Unit 1 & 2 Flashcards
Infancy
Birth to 18 months Trust versus mistrust POS. Learning to trust others NEG. Mistrust, withdrawal, estrangement
Toddler
18 months to 3 years
Autonomy versus shame and doubt
POS.Self-control without loss of self esteem
NEG. Compulsive self-restraint or compliance
Preschool
3 to 6 years
Initiative versus guilt
POS. Learning the degree to which assertiveness and purpose influence the environment
Beginning ability to evaluate one’s own behavior
NEG. Lack of self-confidence
Pessimism, fear of wrongdoing
Overcontrol and over-restriction of own activity
School age
6 to 12 years
Industry versus inferiority
POS. Beginning to create, develop, and manipulate
Developing sense of competence and perseverance
NEG. Loss of hope, sense of being mediocre
Withdrawal from school and peers
Adolescence
12 to 20 years Identify versus role confusion POS. Coherent sense of self Plan to actualize one’s abilities NEG. Confusion, indecisiveness, and inability to find occupational identity
Young Adult
20 to 30 years Intimacy versus isolation POS. Intimate relationship with another Commitment to work and relationships NEG. Impersonal relationships Avoidance of relationships, career, or lifestyle commitments
Middle adult
30 to 65 years
Generativity versus stagnation
POS. Creativity, productivity, concern for others
NEG. Self-indulgence, self-concern, lack of interests and commitments
Later adult
65 years to death Ego integrity versus despair POS. Acceptance of worth and uniqueness of one’s own life Acceptance of death NEG. Sense of loss, contempt for others
Compensation
Covering up for weakness, or overemphasizing, or making up a desirable trait.
Example: A withdrawn patient becomes known for his paintings.
Conversion
Unconscious expression of psychological problem in a physical way.
Example: A depressed patient witnesses a robbery and can no longer see.
Denial
Unconscious refusal to admit an inappropriate behavior or idea.
Displacement
Discharging pent-up feelings to a less threatening object.
Example: A patient yells at the nurse after the doctor refuses to order Valium.
Dissociation
Unconscious separation of painful emotions from thoughts
Example: Person describes her rape with no facial expressions.
Identification
Unconscious or conscious attempt to model oneself after a respected person.
Example: A patient with mental disorder states she wants to become a psychologist when she gets well.
Introjection
Unconscious incorporation of other beliefs as if they were your own.
Example: A patient takes over group therapy without realizing it, and analyzes other patients.
Projection
Blaming someone else for your problems or placing your beliefs on someone else.
Example: A patient blames his Xanax addiction on his wife because “she makes me take it with her.”
Rationalization
Attempt to prove one’s behavior as justifiable.
Example: A patient states she cannot take her medication because “it is poison.”
Reaction formation
Conscious behavior that is the exact opposite of the unconscious feeling.
Example: A patient who dislikes her mother unconsciously always brags about her to the staff
Regression
Return to an earlier and more comfortable developmental level.
Example: A teenage patient sucks her thumb when she gets upset.
Repression
Unconscious and involuntary forgetting of painful ideas, events, or conflicts.
Example: A patient who was a victim of incest from her father never understands why she hates her father.
Sublimation
Channeling instinctual drives into acceptable activities
Example: A nurse who has a history of chemical dependency leads the local AA meetings
Suppression
Voluntary exclusion from anxiety producing situations
Example: A patient states he cannot talk about the death of her mother
. DSM 5
Diagnostic and Statistical Manual
of Mental Disorders May 2013
The purpose of this book is to specify the criteria for diagnosing mental disorders. This includes diagnosing all psychiatric disorders, developmental disorders, and personality disorders. By providing the criteria that must be met in order to diagnose or label a patient with a diagnosis, it eliminates pure subjectivity based on individual practitioner’s opinions. This aids in the prevention of misdiagnosing patients.
Ego
is the organized, realistic part that mediates between the desires of the id and the super-ego
Id
source of our bodily needs, wants, desires, and impulses, particularly our sexual and aggressive drives; acts according to the “pleasure principle”
Super Ego
plays the critical and moralizing role
defense mechanisms
Learned Coping Mechanisms
Focus on positive responses or adaptive (positive)coping mechanisms
Everyone uses them
Negative when overused
Patients often unaware they are using them
Nurses must recognize use and redirect to positive coping mechanisms
dual diagnosis
mental illness and chemical dependency
seclusion
the act of placing or keeping someone away from other people
restraint
a way of limiting, controlling, or stopping something. : a device that limits a person’s movement. : control over your emotions or behavior
staff splitting
patients play one staff member against another. The patient will often complain about other staff members such as : “My Doctor never listens to me or helps me,” “That Group Leader is mean,” “That Social Worker is not helping me.”
The intervention for this is to refer the patient back to the staff member they are having problems with. It is important that the nurse not get drawn into the patient’s manipulation and to not discuss this with patient since the nurse was not present when the issue happened.
Assign one staff member to care for manipulative pt
habeus corpus
which means they have the right to appear in court if they feel they are being held unjustly
affect
refers to the experience of feeling or emotion;refers sometimes to affect display, which is “a facial, vocal, or gestural behavior that serves as an indicator of affect” (APA 2006).
mood
is an emotional state. Moods differ from emotions in that they are less specific, less intense, and less likely to be triggered by a particular stimulus or event. Moods generally have either a positive or negative valence
mental health
The definition of mental health is an individual’s ability to cope with life’s processes.
criteria for mental health
Reality based / oriented (person, place, time, and situation) Positive self concept / self esteem Autonomy and self determination Environmental mastery Appropriate behavior Appropriate affect/ expression of feelings Progressing through developmental stages Positive coping skills / problem solving Social and occupational functioning Rational thoughts
Mental illnesses
are biological, medical disorders of the brain. Mental illnesses disrupt an individual’s : Thinking Feeling Mood Behavior Ability to relate to others Daily Functioning
, primary prevention
is maintaining our mental health and prevention of mental illness
higher risks for having mental illness
Gender Age Culture Genetics Neurostructural Changes-(occur as a result of head trauma, accidents, and birth causing mental illness) Stress-major contributor to acquiring mental illness. Individuals decompensate mentally when their under extreme stress Defense Mechanisms Familial Patterns Substance Abuse Physical Illness/Medications
Diagnostic studies/ Secondary Prevention
EEG’s- to rule out neurological disorders or seizures
- Cat Scans, MRI’s, and PET Scans of the head -especially in cases of head trauma/history of head trauma or sudden onset of bizarre behavior/symptoms -to rule out neurostructural problems
- Drug Screen – to rule out substance abuse
- Thyroid Function Tests- to rule out hypo or hyperthyroidism - hypothyroidism can mimic depression and hyperthyroidism can mimic anxiety or manic symptoms
- CBC- to rule out electrolyte imbalances and infections
- UA-to rule out infection-many times elderly patients are admitted with confusion, sudden change in mental condition, and even aggressive behavior. Often infection is the cause; particularly urinary tract infections.
- GI studies – many individuals have GI complaints/symptoms- to rule out physical GI problem
- Stress Test, cardiac enzymes, and EKG – to rule out cardiac problem’ particularly those patients with physiological complaints of anxiety
- Folate/B12- to assess nutritional status of patients especially elderly or for patients who for some reason are not eating. For example, eating disorders, paranoia, chemical dependency, etc.
Other test for Secondary Prevention
IQ tests and Growth and Development Tests are often done on children and adolescents to rule out learning developmental disabilities. The term “mental retardation” is no longer used. Now, the term developmental disability is used if an individual does not perform skills at the appropriate age level.
- Learning Disabilities Tests are also many times given to children and adolescents to rule out learning disabilities and attention difficulties.
- Minnesota Multiphasic Personality Inventory (MMPI) and other personality tests are administered to adults to diagnose personality disorders.
Maslow
Maslow was notable for developing the hierarchy of needs.
Review the above 5 levels of needs: Physiological, Safety and Security, Love and Belonging, Self esteem, Self actualization. Patient needs are to be met from the bottom of the triangle up
Physiological needs must be met before moving to the higher levels. Examples times when physiological needs are a higher priority on the behavioral health unit are: patients not eating due to- paranoia, eating disorder, mania, or depression.
-After basic physiological needs are met, safety and security needs are next in priority. Many patients with mental health disorders are suicidal or homicidal and these needs are next in priority order.
inpatients
All inpatients must be evaluated
within 24 Hours of Admission by a
physical Doctor and Psychiatrist.
Basic Principles of a Mental Health Nurse
- Accept patient.
- Be nonjudgmental.
- Be consistent.
- Be objective.
- Build trust.
- Treat patient with respect and dignity.
- Restraints are only used when the patient is in the crisis phase.
- Maintain confidentiality
- Be empathetic.
- Maintain personal space.
- Be aware of manipulation.
Competency Assessment
A Psychiatrist is the only one
that can perform a competency assessment on a patient to deem the patient competent or incompetent to make decisions.
Psych Medications
Palliative(Tx symptoms not a cure) Patient’s right to refuse Informed Consent “cheeking” Many times when a patient is newly admitted, the only thing we can do is get them to take their meds, keep them safe, and attend to their ADL’s
Giving MedicationWithout Client Consent
Treatment Team MUST determine that ALL 3 criteria are met:
Patient MUST Exhibit behavior that is dangerous to self or others.
The medication ordered by the Physician MUST have a reasonable chance of providing help to the patient.
Client who has refused medication MUST be judged incompetent to evaluate the benefits of the treatment in question.
Documentation
Tell the complete detailed story with quotes.
Treatment Team including Physician are notified and documenting patient meeting 3 previous criteria in previous slide.
Remember Psychiatrists are the only ones who can determine competency.
No long acting antipsychotics can be given as forced med. (Deconate, Consta, Sustenna)
Get 1 time med order NOT PRN
Voluntary Admission
Signature on consent for voluntary treatment
May change to involuntary
Involuntary
3 Types of Involuntary Admissions
- 24 hour ER and Care
- 72 hour hold
- Probate
Criteria for Emergency admission
suicidal, homicidal, or gravely disabled due to a mental illness
At the end of the 72 hours of the involuntary or emergency admission, three things may happen.
1. The physician can discharge the patient if they are no longer a danger to self or others.
2. The patient may be asked to sign a voluntary admission form which changes them to voluntary status.
3. If the patient refuses to sign voluntary admission within 72 hours and continues to be a danger to self or others or gravely disabled. The treatment team will initiate probate procedings.
Legal Aspects of Psychiatric Care
Patients have the right to the least restrictive environment. This means if they can be maintained in an outpatient setting, they should not be on an in-patient unit. Please review the other patient rights in your course shell
Patients have the right to habeas corpus, which means they have the right to appear in court if they feel they are being held unjustly. This is a court appearance and the patient should be referred t legal representation or a lawyer.
-M’Naughten Rule- This is the law where individuals who do not understand the nature of a murder due to incompetence may be found not guilty of his or her crime
Children, adolescents, legal guardians, durable power of attorney/power of attorney – pay attention to paperwork
A patient can only read the chart with Dr. present.
Release of Information
signed consent by a competent adult patient, which allows staff to share information with the specific designated person or institution.
On some mental health units the patient may be given a security or code word for significant others to provide to staff so they can speak with or visit with the patient.
3 Forms of Manipulation
- “poor pitiful me” syndrome
-2. “buttering you up”
-3. “staff splitting
Make sure to document manipulative behavior and inform fellow healthcare providers.
Poor Pitiful me syndrome
patient tells you a long detailed story of negative past life experiences and usage of negative coping mechanisms. Often this patient is wanting sympathy and something in return
The intervention for this type of manipulation is making patients responsible for their actions and life choices
Buttering up
the patient excessively compliments the staff. Many times saying “you are the only one that will listen to me” or “you are the best nurse.” Again, this patient is wanting something in return, which may include bending the unit rules. The intervention for this is a quick, “thank you” to the patient and then focus on the patient treatment goals
The intervention for this is a quick, “thank you” to the patient and then focus on the patient treatment goals. It important not to internalize the constant compliments and inflate you self esteem
Aggressive Patient
Assessment important Address problems quickly DO NOT Ignore… Patients escalate quickly (labile), watch for S/S Stay at a safe distance Don’t be in room alone or in closed area Interventions Safety Notify staff Separate THEN Approach patient!!! Use verbal interventions Firm/Assertive Calm Repetitive/Concrete Focus on behavior Ask for pat. To control self Set limits/remind of rules Offer PRN meds Direct to quiet area/decrease stimuli Code Violet
Aggressive Patient cont.
REMEMBER
least restrictive environment
try verbal intervention 1st
prevent them from hurting selves or others
Documentation is VERY IMPORTANT!!!!!
have another RN/Team Leader check documentation
Aggressive/Anger Stages
Trigger Phase
Crisis
Recovery Phase
Trigger Phase
Definition-an event causes a person to be angry and upset though the person remains in control of behavior. Symptoms seen are:Restless, pacing, psychomotor agitation
Muscle tension with complaints of HA/pain
Irritable, sarcastic, crying, angry, anxious, suspicious
Repeated verbalizations
Perspiration
Changes in breathing
Interventions For Trigger Phase
Maintain personal space Remain calm Use clear, simple, repetitive statements Provide empathy Encourage ventilation of feelings Listen, reflect, and validate feelings Maintain 15 minute checks Offer constructive outlets Offer PRN meds Decrease stimuli Contract for safety Assess for escalation of anger/aggression
Crisis
Definition-a person’s behavior is out of control. Symptoms from trigger phase escalate to:
Suicidal/homicidal thoughts or gestures-fighting, hitting, kicking, biting, scratching
Destructive to property
Decreased cognition
Increased physical strength
Screaming/yelling/demanding/
threatening/cussing
Increase in psychomotor agitation
Rage/hostility
Invades others’ personal spaceInterventions for Crisis(patient care in seclusion/restraints)
Contact physician within one hour to obtain orders for seclusion room, restraints, and/or medications
Maintain 15 minute checks or check more frequently
Document what happened before, during, and after the crisis
Offer bathroom and fluids/nutrition Q 2 hours
Assist with ADLs
Assess mental and physical status
Explain rules/expectations
Provide restraint care-remove 1 restraint at a time for 10 minutes every 1-2 hours for ROM, assess for skin integrity and circulation, renew restraint order every 4 hours for adults and every 1-2 hours for children and adolescents
Restrict visitors, contact with other patients, telephone calls, and group therapy to reduce stimuli
Secure patient’s belongings
Recovery Phase
Definition-person is back in control of behavior. Symptoms are: Muscles relaxed Increased cognition Calm Decreased anxiety and agitation Self-control Mood more stable Makes accusations or is apologetic Lowered voice More normal responses
Interventions For Recovery Phase
Calm Discuss trigger and crisis events Assist with alternative problem-solving Gradually reduce degree of seclusion/restraints Offer po PRN meds if needed Contract for safety Maintain 15 minute checks Facilitate reentry to the unit and unit routines by having patient return to regular room, dress in street clothes, eat with other patients, attend group, etc.
Seclusion and Restraints (state mandated)
Nurse can initiate.
1 hour total to get verbal order
EVERY 2 hours Monitor physical status ROJM- 1 limb at a time Vital signs Nutritional status Decrease stimuli
Charting Legal Requirements
every 15 minutes by mental health professional
every 2 hours by nurse
Types of Restraints
- Violent – behavioral reasons
- harm to self or others - Nonviolent – medical reasons
– pulling out medical devices
Differences I Documentation:
Violent —- Nonviolent
Violent
1. Renew every 4 hours
2. One hour Face to Face
by doctor
Nonviolent
1. Renew every 24 hours
2. No need for One hour
face to face by doctor
