading cause of death in US (75 a day)
- rate increasing for 15-24 year olds
- highest risk: elderly males, over 65, increases with age, illness, losses
- men > women to commit (men are more lethal)
- risk factors: depression, ETOH, hopelessness
what are the suicide warning signs
- suicidal talk
- death preoccupation (planning funeral, giving away things, giving away career)
- behavioral changes/signs of depression (lack hygiene, low mods, increased substance use)
- giving away possessions, finishing business
- appetite/sleep disturbances
- taking excessive risks, increased drug use
what is the suicide assessment
- ask if thoughts are present?
- if so, is there a plan?
- what is the plan?
- do they have access to the plan
- how lethal is the plan? make a contract & ALERT
- assess risk factors: past attempts, family hx., degree of hopelessness, isolation, medical condition, social supports (or lack thereof)
“you sound like you’re suicidal, are you thinking about ending your life”
what are the nursing interventions for suicide
- if in hospital = precautions (1:1, q15min, GSP)
- observe mood, behavior, thoughts, secure unit, follow unit policies
- PRN’s if antipsychotics needed
- establish rapport & rally supports
- drug therapy, psychotherapy (providers aware)
- crisis hotline phone number given at DC
- encourage ventilation & problem solving (general safety protocol)
minimizing suicidal opportunity
- suicide precautions 1:1 monitoring OR
- suicide observations q15m visual checks PLUS
- plastic utensils, dinnerware
- do not assign to private room
- do not allow extended time alone in room
- break away shower rods, recessed shower nozzles
- short electrical cords
- lock unbreakable windows and safety screens
- lock utility and examining rooms, kitchens, stairwells, offices, closets
- remove harmful objects from clients: belts, shoelaces, metal nail files, scissors, razors, tweezers, matches, meds, cords, perfume, glass containers
- inspect gifts from visitors and remove harmful objects
- ensure that visitors do not leave harmful objects
- some agencies inspect client unit after visiting hours
- search client for harmful objects on return from pass
what are the characteristics of high risk patients for suicide
- 1:1 status
- client verbalizing clear intent to harm self
- unwilling to make contract
- no insight into problems
- poor impulse control
- delusional, hearing voices
- prior attempts
suicide can be
- impulsive or have lots of thoughts and planning put into it
- intentional: self harm, have a plan
- unintentional: OD
- study shows that population of people with past suicide attempts, only 10% were really intent on carrying it through
goals of therapeutic relationship
- facilitate communication of distressing thoughts & feelings
- assist in problem solving
- help examine self defeating behaviors and test alternatives
- promote self care and independence
types of relationships
social, intimate, therapeutic
social relationship
primarily for friendship or task accomplishment
needs are mutually met
communication
- often superficial
- techniques: advice, meeting dependency needs
intimate relationship
- between two individuals with an emotional commitment to each other
- mutual needs met
- communication (personal info., intimate desires, fantasies shared)
therapeutic relationship
- between nurse/client to enhance client growth
- focus on client issues, problems, and concerns
- communication (therapeutic technique used to identify and explore needs, set goals, assist in development of new coping skills encourage behavioral change
factors enhancing growth in others 4
- genuineness: congruence
- empathy: understanding ideas expressed and feelings present in the other
- positive regard: implies respect: attitudes, actions (attending, suspending value judgements)
- helping clients develop resources: awareness, encouragement
bounding blurring
relationship slips into a social context
- nurse behavior meets personal needs at expense of client: (1) over helping, (2) controlling, (3) transference, (4) countertransference
4 phases of relationship (peplau)
- preorientation
- orientation
- working
- termination
preorientation relationship
pre meeting concerns
orientation relationship
setting atmosphere
begin rapport
nurse’s role defined
confidentiality
problems are identified
set time, place, and duration of meeting
working relationship
problem solving
work on change
support efforts
alternative adaptive behaviors
termination relationship
summarize goals achieved
incorporate into daily life
exchange memories that validate the experience
factors beneficial to relationships
- consistent, regular and private interactions with client (w/ assigned nurse, regular routine of activities)
- being honest/congruent
- letting client set the pace
- listening to client concerns
- positive initial attitudes and preconceptions
- promoting client comfort and balancing control
- client demonstrating trust and actively participating in relationship
factors of the client interview (how to start)
- setting: open area, physical space, confidentiality, set tie
- seating: arms length, eye contact if permitted
- introductions
- turning it over to the client: “where should we start?” “tell me a little about what has been going on” “what are some of the stresses you’ve been dealing with lately” “perhaps you could start by telling me what brought you to the hospital”
factors to help the client (4)
- identify and explore problems relating to others
- discover healthy ways of meeting emotional needs
- experiences satisfy interpersonal relationships
- feel understood and comfortable
active listening components (5)
- observing nonverbal behaviors
- listening to/understanding verbal messages
- understanding in context of life
- listening for inconsistencies
- giving feedback
4 therapeutic techniques
- silence
- active listening
- clarifying
- questions
silence therapeutic technique
meaningful moments, reflection
active listening technique
- observing verbal/nonverbal
- understanding & reflecting on verbal message
- context
- inconsistencies
- helps strengthen pt’s ability to solve problems
clarifying technique
paraphrasing
restating
reflecting
exploring
questions technique
open ended (what, how, what if..)
clinical interview guidelines
- speak briefly
- when you don’t know what to say, say nothing
- lead with empathy
- when in doubt, focus on feelings
- don’t always rely on questions
- pay attention to non verbal cues & possibly comment on them
ex: open ended question (what, where, when, tell me about), clarifiers (I’m not sure I understand, who is they), explorers (tell me more about your relationship with your wife, give me an example of how she was “mean” to you), empathetic statements (that must have been really hard for you, I can see how upset you are about the marriage ending)
obstructive techniques
- asking close ended questions (unless during intake interviews)
- giving approval/disapproval
- advising
- asking “why” questions -> try “what”
- giving premature advice (give none period)
what are the components of the mental status assessment
- appearance
- behavior
- speech
- mood & affect
- thought process/content
- perceptual disturbances
- cognition
(obj/subj data)
what is the nursing process in mental health nursing
serves as problem solving approach for:
- safe, competent, relevant, quality care
- for patients, families, groups
- based on theory
- serves as foundation for the standards of practice
- special considerations for children, adolescents, elderly, language barriers
what is part of the assessment
- psychosocial
- spiritual/religious
- mental status examination
- history taking
- interviews
- standardized rating scales (screeners)
- verify the data - secondary sources (family)
nursing diagnosis for mental health
- based on NANDA
- unmet need or problem
- etiology or probable cause
- supporting data
- common Nsg Dx: domains 5,6,9 (& others)
ex: ineffective impulse control, impaired verbal communication, hopelessness, risk for loneliness, disturbed personal identity, chronic low self esteem, ineffective coping
goals and outcomes for mental health
- goals are broad, rider to the nursing diagnosis statement, can be short term or long term
- outcomes are measurable, specific, and support the goal; a way of defining the goal
interventions for mental health
- coordination of care
- health teaching
- pharmacological
- biological
- strive for evidence based actions
evaluation for mental health
- patient’s response to treatment
- systematic ongoing criteria based
- allows for revision of care plan (nursing diagnosis) or interventions
