NUR 308 Exam 1 Study Guide

Chapter 1

Mental Health

- World Health Organization (WHO) defines health as a state of complete physical, mental, and
social wellness, not merely the absence of disease or infirmity

- People in a state of emotional, physical, and social well-being fulfill life responsibilities, function
effectively in daily life, and are satisfied with their interpersonal relationships and themselves.

- A persons mental health is a dynamic, or every-changing, state

- Factors influencing a persons mental health can be categorized as individual, interpersonal, and
social/cultural
Individual: biological makeup, autonomy, and independence
Interpersonal: effective communication, relationships, connectedness
Social/Cultural: environmental, sense of community, access to adequate resources,

Mental Illness

- Mental illness includes disorders that affect mood, behavior and thinking, such as depression,
schizophrenia, anxiety disorders, and addictive disorders.
- Cause distress and/or impaired functioning
- Daily life becomes unbearable or overwhelming
- Factors: Individual, Interpersonal, Social/Cultural

Diagnostic and Statistical Manual of Mental Disorders (DSM-5)

- Taxonomy published by the American Psychiatric Association and is revised as needed

- Describes all mental disorders, outlining specific diagnostic criteria for each based on clinical
experience and research
- Offers a standardized language for practitioners
- Presents defining characteristics and/or symptoms that differentiate the specific diagnoses
- Assists in the identification of underlying cause

Evolution

- Demonic possession
- Breaking taboo
- Effect of harmful substance
- Body Humors
- Influence of the moon- lunatic

Ancient Times

- Aristotle
 His theory that the amount of blood, water, and yellow and black bile in the body controlled
the emotions
Imbalances of the four humors were believed to cause mental disorders; treatment was
aimed at restoring the balance through bloodletting, starving, and purging.
Continued until the 19th century
- Sickness a displeasure of the gods
- Devine or demonic
- Magic, prayer, seclusion, incarceration, punishment (flogging or starving), or care by untrained
persons
- Early Christian times
Primitive beliefs and supersititions
Diseases blamed on demons
Exorcisms
Dungeons, flogging, and starvation
- Renaissance
Mental illness distinguished from criminal
Harmless
Lunatics
Hospital of St. Mary of Bethlehem (1547, hospital for insane, first of its kind)

Period of Enlightenment- 1790s

- Short lived
- Asylum: two meanings
Protection, sanctuary (initial intent)
Places of maltreatment, hopelessness
- Proponents:
Tuke and Pinel: termed Asylum
Dix: 1860s, charged with getting the asylums up and running, and assisted monetarily as
well; she advocated for adequate shelter, nutritious food, and warm clothing
- 1773
First mental hospital in the US: Williamsburg, VA
- Asylums
Originally temporary
Treatment and cure of the insane
Large, public institutions
Provide humane and rational methods of treatment
Self-sufficient communities
Inmates had rigorous daily schedules
Short-term hospitals for individuals who were expected to recover and return to society
- Jonathan Swift
Most likely had some mental illness and left money when he died to start St. Patricks
Hospital

Freud and Treatment of Mental Disorders

 - Began a period with scientific study- 1870s
- Term Psychiatry introduced- 1846
- Major Scientists:
Freud challenged people to view humans objectively; he studied the mind, its disorders, and
their treatment as no one had done before
Kraepelin began classifying mental disorders according to their symptoms
Bleuler coined the term schizophrenia

Psychopharmacology

- 1950s started a shift in the treatment of mental health patients

- Psychotropic medications
- Psychotropic: Chlorpromazine (Thorazine)
- Mood Stabilizer: Lithium (used in Bipolar disorders, in forms of salts)
- Antidepressant: Imipramine
- KNOW: Antipsychotic and antidepressants started in 1950s and changed the world.

Movement towards Community Health

- Funding starts to shift from the institutions to the community facilities

- Community Mental Health Centers Construction Act (1963)
- Deinstitutionalization
ATD (aid to the disabled)
Commitment law changes (early 1970s)
Recidivism
ED load increases
Homelessness as end product of chronic mental illness
Accomplished the release of individuals from long-term stays in state institutions, the
decrease in admissions to hospitals, and the development of community-based services as
an alternative to hospital care
Commitment laws changed in the early 1970s, making it more difficult to commit people for
mental health treatment against their will.

Community-Based Care

- After deinstitutionalization community, mental health centers were not built as planned
- Community support service systems were developed- funding sources varied
- Needs of the community were inaccurately estimated
- Despite flaws, improvement has occurred for the clients but more is needed

Mental Illness- 21st Century

- National Institute of Mental Health (NIMH)

Approximately 57.7 million persons have mental illness
- Impairment
15 million adults
4 million children and adolescents
- Economic burden
 Exceeds the cost of cancer
Health care cost and decreased productivity
- Disability
Mental illness is the leading cause in the 15-44-year-old group
- Revolving door effect: shorter hospital stays, but more frequently.
- Planned/scheduled short hospital stays do not contribute to the revolving door phenomenon,
and may show promise in dealing with this issue.
- Use of alcohol and drugs exacerbates symptoms of mental illness, again making
rehospitalization more likely

Benchmarks

- Decade of the Brain: 1990s

- Increase in brain research
- Increased public interest in biologic explanations for mental disorders
- DSM revised
- Nursing textbooks include psychobiology and psychopharmacology

Objectives for the Future

- Health People 2020 Mental Health Objectives

Decrease rates of suicide and homelessness
Increase employment among those with serious mental illness (SMI)
To provide more services both for juveniles and for adults who are incarcerated and have
mental health problems
Reduce suicide attempts by adolescents
Reduce proportion of adolescents who engage in disordered eating behaviors in attempt to
control their weight
Reduce the proportion of persons who experience major depressive episode (MDE)

Cost Containment and Managed Care

- Cost containment
Many under-diagnosed and untreated
Hospitals stays limited
Stabilized on medication and released
Discharged with unrealistic plans for follow-up care
- Increased need for home care and community based care
- 1990s: Case managers
Decreased fragmented care
Eliminated unneeded overlap of service
Provide care in least restrictive environment
Decrease costs for the insurers

Cultural Considerations

- More clients are being seen from culturally diverse populations

- Must be aware of differences that influence mental health and the treatment
 - Must look at family structure
Single
Blended
Same sex
- Diversity is not limited to culture

Psychiatric Nursing Education

- 1880s: Linda Richards

First psychiatric nurse
Developed nursing care in psychiatric hospitals
Directed a school of psychiatric nursing
1882: first training of nurses to work with persons with mental illness
- 1920s: First psychiatric nursing textbook
Written by Harriet Baily
- 1937: Psychiatric nursing included as part of general nursing education curriculum
- 1952: First psychiatric nursing theorist
Hildegard Peplau
The interpersonal dimension that was crucial to her beliefs forms the foundations of
practice today
Developed the first model for psychiatric nursing

Evolution of Care for Nursing

- Moving from unskilled caretakers to skilled caregiver to educated care provider

- Moving from guard to compassionate attendant
- Schools for mental health nurses separate from other nursing education

Factors influencing Mental Health

- Overview
Factors that influence responses to treatment and illness
Individual factors
Interpersonal factors
Cultural factors
Culture
Socially learned behavior, values, beliefs, customs, and ways of thinking of a population
Guides views of self and the world
Diversity refers to the differences that exist among populations
- Individual Factors
Response to drugs
Biological differences impact responses to psychotropic medication
Ethnicity plays a large role in medication response
Western dosing protocols
Age, stage of growth and development
Age impacts coping ability
Lack of experiences
 Ability to express or understand feelings
Erikson for stages of psychosocial development (development during whole life, while
Freud stopped at age 18) table 7.1 pg. 121
Genetics and Biological factors
Not under voluntary control
Genetic makeup influences response to illness and possibly even treatment
Importance of family history
Physical health and health practices
Healthier people generally cope better
Many under voluntary control
Exercise
Cessation of exercise may indicate declining mental health
Self-Efficacy
Belief that personal abilities and efforts affect events in ones life
High self-efficacy [set personal goals, self-motivated, cope effectively and ask for help
when needed]
Low self-efficacy [low aspirations, experience self-doubt, may struggle with anxiety and
depression]
Helps to build: experience of success or mastery in overcoming obstacle, social
modeling, social persuasion, reducing stress, building physical strength and learning how
to interpret physical sensations in a positive way
Hardiness
Ability to resist illness when under stress
Components: commitment, control, challenge
Resilience and Resourcefulness
Resilience: healthy responses to stressful circumstances or risky situations
Resourcefulness: involves using problem-solving ability and belief that one can cope
with adverse situations
Spirituality: it is important to all nurses
Evidence supports importance of spiritual care
Unique; NANDA: spiritual distress, risk for spiritual distress, spiritual well-being,
readiness for enhanced; DSM-5; JACHO
- Interpersonal Factors
Sense of Belonging
Sense of connectedness or involvement
Maslow (fit, value)
Closely related to social and psychological functioning
Can decrease anxiety, give sense of purpose, feel needed, feel productive socially, and
decrease sense of alienation or isolation
Social networks and social support
Key are the clients perception and the responsiveness of the support system
Social network: reduces stress, diminishes illness, positively impact on coping and ability
to adapt
 Social support: emotional support from friends, family, or healthcare providers
Family support
Key factor for positive outcome with mental health clients
Very important in the recovery phase

20th Century Changes

- 1955 NLM requirement for clinical experience as well as classroom info on psychiatric nursing
- 1961 Publication of The Dynamic Nurse Patient Relationship (Ida Jeane Orlando)
- 1960s Journals established
Perspectives in Psychiatric Care
Journal of Psychiatric (psychosocial) nursing and mental health services
- 1970s First certification and standards of practice
- 1987 Scope of Practice (ANA)
- 2003 ANA Nursing: scope and Standards of Practice
- 2007 ANA revised Psychiatric Mental Health: scope and standards of practice
Chapter 3: Psychosocial Theories and Therapy

Psychosocial Theories

- Eclectic approach
- Many psychosocial theories and models
- Medical model (practice, research, and theory all interrelated)
- Each from belief, assumptions, and worldview

Psychiatric Nursing

- Knowledge and understanding of theories

- Evidence based practice
- Governed by practice standards
- The art and science of nursing; the art of caring therapeutic alliance

Nursing Approach

- Most nurses combine the various theoretical frameworks and pull out the concepts that they
feel are most relevant to the client.

Psychoanalytic Freud (1856-1939)

- Father of Psychoanalysis
- Based on idea that all behavior is caused and can be explained:
Repression of sexual impulses and desires
All behavior has meaning
- Personality components:
Id: part of ones nature that reflects basic or innate desires such as pleasure-seeking
behavior, aggression, and sexual impulses
Superego: the part of a persons nature that reflects moral and ethical concepts, values, and
parental/social expectations; direct opposite of Id. [think superhero]
Ego: the balancing or mediating force between the id and superego; it represents mature
and adaptive behavior that allows a person to function successfully.
- Anxiety occurs with concern over being able to master the impulses of the id with the rules of
the super ego
Anxiety occurs over conflict between id and superego; malfunction of the ego
- Subconscious motivates us:
Those thoughts and feelings that are in preconscious or unconscious level of awareness
Freudian Slips
- Three levels of awareness:
Conscious: in awareness or easily remembered
Preconscious: not in awareness by can be recalled with some level of effort
Unconscious: not remembered; defense mechanism
- Dream analysis
Discussing dreams to discover true meaningit is a primary technique used in
psychoanalysis
- Free Association
 Uncover repressed thoughts or feelings by saying first thing that comes to mind from word
therapist says
- Ego defense mechanisms
Major dynamic behind a persons use of ego defense mechanisms is to alleviate anxiety
when the ego is no longer able to apply rational measures to decrease feelings of discomfort
Denial: pretending, not accepting
Displacement: take out on something less threatening
Dissociation: temporary blocking out
Intellectualization: just the facts
Rationalization: creating reasonable explanations
Reaction formation: cant stand to be around someone, but acting like they are your
best friend ever.
Regression: going backwards
Repression: stuff it all down
Sublimation: substitute something unacceptable with something more tolerable
Undoing: beating yourself up today but moving on tomorrow
- Psychosexual development
Oral (0-18 months): oral gratification, sucking.
Anal (18-36 months): rectal gratification, control of bowels
Phallic/Oedipal (3-5 years): genital fixation and concentration
Latency (5-11 years): some say 13 years too, repression of sexual feelings and memories
Puberty (11-18 years): rise in sexual energy, parental independence
- Transference: displaces feelings and attitudes onto the clinician that they experienced in other
relationships (automatic and unconscious)
- Countertransference: occurs when clinician displaces attitudes or feelings from their past onto
the client
Avoid this by: self-awareness, talk with colleagues, examine own feelings

Developmental:

1. Erikson (1902-1994)
- Best known for Psychosocial development expanded across the life-span focused on social
growth, which was the major difference between him and other theorists
- Stage/ Virtue/ Task
- Identity Crisis:
Growth reflects mastery of critical tasks
Lack of mastery results in developmental deficits
Polarity of functioning produces problems
- Each stage is viewed as an emotional crisis
- Nursing implications
Assess clients level of functioning based on their developmental stage and plan nursing care
accordingly
- Eriksons stages (most of personality develops in the first 3 stages)
Trust vs. Mistrust (0-18 months)
Autonomy vs. Shame and Doubt (18 mon- 3yrs)
 Initiative vs. Guilt (3-6 yrs)
Competence (Industry) vs. Inferiority (7-11 yrs)
Identity vs. Role Confusion (12-18 yrs)
Intimacy vs. Isolation (18-21 to 40yrs)
Generativity vs. Stagnation (40-65yrs)
Ego Integrity vs. Despair (65yrs death)
2. Piaget (1896-1980)
- Explored development of intelligence and cognitive functioning in children
- Strong belief in biologic changes and maturation
- Useful when working with children
- Stages
Sensorimotor Intelligence (0-2yrs; differentiates self)
Preoperational Thought (2-7yrs; here-and-now thinking)
Concrete Operations (7-11yrs; past and present thinking)
Formal Operations (11yrs-adulthood; future thinking//abstract thinking)

Interpersonal

1. Peplau (1909-1999)
- Built her theory on Sullivans Interpersonal relationships
- Saw nurse as participant observer
- Peplau is recognized as the most powerful force in developing current Mental Health Nursing
theory and practice
- Therapeutic nurse: patient relationships
Orientation phase
Identification phase
Exploitation phase
Resolution phase
- Roles of the Nurse:
Stranger
Resource person
Teacher
Leader
Surrogate
Counselor
- Saw anxiety as response to psychic threat
- Described four levels of anxiety
Mild
Moderate
Severe
Panic
2. Sullivan
- Interpersonal relationships and Milieu therapy
- Greatest contribution to mental health is on importance and significance of interpersonal
relationship
 - Focus on the here and now
- Therapy: therapist/clinician is the participant observer
- Goal: develop mature, satisfactory, anxiety-free relationship
- Rejected Freuds idea of instinctual drives
- Believed mans motivation influence was anxiety
- Belief that unsatisfying relationships are the basis for all emotional problems
- Relationships are source of anxiety and maladaptive behaviors as well as personality formation
- Felt the goal of health care should be to restore self-respect and self-esteem
- Established five life stages:
Infancy
Childhood
Juvenile
Preadolescence
Adolescence
- Three developmental cognitive modes of experience
Prototaxic: involves brief, unconnected experiences that have no relationship to one
another; characteristic of infancy and childhood; also, some adults who have schizophrenia
Parataxic: beings to connect experiences in sequence; characteristic of early childhood
Syntaxic: person begins to perceive himself or herself and the world within the context of
the environment and can analyze experiences in a variety of settings; characteristic of
school-aged children, more predominant in preadolescence

Humanistic

1. Maslow
- Hierarchy of needs: physiological; safety and security; loving and belonging; esteem and self-
esteem; self-actualization
- Focused on the total person
- Needs that are not satisfied become source of motivation
2. Rogers
- Client-centered therapy
- First to use term client rather than patient
- Person centered approach
Unconditional positive regard
Genuineness
Empathetic understanding
3. Focus is on positive qualities, capacity to change, and promotion of self-esteem

Behavioral

1. Pavlov (1849-1936)
- Work with the dogs
- Classical conditioning conditioned response
2. Skinner (1904-1990)
- Operant Behavioral Conditioning
 Behavior learned from history or past experiences
Changing behavior was most importantthen accompanying thoughts/feelings
Behavioral modification
Positive (reward) and Negative (consequence) reinforcement
Systematic desensitization (used to help clients overcome irrational fears and anxiety with
phobias)
3. Focused on observable behaviors and what can be done externally to bring about change

Existential

- Existentialist Perspectives
Self-awareness, identity, and relationships
Freedom and responsibility
Search for meaning
Anxiety as a condition of living
Awareness of death and nonbeing
Beck: cognitive therapy (thinking; depression screening)
Ellis: rational emotive therapy
Frankl: Logotherapy
Perls: Gestalt therapy
Glasser: reality therapy

Cognitive-Behavioral Model

- Motivational enhancement therapy

Uses motivational interviewing to increase willingness to change habits related to addictions
- Dialectical Behavior Therapy
Linehan
Changing self-mutilating behaviors
Used especially with patients with Borderline Personality Disorder

Nurse Theorists

- Oren (Self-Care Deficit Theory)

Self-care requisites, self-care agency, self-care demand, self-care nursing agency
- Roy (Roy Adaptation Model)
System, environment, health, and nursing elements
Adaptive modes: physiological, self-concept, role function, interdependence
- Watson (Science of Caring)
Emphasis on providing support through means of human caring
- Neuman (Systems Model)
Stress and reaction to stress
Stressors (Intrapersonal, Interpersonal, and Extrapersonal)
Crisis Intervention

- Time that produces overwhelming emotional response

- Caplan stages of crisis:
Exposed, experiences anxiety, tries to cope
Anxiety increases when customary coping skills fail
Makes all efforts to deal with stressor, tries new coping techniques
Coping fails resulting in disequilibrium and significant distress

Categories of Crisis

- Maturational (developmental)
Predictable events in a normal course of life
- Situational
Unanticipated or sudden events that threaten an individuals integrity
- Adventitious (social)
Natural disasters or violent crimes

Selye: three stages of reaction to stress

- Alarm reaction: +1 to +2 anxieties

Mobilization; activation of fight or flight mechanism
Stress stimulates the body to send messages from the hypothalamus to the glans and organs
to prepare for potential defense needs
- Stage of Resistance; +2 to +3 anxieties
Adaption to stress within individuals capabilities
The digestive system reduces function to shunt blood to areas needed for defense
- Stage of Exhaustion: +3 to +4 anxieties
Loss of ability to resist stress; depletion of resources
Occurs when the person has responded negatively to anxiety and stress; body stores are
depleted, or the emotional components are not resolved, resulting in continual arousal of
the physiologic responses and little reserve capacity.

Cultural Considerations

- Most theorist were Caucasian born in the United States or Europe

- What was considered normal to them may not apply to others
- Caution to avoid reaching faulty conclusions

Treatment Modalities

- Community
- Individual
- Group
- Complementary and Alternative Medicine
- Psychiatric Rehab

The Nurse and Psychosocial Interventions

 - Psychosocial Interventions:
Are activities that enhance clients social and psychological functioning
Improve social skills
Interpersonal relationship
Communications

Chapter 4: Treatment setting and therapeutic programs

- Immanent changes over the past 50 years:

- 1950s not humane nor good care.
** 1950s was the introduction of the psychotropic drugs.
- 1970s- commitment laws changed. Least restrictive environment. Deinstitutionalization.
- Today- larger range of treatment settings, integrating mental health care into the community.
- Continuum of care- crisis intervention, acute inpatient care, partial hospitalization programs,
residential services, respite residential care, in-home mental health care, community outreach
programs, outpatient care.
lost funding, werent able to provide care over an extended period of time.
- Mental health is a balance on the continuum. (ex. Stress increases pathology)
- Case management- Look at individual one size does not fit all. Developed individually.
- Interdisciplinary teams- everyone involved in patient care.
- Case manager is an organizer and a communicator.
- Nursing role in milieu management- consistent force in the milieu, provide guidance to staff,
consider 6 environmental elements: safety, structure norms, limit setting, balance, and
environmental modification.
- 1980s inpatient primary mode of care
Talk therapy; 1-on-1 therapy; milieu therapy (one-on- one effective but not used as
much anymore because of quick hospital turnover).
Individual & groups for longer time
- 1990s stays became shorter
Managed care;
Clients are sicker & stays are shorter
- Today
Rapid assessment, stabilization & discharge planning
Client-centered multidisciplinary approach
Financial impact on readmissions
Locked unit debate
- Priority of hospital based level of care- safety 24-hour secure supervised setting for suicidal,
self-mutalating, threatening others with harm.
- Hospital based goals- assist in initial stabilization, achieve safe (highest) level of function,
appropriate referrals for aftercare.
- Other reasons to hospitalize- protect gravely disabled at risk for accidental harm, protect acutely
psychotic who cannot meet basic need, provide thorough medical and psychiatric medical
evaluation, treat toxic medication reactions, treat withdrawal from substances.
- Inpatient short stays can be effective if they are compliant in their follow up. (START program
for VA work).
- Inpatient long stay clients have severe persistent mental illness and require acute care services,
have case management, discharge planning, hostel (like hotel) approach to care, crisis resolution
and respite care, they usually have a dual diagnosis.
- Partial hospitalization- negative side is insurance driven. day treatment centers have 8 goals:
Focus on stabilizing psychiatric symptoms
Monitoring drug effectiveness
Stabilizing living environment
Improving activities of daily living
Learning to structure time
Developing social skills
Obtaining meaningful work, paid employment or volunteer position
Providing follow-up for health concerns
- Residential care- group homes, supervised apartments, board care homes, and respite/ crisis
holding. This is voluntary care. It is intensive treatment. This is kind of a last resort because the
bad side is youre living with people with the same disabilities as you.
- Respite care- relief care. Mainly seen in pediatrics and geriatrics.
- Transitional care- peer support.
- Other services:
Outpatient Detoxification-
In-home Detoxification-
Relapse prevention after-care programs-
- Psychiatric rehab programs: encourages personal growth and improved quality of life,
reintegration into the community, recovered sense of self.
Recovery is NOT curing, but it is beyond symptom control and medication management.
- Clubhouse model- pioneered in NYC by fountain house. Physician-client relationship very
important. Focuses on health not illness. 4 goals: a place to come, meaningful work, meaningful
relationships, a place to return to(lifetime member).
- ACT, Assertive Community Treatment- one of the most effective approaches. Problem-solving
orientation (no problem is too small), direct provision of service rather than referral, services
intense (no time constraints), multidisciplinary team approach, long-term commitment. Team
goes to patient. Since 1973. Too few. Real effective. Floridas are FACT.
- Technology- helpful for rural populations. Doing psych evaluations over a computer. Patients are
able to keep diary and use app.
- Homeless & mental ill- 50% or more of homeless population end up in jail. 13% of the jail
population have a mental illness. Factors for placement in criminal justice system:
Deinstitutionalization, More rigid criteria for civil commitment, Lack of adequate community
support, Economization of treatment for mental illness, Attitudes of police, society.
- Barriers to successful community reintegration (prisoners)- poverty, homeless, substance use
violence, self-harm, and victimization (rape and trauma).
- Criminalization of mental illness- arrested and prosecuted at a rate 4 times that of the general
population.
- Military and veterans- increased PTSD, depression, suicide, homicide, injury, and physical illness.
OCD and sexual trauma. Multiple mental health concerns. Might not seek treatment because of
stigma.
 - Interdisciplinary or multidisciplinary team: pharmacist, psychiatrist, psychologist, psychiatric
nurse, psychiatric social worker, occupational therapist, recreation therapist, vocational rehab
specialist. Skills: tolerance, patience, humanity, knowledge base, communication skills, personal
qualities (consistency, assertiveness, problem-solving), teamwork skills, risk assessment and risk
management.
- Discharge planning- begins at admission. Have client at highest level of functioning in least
restrictive environment, prevent readmission. Impediments: drugs/alcohol, criminal or violent
behavior, medication noncompliance, self injury thoughts or behavior.
- Managed care- best care for the most people for the least amount of money. Efforts to
coordinate patient care efficiently and cost-effectively. Goals: to increase access to care and
provide the most appropriate level of services in the least restrictive environment. Managed
behavioral health care standardizes admissions criteria, reduces length of patient stay, and
directs patients to the proper level of care.
- Assertive Community Treatment (ACT)- programs provide money of the services to stop the
revolving door of repeated hospital admissions punctuated by unsuccessful attempts at
community living.
- Case management- management of care on a case by case basis. Usually managed by nurse or a
social worker who follows client form admission to discharge.
- Partial hospitalization programs (PHPs)- to help clients make a gradual transition from being
inpatients to living independently and to prevent repeat admissions.
- Day treatment- clients go home at night.(evening programs- clients go home during day.)
- Residential treatment settings- a community where people with mental illness can live. Can be
transitional housing or long term.
- Evolving consumer household- group living in which residents make the transition from
traditional group home to a s residence where they fulfill their own responsibilities without an
onsite paid supervisor.
- Recovery- beyond symptom control and medication management to include personal growth,
reintegration into the community, empowerment, increased independence, and improved
quality of life as the beginning of the recovery process.
- Clubhouse model- community based rehabilitation. An intentional community based on the
belief that men and women with serious and persistent psychiatric disabilities can and will
achieve normal life goals when given the opportunity, time, support, and fellowship. 4
guaranteed rights: a place to come, meaningful work, meaningful relationships, and a place to
return to(lifetime member).
- Criminalization of mental illness- the practice of arresting and prosecuting mentally ill offenders,
even for misdemeanors, at a rate 4x that of the general population in an effort to contain them
in some type of institution where they might receive needed treatment.
- Stigma- veterans may be reluctant to seek treatment because of mental illness stigma or
perceived stigma.
- Interdisciplinary (multidisciplinary) team- approach is most useful in dealing with the
multifaceted problems of clients with mental illness.
-
Chapter 5: Therapeutic Relationships

Overview:

1. It is the most important skill

 2. Communication is essential to treatment and success
3. Nurses have the responsibility to develop this communication

Components of Therapeutic Relationship

- Trust
Congruent
Trusting Behaviors (caring, openness, objectivity, respect, interest, understanding,
consistency, treating the client as a human being, suggesting without telling,
approachability, listening, keeping promises, honesty)
- Genuine Interest
Patient know dishonest or artificial behaviors
Self-disclosure (when appropriate, but do not go too deep, this is more for the client)
- Empathy
Essential skills to provide high-quality care
gift of self
Client feels safe enough to share
Nurse listens closely enough to understand
Remember the to be empathetic not sympathetic
- Acceptance
Demonstrated by nurse behavior
- Positive Regard
Unconditional, nonjudgmental attitude
Nonverbal techniques
- Self Awareness
Values: abstract standards that provide a person with his/her code of conduct
Beliefs: ideas that one holds to be true
Attitudes: emotional frame of reference by which one sees the world is created by
It is imperative that the nurse be aware of self
- Therapeutic Use of Self
Peplau
- Johari Window
Took to learn about self
Four areas to evaluate (open-public, blind-unaware, hidden-private, unknown)
- Patterns of Knowing
Empirical: derived from the science of nursing
Personal: derived from life experience
Ethical: derived from moral knowledge of nursing
Aesthetic: derived from the art of nursing
Unknowing: for the nurse to admit she/he doesnt know the client or the clients subjective
world opens the way for a truly authentic encounter.

Therapeutic Relationship

- Mutual learning experience

- Corrective Emotional Experience for the Patient
 - Therapeutic Alliance: key factor in the clients successful participation in therapy

Characteristics of a Therapeutic Relationship

- Professional (therapeutic) not social

- Can be friendly but not a friendship
- Differing levels of responsibility
- No reciprocal meeting of needs, this is all about the clients needs
- Planned
- Client Centered
- Focused and goal directed
- Time Limited rather than open ended
- Nurse purposefully guides conversation

Hildegard Peplau

- Believed it facilitated forward movement

- Designed to facilitate boundary management, independent, problem-solving and decision
making that promotes autonomy
- Described the nursepatient relationship as one that evolves through interlocking and
overlapping phases

Establishing the Therapeutic Relationship

- Phases
Orientation or Introduction
First meeting
Confidentiality
Testing the relationship
Working
Identification of problems
Problem solving
Termination or Resolution
Problems resolve
Relationship ends
- Orientation
Beings with the meeting (is time limited)
Becoming acquainted
Identifies strengths, limitations, and problems are identified.
Build trust and rapport
Nurse to examine preconceptions or prejudices
Plan of care
Self-disclosure
Contract (outline roles and responsibilities of both parties)
Confidentiality
Respecting privacy of information and care
Third party access to information (abuse, duty to warn)
 Adult clients
Clients with appointed guardian
Pediatric clients
- Working Phase
Responsible for own behaviors
Prioritize needs
Reality Testing
Writing and Journaling
Support confrontation
Promote change in safe environment
Teach and practice new skills
Transference
Countertransference
- Termination Phase (Resolution)
Response
Feelings or behaviors
Actions
Coping, review successes and accomplishments
Share feelings and review plan for continued care
Miscellaneous issues
Gifts
Closures

Goals of a Therapeutic Relationship

- Relief from distress

Negative response to stimuli that are perceived as threatening
Increase self-respect and self esteem
Improve quality of relationships
Improve functioning
Develop more effective behavior
Understand own illness
Increase compliance
Effective communication and social skills

Roles of the nurse

- Teacher
- Caregiver
- Advocate
- Parent Surrogate
- Implementation of nursing process
- Milieu
- Medications
- Therapy
- Team collaboration and input
Avoiding Behaviors that Diminish the Therapeutic Relationship

- Inappropriate Boundaries
All are at risk
Self-awareness is key
- Feelings of Sympathy
Empathy is appropriate
- Encouraging Client Dependence
Nurse needs to promote independence
- Nonacceptance and Avoidance
Know history prior to engagement
Explore with colleague or request change of assignment if unable to resolve

Brief Interventions

- Violent behavior
Precautions
Call for assistance if losing control
- Hallucinations
- Delusions
- Conflicting Values
- Severe anxiety and incoherent, speech patterns
- Manipulation
- Crying
- Provide opportunity to discuss episode
- Sexual innuendo, inappropriate touch
- Denial and lack of cooperation
- Depressed affect, apathy, psychomotor retardation
- Suspiciousness
- Hyperactivity

Who makes up the interdisciplinary team

- Psychiatric nurse- RN
- ARNP
- Psychiatrist- MD
- Psychologist/clinical psychologist
- Psychiatric social worker
- Activity therapist. Reactional therapist
- Occupational therapist
- Certified addictions counselor
- Psychiatric technician, aide, or assistant
- Student nurse
Chapter 6: therapeutic communication

- Verbal- context and content

Context= about the environment. Situations or circumstances that clarify the meaning of
the content. Can include time and the physical, social, emotional, and cultural
environments.
Content= the literal words the patient is saying.
- Nonverbal- process, congruent, and incongruent.
Process- denotes all nonverbal messages that the speaker uses to give meaning and
context to the message.
Congruent- when content and process agree. When nonverbal match your words.
Incongruent- when content and process disagree. When nonverbal dont match your
words.
- Themes- content (affect), mood, interaction, paradigm shift
affect= how you are seen
mood= how you feel.
Paradigm shift- seeing things differently from different points of view.
- Therapeutic communication- establish a therapeutic relationship, identify the clients most
important concerns, assess the clients perceptions, facilitate clients expression of emotions,
teach client and family necessary self-care skills, recognize clients needs, and guide the client
toward satisfactory and acceptable solutions.
- Essential components- confidentiality, self-disclosure (therapeutic use of self, requires self
awareness), and silence. Privacy and respecting boundaries. Active listening and active
observing.
Intimate space- patients with young children, people who mutually desire physical
contact, people whispering.
Personal zone- comfortable distance between family and friends.
Social zone- communication in social work and business setting.
Public zone- speaker and audience, small group, and other informal functions.
- Types of communication-
Intrapersonal- self communication
Interpersonal- social, collegial, and therapeutic..
- Influences on communication- environment, relationship, context, attitude, knowledge,
perception, illness & emotional factors, physical considerations(pain, sensory limitations, speech
impediments.), kinesics considerations(body language)
- Obstacles- resistance, transference, countertransference, boundary violations.
- Verbal communication skills- concrete and abstract.
Concrete- specific and clear*
Abstract- unclear, vague, requires interpretation.
Questions- direct, open, dont ask why.
- Nonverbal- 2/3 of conversation is in nonverbal.
- Never do something for a patient they can do for themselves.
- Examining nonverbal communication helps understand the clients true meaning in the
conversation.
 - Be sure the client understands your question.
- Understand the context- Use extreme caution in interpreting: I am going to kill you I fell out
Ill kill myself Focus on who, what, when, where, and why the client believes it happened
- Spirituality- work with clients religion as best you can.
- Cultural considerations- Speech patterns and habits, styles of speech and expression, Eye
contact, Touch, Concept of time, Health and health care
- Goals of therapeutic communication- Establishing rapport, Being empathetic, genuine, caring,
Identifying issues of concern, Understanding the clients perception, Exploring the clients
thoughts & feelings, Assessing the context of the concern, Upholding ethical principles,
Maintaining a positive attitude about the clients capacity for growth & change, Developing
problem-solving skills, Promoting the clients evaluation of solutions
- Assertive communication- Ability to express positive and negative feelings in an open, honest,
and direct way, Use professionally and personally, Useful for those that can never say no,
Focus on the I statements
Responses: Aggressive, Passive-aggressive, Passive, & Assertive
- Challenges: confidentiality, legal status/rights, informed consent, brief stays, physical
impairments, language/ cultural differences, difficult clients.

Chapter 7: Clients response to illness

- Factors that influence response to treatment and illness- individual factors, interpersonal
factors, and culture factors.
Individual factors- age, state of growth & development. Age impacts coping abilities,
there is a lack of experiences, ability to express or understand feelings. Where Eriksons
stages for psychosocial development are shown.
o Genetic and biological factors (not under voluntary control. Genetic makeup
influences response to illness and possibly even treatment. Genetics=the
importance of family history.
o Physical health & health practices- healthier people generally cope better,
voluntary control, exercise, cessation of exercise may indicate declining mental
health.
o Response to drugs- biological differences impact responses to psychotropic
medication, ethnicity plays a large role in medication response, western dosing
protocols may not be effective in someone from a different country.
o Self-efficacy- belief that personal abilities and efforts affect the events in our
lives. those who have a high self-efficacy set personal goals, self-motivated, and
cope effectively and ask for support when needed. Those with low self-efficacy
have low aspirations, self-doubt, and may struggle with anxiety and depression.
Help build self-efficacy.
o Hardiness- the ability to resist illness when under stress. 3 components:
commitment, control, and challenge.
o Resilience- having a healthy response to stressful circumstances or risky
situations. High resilience = flourishing.
o Resourcefulness- involves using problem solving abilities and believing that one
can cope with adverse or novel situations.
o Spirituality- persons being or their belief about the meaning and purpose of life.
 Interpersonal factors-
o Sense of belonging- the feeling of connectedness with or involvement in a social
system or environment of which a person feels an integral part. Closely related
to social and psychological functioning. (Maslow)
o Social networks- groups of people whom one knows and with whom one feels
connected.
o Social support- emotional sustenance that comes from friends, family, and
health care providers who help a person when a problem arises.
o Family support is a key factor for positive outcome with mental health patients.
Most important in the recovery phase.
Cultural factors- internal and external manifestation of a persons, groups, or
communitys learned and shared values, beliefs, and norms that are used to help
individuals function in life and understand and interpret life occurrences.
o Cultural competence- process whereby the nurse proficiently develops cultural
awareness, knowledge, and skills to promote effective and quality health care
for patients.
o Cultural patterns/differences- learn as much as possible, variations can occur
within a culture group, not everyone fits general mold.
o Barriers- clients definition of health, miscommunication, lack of knowledge
about culture, failure to assess patients cultural perspective, differences
between nurse and patient worldviews.
o Beliefs about the causes of illness- culture has the most influence on health
beliefs and practice. Nurse/patient health care actions and beliefs are
formulated by: definition of health and perception of how illness occurs
(natural, unnatural, and scientific.)
o Factors- customs and meanings of educations, belief of illness cause, physical
distance or space, social organization, time orientation, environmental control,
biologic variations.
o Socioeconomic status & social class- refers to ones income,education, and
occupation. Strong influence on health, poverty-higher risk, social class has less
influence in US. Social class does influence relationships.
Ethno pharmacology- study of drug response that may be unique to an individual owing
to social, cultural, and biologic phenomena.
o Madeleine Leininger- concept of transcultural nursing.
o Traditional health practices- herbs, teas, spices, special foods, homeopathic
remedies.
o Healers- widely used worldwide.
o Complementary health practices- combines traditional health beliefs with
mainstream health practices.
o Cultural assessment issues- elements (communication, orientation, nutrition,
family relationships, health beliefs, education, spirituality and religion, and
biologic or physiologic elements. Culturally competent techniques to use during
assessment (cultural preservation, cultural negotiation, cultural repatterning).
 o Culture bond mental health issues- culture-bound syndroms (broken heart,
susto, mal ojo.) psychotic symptoms (amok, ghost sickness, spells) person with
culture bound syndrome usually respects traditional healer interventions.
o Alternative medicine- understand and make sure patients reliance on them to
be culturally competent.
o Common alternative therapies acupuncture, acupressure, nurtional therapies
(various hot or cold foods to restore equilibrium), coining moxibustion, cupping.
- Culture- socially learned behaviors, values, beliefs, customs, and ways of thinking of a
population that guides its members views of themselves and the world.
- Diversity- the differences that exist among populations.
- Culturally competent- nursing care thats sensitive to issues related to culture, race, gender,
sexual orientation, social class, economic situation, and other factors.
- Social organization- family structure and organization, religious values and beliefs, ethnicity,
and culture.
- Time orientation- differs between cultures. Some make time urgent, some dont.
- Environmental control- clients ability to control the surroundings or direct factors in the
environment.
- Ethnicity/ culture- differences in response to some psychotropic drugs.
- Biological variations based on physical makeup are said to arise from race.
- Socioeconomic status- ones income, education, and occupation.

Chapter 9: legal and ethical issues

- Historically mentally ill patients had very few rights. They were institutionalized, warehoused,
and received inhumane treatment.
- Warehousing= dragging your feet before you do something.
- 1970s the commitment laws changed. This was a change toward improvement, and recognition
of patient rights.
- Admitted unwillingly when they pose a risk to themselves, have been judged of committing a
crime while legally insane, unable or unwilling to consent to treatment, incapable of
understanding medication risk, require restraint for safety or others, threats that obligate their
care takers to warn potential victims (duty to warn), and undergo forensic evaluation where the
nurse has to testify in court.
- Client has all rights, except the right to leave if baker acted.
- Document everything, (Restrictions, if the client said theyre suicidal.. etc)
- Habeas corpus- You are holding me too long. Appealing to the court to be discharged.
- Patients have the right to personal stuff, but items may be restricted. (ex. Belts, shoelace,
necklace, etc.)
- Involuntary hospitalization under a baker act is 72 hours from the time of medical clearance
with other medical issue. They only lose their right to freedom.
- Unable to give informed consent
Ex parte order- court executed. Judge ordered.
Marcheman act- alcohol. Court ordered. Family initiated.
Law enforcement- police baker act
 Professional- psychiatrist, psychiatric nurse, psychologist; sign baker act. When baker
act is signed find a safe way to transport them to hospital to make sure they get where
they need to be.
- A psychiatrist rescinds a baker act. They can do so at any point. They can get a second opinion if
they think the client should be held more than 72 hours.
- Release from hospital- if voluntary can leave at any time and sign AMA if needed. (escort off
grounds).
- There is a requirement to continue care after inpatient (ex. medications, appointments, follow-
ups.) this may be called a conditional release. Most common in severe chronic patients that
have frequent contact with social, legal, and welfare agencies.
- Legal guardianship- hearing appointed person to speak for the patient for patient who is
deemed incompetent.
- Incompetent clients cannot enter legal contracts, sign checks, use credit card, make a will, open
bank account, sell property, or get married.
- Incompetence is decided legally and can be short term.
- Keep patient in the least restrictive environment. Cant restrict or put in seclusion unless for their
safety. Meet patients needs in least restrictive way.
- Use restriction and seclusion for the least amount of time. Make sure client knows it is for their
safety not punishment.
- Physical restraints- must be put on back. One-on-one with sitter.
- Chemical restraint- drugs to sedate. (ex. Hadol versaid)
- Least restrictive alternative- requires client to be treated with least amount of constraint of
liberty consistent with their safety.
- Confidentiality- 1996 HIPAA, 2003 HIPAA privacy rule.
- Duty to warn- one time you can break confidentiality, if patient confides to you they plan to
harm self or someone else. Because of Tarasoff case. Ask these questions:
Is client dangerous to others?
Is danger due to serious mental illness?
Are there means to carry out the threat?
Is danger imminent?
Is danger targeted at identifiable victim?
Is the victim accessible?
- Insanity- plea of insanity not used effectively often.
- Nursing liability- competent, legal, and ethical care for patient and family.
- Torts- wrongful acts that result in injury, loss or damage, and may or may not be intentional.
Negligence- unintentional, involves harm caused by failure to do what is reasonable and
prudent. (ex. Not washing hands before wound care; abandonment)
Malpractice- duty, breach of duty, injury or damage, breach of duty was the cause.
- Assault= threat; battery= touch of the threat.
- Nursing liability- do your best and what youre supposed to do.
- Document everything concretely.
- Professional negligence- sexual involvement with clients, breaching confidentiality, failure to
honor individual rights, failure to prevent dangerous client behavior.
 - Ethics- a branch of philosophy that deals with values of human conduct (rightness and
wrongness of actions) and the goodness or badness of the motives of such actions.
- Utilitarianism- greatest good for the greatest number of people.
- Deontology- looks at human duties to others and analyzes the principals on which the duties are
based. Is action morally right or wrong with no regard for consequences.
- Autonomy- right to self- determination and independence.
- Beneficence- view that all treatments must be for the clients good, duty to benefit others, or
promote good.
- Nonmalefience- above all, care providers must do no harm
- Justice- principle ensuring fairness.
- Veracity- honesty, truthful
- Fidelity- individuals obligation to be faithful to commitments and contracts.
- Ethical dilemma- a situation in which ethical principles or there is no one clear course of action.
- Models for ethical care gathering info, clarifying values, identify opinions, identify legal
considerations and practical restraints, building consensus for decisions reached, reviewing and
analyzing the decisions to determine what was learned.

Chapter 2: Neurobiological Theories and Psychopharmacology

Overview

- Progress is being made in knowledge about Mental Health

- Basic understanding is needed by nurses
- Psychopharmacology: use of medications to treat mental illness

Nervous System

- CNS
Brain
Spinal Cord
Associated nerves that control voluntary acts
- Brain
Cerebrum
Cerebellum
Brain Stem
Limbic System
- Cerebrum
Two Hemispheres:
Right: controls left side of body; center for creative thinking, intuition, and artistic
abilities
Left: Controls the right side of the body; Center for logical reasoning, analytical functions
such as reading, writing and math
Four lobes: frontal (smell), parietal (touch and taste), temporal (hearing), occipital (vision)
 Some lobes have specific functions while others are integrated
Frontal
Thought, body movement, memories, emotions, and moral behaviors
Integration of all: regulates arousal, focuses attention, enables problems solving and
decision making
Abnormalities: schizophrenia, ADHD, dementia
Parietal
Sensations such as taste and touch
Assist in spatial orientation
Temporal
Sense of smell and hearing
Memory
Emotional expression
Occipital
Assists in coordination of language generation and visual interpretation such as depth
perception
- Cerebellum
Located below cerebrum
Center for coordination of movement and postural adjustments
Inhibited transmission of dopamine in the area is associated with lack of smooth
coordinated movements in disease such as Parkinsons and Dementia
- Brain Stem
Includes midbrain, pons, and medulla oblongata
Connection between brain and spinal cord
Coordination of many important reflexes
Control of the heart and lung
- Limbic system
Located above brain stem
Disturbances implicated in a variety of mental illness such as memory loss that accompanies
dementia and poorly controlled emotions and impulses

Neurotransmitters

- Excitatory: excite or stimulate an action in the cell

- Inhibitory: inhibit or stop an action
- Fit into specific receptor cells into the membrane of the dendrite: think of lock and key!
- After message is relayed to receptor cells
Message relayed by release into synapse
Options:
Transport back from synapse to the axon to be stored for later use (reuptake) or
Metabolized and inactivated by enzymes, primarily monoamine oxidase (MAO)
- Why do we care?
Major neurotransmitters:
Found to play role in psychiatric illness
It has a role in the action and side effects of psychotropic drugs
- Chemical substances that aid in the transmission of information throughout the body
- Manufactured in the neuron
- Dopamine
Located primarily in brain stem
Control of complex movements, motivation, cognition and regulation of emotional
responses
Generally excitatory and synthesized by tyrosine (dietary amino acid)
Implicated in schizophrenia and other psychoses
Thought is that too much dopamine contributes to the schizophrenia
Antipsychotic meds block dopamine receptors and reduce the dopamine activity
- Norepinephrine
Most prevalent, located in brain stem
Role in attention, learning and memory, sleep and wakefulness, mood regulation
Excess noted in anxiety
Deficits may contribute to memory loss, depression and social isolation
Antidepressants may block reuptake of norepinephrine while other inhibit MAO from
metabolizing it
- Epinephrine
Limited distribution in brain but controls fight or flight of the peripheral nervous system
- Serotonin
Found only in the brain
Derived from tryptophan (dietary amino acid)
Mostly inhibitory involved in food intake, sleep, temperature regulation, pain control, sexual
behavior and regulation of emotions
Significant role in anxiety, mood disorders and schizophrenia
Some antidepressants block serotonin reuptake, thus leaving it available longer in the
synapse = improved mood
- Histamine
Role in mental illness is under investigation
Involved in peripheral allergic responses, control of gastric secretions, cardiac stimulation
and alertness
Some psychotropic medications drugs block histamine resulting in weight gain, sedation and
hypotension
- Acetylcholine
Found in brain, spinal cord, and peripheral nervous system
Can be excitatory or inhibitory
Found to affect the sleep-wake cycle and signals muscles to be active
Alzheimers patients have been found to have decreased acetylcholine-secreting neurons
- Glutamate
An excitatory amino acid with neurotoxic effects at elevated levels
Implicated in the brain damage caused by stroke, hypoglycemia, sustained hypoxia and
some degenerative disease such as Huntingtons or Alzheimers
- Gamma-Aminobutyric Acid
GABA an amino acid
 Major inhibitory neurotransmitter in the brain
May modulate other neurotransmitters rather than provide direct stimulus
Drugs that increase GABA are used to treat anxiety and induce sleep (benzodiazepines)

Brain Imaging

- Computed Tomography (CT)

Cross-sectional images layer-by-layer
CT looks at the soft tissues
DX tumors, effusions, metastases, brain ventricle size
- Magnetic Resonance Imaging (MRI)
Better tissue detail, blood flow, measures thickness and size of brain structures
Metal devices and pacemaker patients unable to have MRI
Claustrophobia issues of concern
- Positron Emission Tomography (PET)
Uses two photons simultaneously
- Single Photon Emission Tomography (SPET)
Uses single photon
- Both used primarily in research and not in mental health, do allow examination of brain
function, radioactive material injected and the flow monitored
- Limitations of the Imaging Techniques
Frequency of use especially with substance injections
Expensive equipment so availability may be limited
Patient fear or claustrophobia
Research is finding much non-detectable by these images as changes are at the molecular
level

Neurobiologic Causes of Mental Illness

- Genetics
Possible but no smoking gun so to say
Twin studies (comparing identical vs fraternal twins), adoption studies (biological vs
adoptive), family studies (first-degree relative vs distant relations or general population)
Nature vs. Nurture (investigation continues about the influence of inherited traits versus the
influence of the environment)
- Stress and the Immune System
Compromise immune system may participate
Links to specific stressors are not available
- Infection
Viral theories and schizophrenia not conclusive
Prenatal development possible

Nursing Role in Research and Education

- Keep patients and families up to date with valid evidence based information
- Supportive approaches
- Serve as a resource
 - Ensure patient understanding
- Answer questions

Psychopharmacology

- Med management crucial and often determines the outcome for mental health patients
- Efficacy: max therapeutic effect that a drug can achieve
- Potency: amount needed to achieve maximum effect (low potency drugs require higher doses to
achieve efficacy)
- Half-life: amount of time needed for half the drug to be removed from the blood stream
- FDA: responsible for testing and marketing of medications; approves drugs for certain diseases
with certain populations
- Off-label: drug proves effective for a disease that is different than what the FDA approves
- Black Box Warning: package inserts must have highlighted area which contains warning about
serious or life-threatening side effects

Guiding Principles

- Med selection needs to target symptoms

- Meds may take time to work
- Start at low doses and move up to therapeutic levels
- Generally older adults require lower doses
- Decrease and taper off these meds
- Follow up care is essential during and after medication therapy
- Compliance is not always a choice

Antipsychotic Drugs

- Formally known as neuroleptics

- Block the dopamine receptors
- First (mainly used to treat positive psychotic symptoms), Second (treat both positive and
negative symptoms), and Third (treat both positive and negative symptoms while improving
cognitive function) generation drugs
- Some in depot injection (time-release IM medication for maintenance) form which increases
compliance or helps early on to stabilize and then move to oral
- EPS: dystonia (acute muscular rigidity and cramping, a stiff or thick tongue with difficulty
swallowing, and, in severe cases, laryngospasm and respiratory difficulties),
pseudoparkinsonism (drug-induced parkinsonism; stiff stooped posture, masklike facies,
decreased arm swing, a shuffling festinating gait, cogwheel rigidity, drooling, tremor,
bradycardia, and coarse pill-rolling movements of the thumb and fingers while at rest), akathisia
(intense need to love about, restless or anxious and agitated), NMS (rigidity, high fever,
autonomic instability such as unstable BP, diaphoresis, and pallor, delirium, and elevated levels
of enzymes i.e. creatine phosphate), TD (permanent involuntary movements), Anticholinergic
side effects (orthostatic hypotension, dry mouth, constipation, urinary hesitance or retention,
blurred near vision, dry eyes, photophobia, nasal congestion, and decreased memory)
Antidepressants

- Anxiety and depression

- Off label use
- Suicide risk
- May take 4-6 weeks to feel better
- Four groups
Tricyclic
SSRI: Selective Serotonin reuptake inhibitors
MAO: MAO inhibitors
Others

Mood Stabilizers

- Treatment of bipolar
- Lithium is the gold standard but mechanism is poorly understood
- Some anticonvulsant drugs have been effective
- Valproic acid topiramate know to increase levels of GABA
- Kindling process: the snowball-effect seen when minor seizure activity seems to build up into
more frequent and severe seizures

Anxiolytics (Antianxiety)

- Among most widely prescribed drugs today

- Benzodiazepines most effective in relieving anxiety
- Most common side effects are associated with the CNS depression
- Benzo withdrawal can be fatal

Stimulants (amphetamines)

- First used in 1930s to treat psychiatric disorders

- Primary use today is in children/adolescents for treatment of ADHD
- Used in narcolepsy
- High potential for abuse

Disulfiram (Antabuse)

- Used as a deterrent to drinking alcohol in motivated persons

- Variety of symptoms begin 5-10 minutes after the ingestion of alcohol
- Symptoms can last up to a couple hours
- Metabolized in the livermost effective if liver enzymes close to normal to start
- Inhibits acetylcholine (ALDH) metabolism and causing levels to increase 5-10 times higher than
normal
- Important to teach label reading for alcohol based items
- Acamprosate (Campral) helps to reduce physical and emotional discomfort
Increases effect of GABA and decreases glutamate
Must not be used by those who have renal impairment
Culture Considerations

- People from different ethnic backgrounds respond differently to certain medications

- Herbal medications are being used with more frequency in the US
- Learn interactions or look up to ensure safety use and teach patient

Self-Awareness Issues

- What is your opinion on medication

- Remember this is not a choice
- Family education is also important
- Mental illness is a disease
- Stay up on the current theories, research, and treatments

Points to consider

- Mental illness often life a see-saw

- Research is still in the infancy stages
- Noncompliance is not always intentional
Chapter 8: Assessment

- Nursing process- Assessment-> Nursing diagnosis-> planning-> implementation-> evaluation->

assessment.
- Assessment is the first step in the nursing process. Collection, organization, and analysis of
information. Known as a psychosocial (helps formulate plan of care). Creates a picture of
emotional state, mental capacity, and behavioral functioning. Give you a clinical baseline to
evaluate the effectiveness of treatment and interventions and measures the clients progress.
We want to get the client back to the baseline.
- Assessment:
Information- intuition and critical thinking.
Tools- interviewing, nursing history, mental status exam, primary tool is the nurse
interviewer.
- Factors influencing assessment: client participation & feedback, Clients health status, clients
previous experiences/ misconceptions about health care, clients ability to understand, nurses
attitude and approach, clients spiritual and cultural beliefs. When the patient tells you
something listen to them and take them seriously.
- Conducting the interview: environment (comfortable, private, and safe), input from family and
friends, and phrase questions carefully (seeking information, occasionally closed ended will be
used.)
- Content of assessment:
Always Send Mail Through the Post Office A= appearance S=speech M=
memory/mood T=thoughts P= Perceptions O= Orientation
- History- Client and family, chronological age, developmental stage, cultural and spiritual beliefs,
be careful not to stereotype, clients belief on health and illness, view on medications.
- Mood & affect-
pervasive and enduring emotional state.
Affect- outward expression
Congruence- do they match?
Common terms: blunted, broad, flat, inappropriate, restricted, labile(all over the board),
euphoric.
- Thought process & content
Thought process- how the client thinks
Thought content- what the client actually says.
Common terms- circumstantial thinking( big circle), delusion (false and fixed illusion),
flight of ideas (idea hopping, just talking), ideas of reference (turn on tv, person is giving
you special message), loose associations( loose reigns), tangential thinking
(everywhere), thought blocking (trying to regather thoughts, convo stops).
Terms- thought broadcasting (I can send my ideas to you.) , thought insertion (you are
putting things in my brain), thought withdrawal (you can steal my thoughts) , word
salad( makes no sense), grandiosity(Im the best youre all jealous), clang
association(everything rhymes, no meaning).
- Sensorium= orientation. Person, place, time, and situation.
- Intellectual process
 Memory- recent and remote
Ability to concentrate- ask to preform tasks.
Intellectual function- consider level of formal education
Ability to think abstractly- make interpretations or associations about situation or
comment, use of proverbs, literal translations are concrete thoughts.
- Hallucination false sensory perceptions or perceptual experiences
Auditory- voices. hearing
Visual seeing things that arent there.
Tactile feeling things that arent touching.
Gustatory- tasting things.
Olfactory- smelling things. I smell blood.
- Illusion- perception; stimuli that is perceived in a way that is different from reality. ex. seeing a
rope as a snake.
- Judgement- ability to interpret environment and situation correctly and adapt behavior and
decisions accordingly.
- Insight- knowing something, but not necessarily having good judgement.
- Self-concept- way one views self in terms of personal worth and dignity.
- Physiological and self-care considerations- emotional problems can impact physiological
functioning.
Appetite
Sleep
Relationship problems
Chronic illness and medication management
Over-the-counter and illegal drugs
Overall compliance
- Assessment of suicide or injury to others- Ideation? Plan? method? access? Where? When?
Time?
- Data analysis- look at overall picture to help develop nursing diagnosis. (NANDA, actual problem,
Risk problem, wellness diagnosis.) follows the assessment, psychological tests, psychiatric
diagnoses, nursing diagnoses formulated for the plan of care, mental status exam, utilized to
assist interdisciplinary team with discharge plan and other plans of care for the client.
- Psychological tests-
Issues with cultural bias?
Intelligence tests- evaluates intellectual function and cognitive abilities.
Personality tests- assess areas such as self-concept, impulse control, reality testing, and
major defenses. Objective- true/ false or multiple choice. Projective- interview method/
pictures.
- DSM-5 is the universal way to keep consistent in diagnoses.
- Mental status exam- conducted by varied clinicians, generally focused on cognitive abilities, can
use MMSE, can be used to screen for dementia as well.
- Self- awareness- what do I think? Do self-checks to see where you are at.be open, clear and
direct. Be nonjudgmental.
- Proverb/ metaphors
Haste makes waste
A stitch in time saves nine
Ignorance is bliss
Mustn't cry over spilled milk
You can catch more flies with honey than you can with vinegar
You can lead a horse to water, but you can't make him drink
Those who live in glass houses shouldn't throw stones
A bird in the hand is worth two in the bush
A little learning is a dangerous thing
A rolling stone gathers no moss
Good things come to those who wait
A poor workman blames his tools
A dog is a man's best friend