Topic 1 Flashcards
community mental health center act
Push towards community care rather than institutionalization when possible
the mental health continuum
A conceptual line used to represent levels of mental health and mental illness that vary from person to person and vary for a particular person over time.
what is normal function in the mental health contimuum
*Normal mood fluctuations
*Takes things in stride
*Normal sleep patterns
*Physically & socially active
*Usual self-confidence
*Consistent performance
*Engaged in studies
what is common, mild, reversible distress in the mental health contimuum
*Irritable, impatient
*Nervousness, sadness
*Increased worrying
*Difficulty relaxing
*Trouble sleeping
*Lowered energy
*Procrastination, forgetfulness
*Decreased social activity
*Pressured by academic demands
what is significant functional impairment in the mental health contimuum
*Frequent anger, anxiety
*Lingering sadness, tearfulness, worthlessness, hopelessness
*Significantly disturbed sleep
*Difficulty listening, processing, & problem solving
*Avoidance of social situations, withdrawal
*Decreased academic performance
*Missed deadlines, requests for extensions
what is clinical disorder, severe & persistent functional impairment in the mental health contimuum
*Angry outbursts
*Excessive anxiety
*Persistent depressed mood
*Suicidal thoughts, intent, behavior
*Constant fatigue & feeling overwhelmed
*Significant disturbances in thinking
*Not going out or answering email/phone
*Significant difficulty with academic functioning
stigma
a negative stereotype that leads to an attitude or belief that would cause one to view a person with mental illness as inferior, dangerous, or unstable.
DSM-5
the official manual for psychiatric medical diagnosis
What is the difference between a psychiatrist & a psychologist?
Psychiatrists: prescribe medications, go to med school, a MEDICAL DOCTOR
Psychologist: cannot prescribe med, they are a clinical doctor
what are the roles of an RN in the mental health setting?
*Providing a safe, therapeutic environment (milieu)
*Promoting self-care
*(psychoeducational groups)
*Administering medications
*Health teaching on social skills & coping skills
*Health promotion (psychoeducational groups)
*Case management
What are the roles of an Advanced Practice Level: PMH-APRN?
*Counseling & psychotherapy
*Cognitive, behavioral, and milieu therapies
milieu
refers to the environment in which holistic treatment occurs and includes all members of the treatment team, a positive physical setting, interactions between those who are hospitalized, and activities that promote recovery.
therapeutic relationship/therapeutic alliance
refers to the relationship between a healthcare professional and a client (or patient). It is the means by which a therapist and a client hope to engage with each other, and effect beneficial change in the client.
RN cannot give ______ because the steps into therapy and that is outside our scope of practice.
advice
professional boundaries
are the spaces between the nurse’s power and the patient’s vulnerability.
transference
occurs as the patient projects intense feelings onto the therapist realted to unfinished work from previous relationships
Signs of inappropriate behavior can be subtle at first, but early warning signs that should raise a “red flag” can include:
-Discussing intimate or personal issues with a patient
-Engaging in behaviors that could reasonably be interpreted as flirting
-Keeping secrets with a patient or for a patient
-Believing that you are the only one who truly understands or can help the patient
-Spending more time than is necessary with a particular patient
-Speaking poorly about colleagues or your employment setting with the patient and/or family
-Showing favoritism
-Meeting a patient in settings besides those used to provide direct patient
Countertransference
anyone else placing feelings onto the patient; this must be scrutinized in order to prevent damage to the therapeutic relationship
trauma informed care
presumes everyone will have some kind of event that to them will be traumatic or cause them distress
Client’s Rights Under The Law
-Right to Treatment
-Right to Refuse Treatment
-Right to Informed Consent
-Rights Surrounding Involuntary Commitment and Psychiatric Advance Directives
-Rights Regarding Restraint and Seclusion
due process
legal term referring to the requirement of state and federal government to follow fair procedures before depriving someone of “life, liberty, or property”
writ of habeas corpus
A court order that requires police to bring a prisoner to court to explain why they are holding the person
least restrivtive alternative
mandates that the least drastic meands be taken to achieve a specific purpose
voluntary commitment
usually sought out by the patient or patient guardian through a written application to the facility. Patient has the right to demand and obtain release at any time
emergency involuntary commitment
For a specified period of hours or days to prevent dangerous behavior that is likely to cause harm to self or others (cops putting someone into psych ward)
involuntary commitment
made without the patients consent, usually needed when a person is in need of psychiatric treatment, presents a danger to self or others, or is unable to meet their own basic needs due to mental illness. Requires the patient retain freedom from unreasonable bodily restraints aa well as the right to informed consent and the right to refuse medications.
Tarasoff Doctrine
Gives therapists the duty to warn a patient if they are a potential victim (without breaking HIPAA)
Duty to warn usually includes the following:
*Assessing and predicting a patient’s danger of violence toward another
*Identifying specific individual(s) being threatened
*Identifying appropriate actions to protect victim(s)
Staff nurses and members of the mental health team should..
report threats of harm to providers who have the duty to warn obligation.
duty
A moral or legal obligation; a responsibility
breach of duty
Conduct that exposes a client to an unreasonable risk of harm through actions or failure to act by the nurse
cause in fact
typically evaluated through the “but for” test: “but for what the nurse did, would this injury have occured?”
Proximate cause
Legal cause; exists when the connection between an act and an injury is strong enough to justify imposing liability.
damages
include actual damages (loss of earnings, medical expenses, property damage) and pain and suffering to the injured party as well as immediate family members
Duty to intervene
-If you have information which leads you to feel your patient may be harmed, you need to intervene
-Ask questions
-Clarify Orders
duty to report
As the nurse you are obligated to discuss your concerns with the provider and then report
client/patient abandonment
The nurse is obligated to be certain that care is assumed by an appropriately trained nurse or other mental health professional when s/he is no longer accountable for the care of the client
Child Abuse Reporting
Report any reasonable suspicion of abuse or neglect (anything that another person in a similar position would consider abuse) and abuse
elder abuse reporting
not all states will take report of elder abuse, but report suspicion and actual abuse
Dependent / Vulnerable Adult Abuse Reporting
-Dependent adults (This is typically anyone w a guardian appointed, learning disability) are protected by law from physical or fiduciary neglect or abandonment.
-Laws require a person to report the knowledge of or the reasonable suspicion of mental abuse or suffering.
trauma informes approach principles
- Safety
- Trustworthiness and Transparency
- Peer support
- Collaboration and mutuality
- Empowerment, voice and choice
- Cultural, Historical, and Gender Issues
seclusion
is the involuntary confinement of a person alone in a room or area from which the person is physically prevented from leaving.
restraint
is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a person to move his or her arms, legs, body, or head freely.
Assault vs. Battery
assault = intentional threat to bring harm. Battery = intentional touching/contact w/o consent
when is the use of seculsion and retraint permitted?
-when written order is given by specific provider for a specific restrivtive intervention
-the order includes a specific time linit for the intervention
what is needed when seclusion/restraint is used?
The client’s condition is reviewed and documented regularly, per state law and facility policy (e.g., continuous observation with documentation every 15 minutes)
how long does a retraint order last
24 hours. after that review and reauthorization can determine if it order should be extended
what does a nurse do if they need to seclude/restrain a client in an emergency?
the RN may initiate the client’s placement in seclusion and/or in restraint but must then immediately obtain a written or verbal order.
what is necessary when getting a verbal order for a restraint?
*A telephone order is acceptable, but must be followed by a written order in the chart with provider follow-up and a provider signature
(This typically does not apply to chemical restraint, unless specifically written in facility policy and/or state law)
what must be documented when a client is secluded/restrained?
*Client’s behavior leading to restraint and all less-restrictive interventions attempted
*Time client is placed in and released from restraint or seclusion
*All assessments and observations of the client during the intervention, including any care provided
*Debriefing after the intervention (client is included in the debriefing)
how often should a secluded/restrained patient be assessed and what are they ASSESSED for?
Assessed at regular and frequent intervals for physical status and needs (e.g., circulation, breathing, food, hydration, toileting), safety, and comfort every 15 minutes
how often should a secluded/restrained patient be OBSERVED?
-Observed continuously. Observations must be documented every 15 minutes
symmetrical relationship
a relationship between parties of equal power (friends or colleagues)
complementary relationship
a relationship between parties of unequal power (nurse and pateint or stdent and teacher) one is superior to the other
most communication is
nonverbal
spoken word vs nonverbal behaviors
Spoken word: Represents the public self. Can be straightforward comments or can be used to distort, conceal, deny, or disguise true feelings.
Nonverbal behaviors: Covers a wide range of human activities from body movements to responses to the messages of others.
double messages
Conflicting messages (also known as mixed messages). (usually has the intent to be confusing)
double blind messages
Sent to create meaning; can be defensively used to hide what is actually going on; intent is to create confusion.
what are the 4 areas that may be problematic for the nurse when interpreting specifc verbal and nonverbal messages of clients
- Communication styles
- Use of eye contact
- Perception of touch
- Cultural filters
effective (therapeutic) communication skills
*Active listening
*Clarifying techniques
*Paraphrasing (reflection of content)
*Restating
*Reflection of feelings
*Exploring
*Projective questions (“What if . . .”)
*Presupposition questions (The “Miracle Question”)
prejective question: ‘what if’ question
help people articulate, explore, and identify thoughts and feelings.
-Projective questions can help people imagine thoughts, feelings, and behaviors they might have in certain situations.
Presupposition Question:”The Miracle Question”
These two questions can reveal a lot about a person, which can be used in identifying goals that the client might be motivated to work on.
These questions often get to the crux of what might be the most important issues in a person’s thinking and life.
Nontherapeutic Communication Techniques
Excessive questioning
Giving approval or disapproval
Giving advice
Asking “why” questions
Making value judgments
Changing the subject
Extensive use of silence
Freud’s Psychoanalytic Theory
Freud believed the adult personality develops based on a person’s processing of early childhood experiences within developmental stages.
Sullivan’s Interpersonal Theory
*Anxiety & other psychiatric symptoms arise in fundamental conflicts between individuals and their human environments
*Personality development also takes place by a series of interactions with other people.
Hildegard Peplau, Nurse Theorist
emphasized that the nature of the nurse-patient relationship strongly influenced the outcome for the patient.
what are the phases of the nurse-client relationship as established by nurse theorist Hildegard Peplau.
Initial Phase
Working Phase (identification & exploitation)
Termination Phase
Initial Phase
Orientation Phase
Working Phase (identification)
where the nurse may assume various roles, it is an important period where the patient identifies the nurse as consistently helping, providing unconditional care, and providing empathy.
Working Phase (exploitation)
the nurse starts activating the discharge plan and act primarily as and educator and leader
Termination Phase
allows nurse and patient to disengage from the nurse-patient relationship altogether
Pavlov’s Classical Conditioning
Involves pairing a behavior with a condition that reinforces or diminishes the behavior’s occurrence
Unconditioned Stimulus (US): Food. When presented to a dog, the food naturally causes the dog to salivate. The dog does not need to learn this; it’s a reflex.
Unconditioned Response (UR): Salivation. The dog’s natural response to the food.
Neutral Stimulus: A bell.
During Conditioning: Pavlov started to ring the bell just before presenting the food to the dog. After several repetitions of this pairing (bell + food), the dog began to associate the sound of the bell with the impending presentation of food.
After Conditioning: Once the association was established, Pavlov could ring the bell without presenting the food, and the dog would salivate just by hearing the bell.
Skinner’s Operant Conditioning
Voluntary behaviors occur more frequently with positive reinforcement (less so with negative stimuli but principle still applies)
Rewards and punishments to shape behavior
Positive means you’re adding something (like a treat or a scolding).
Negative means you’re taking something away (like removing the unpleasantness of being stopped or taking away a toy).
Reinforcement means you’re trying to increase the likelihood of a behavior.
Punishment means you’re trying to decrease the likelihood of a behavior.
Positive Reinforcement: Every time Max sits when you say “Sit,” you give him a treat. Max starts sitting more frequently because he learns that sitting on command results in a tasty reward.
Negative Reinforcement: Every time Max pulls too hard on his leash during a walk, you stop walking. When Max comes back to you and stops pulling, you start walking again. Over time, Max learns to walk without pulling because it ensures continuous walking (removing the unpleasantness of being stopped).
Positive Punishment: If Max jumps on guests, you might say “No!” in a stern voice. If he doesn’t like the loud voice, he may reduce his jumping behavior to avoid the scolding.
Negative Punishment: If Max barks excessively, you might take away his favorite toy for a while. The removal of something he likes (the toy) might reduce the unwanted behavior (barking).
Behavior modification
A systematic approach to changing behavior through the application of the principles of conditioning.
Systematic desensitization
“exposure therapy”
invloves gradually exposing a person to a feared object or situation until ther person is free of incapacitating anxiety
aversion therapy
during therapy, an undesirable behavior is associate with an unpleasant stimulus
biofeedback
technique in which indiviudals learn to control physiological responses such as breathing reates, HR, BP , etc.
Rational-Emotive-Behavior Therapy (Ellis)
*Aims to eradicate irrational beliefs
*Recognizes thoughts that are not accurate
Cognitive-Behavioral Therapy (Beck)
*Identifies and tests distorted beliefs (cognitive distortions)
*Client learns to change way of thinking, leading to improved behaviors
A-B-C Theory of Cognitive Therapy
*(A) Automatic thought/activating event; “trigger”
*(B) Beliefs: thoughts/feelings about the automatic thought
*(C) Consequence of belief: challenge the belief with rational evidence
INPATIENT
-24-hour nursing care
-Locked units (for safety)
-Crisis response teams
-Residential treatment programs
-State acute care systems
-General hospital psychiatric units
-Private psychiatric hospital (acute care)
OUTPATIENT
-Primary care providers (PCPs)
-Patient-centered medical homes
-Primary care medical homes
-Community mental health centers
-Psychiatric home care
-Individual or group outpatient treatment
-Intensive outpatient programs
