Chapter One
Chapter One
Foundations of Psychiatric Mental Health Nursing
Mental Health
The WHO defines health as a state of complete physical, mental,
and social wellness, not merely the absence of disease or
infirmity.
Mental health is influenced by individual factors, including
biologic makeup, autonomy, and independence, self-esteem, capacity
for growth, vitality, ability to find meaning in life, resilience
or hardiness, sense of belonging, reality orientation, and coping
or stress management abilities; by interpersonal factors, including
effective communication, helping others, intimacy, and maintaining
a balance of separateness and connectedness; and by social/cultural
factors, including sense of community, access to resources,
intolerance of violence, support of diversity among people, mastery
of the environment, and a positive yet realistic view of the world
(damn, that was a mouthful!). Mental Illness
The APA (2000) defines a mental disorder as a clinically
significant behavioral or psychological syndrome or pattern that
occurs in an individual and that is associated with present
distress or disability or with a significantly increased risk of
suffering death, pain, disability, or an important loss of freedom.
Deviant behavior does not necessarily indicate a mental
disorder.
Diagnostic and statistical manual of mental disorders
The DSM-IV-TR is a taxonomy published by the APA. The DSM-IV-TR
describes all mental disorders, outlining specific criteria for
each based on clinical experience and research. The DSM-IV-TR has 3
purposes:
To provide standardized nomenclature and language for all mental
health professionals.
To present defining characteristics or symptoms that
differentiates specific diagnoses.
To assist in identifying the underlying causes of disorders. A
multiaxial classification system that involves assessment on
several axes, or domains of information, allows the practitioner to
identify all the factors that relate to a persons condition.
Axis I is for identifying all major psychiatric disorders except
MR and personality disorders. Examples include depression and
schizophrenia.
Axis II is for reporting mental retardation and personality
disorders as well as prominent maladaptive personality features and
defense mechanisms.
Axis III is for reporting current medical conditions that are
potentially relevant to understanding or maintaining the persons
mental disorder as well as medical conditions that might contribute
to understanding the person.
Axis IV is for reporting psychosocial and environmental problems
that may affect the diagnosis, treatment, and prognosis of mental
disorders. Included are problems with the primary support group,
the social environment, education, occupation, housing, economics,
access to health care, and the legal system.
Axis V presents a Global Assessment of Functioning which rates
the persons overall psychological functioning on a scale of 0 to
100. This represents the clinicians assessment of the persons
current level of functioning. All clients admitted to a hospital or
psychiatric treatment will have a multiaxis diagnosis from the
DSM-IV-TR. Period of Enlightenment and Creation of Mental
Institutions
In the 1790s Phillippe Pinel in France and Willian Tukes of
England formulated the concept of asylum as a safe refugee or haven
offering protection at institutions where people had been beaten,
whipped, and starved for their mental illness.
In the US, Dorothea Dix (1802-1887) began a crusade to reform
the treatment of mental illness after a visit to the Tukes
institution in England. She was instrumental in opening 32 state
hospitals that offered asylum to the suffering. 100 years after
establishment of the first asylum, state hospitals were in trouble.
Attendants were accused of abusing the residents, the rural
locations of the hospitals were viewed as isolating patients from
their families and homes, and the phrase insane asylum took on a
negative connotation.
Development of Psychopharmacology
In the 1950s the development of psychotropic drugs were used to
treat mental illness. Chlorpromazine (Thorzine), an antipsychotic
drug, and lithium, an anti-manic agent, were the first drugs to be
developed. 10 years later, monoamine oxidase inhibitors,
haloperidol (Haldol), an antipsychotic; tricyclic antidepressants;
and antianxiety agents (benzodiazepines), were introduced.
Because of these new drugs, hospital stays were shortened, and
many people were well enough to go home. Move toward Community
Mental Health
The enactment of the Community Mental Health Centers Act came
about in 1963. Deinstitutionalization, a deliberate shift from
institutional care in state hospitals to community facilities,
began. In addition to deinstitutionalization, federal legislation
was passed to provide an income for disabled persons: SSI and SSDI.
This allowed people with mental illnesses to be more independent
financially and not to rely on family for money. Mental Illness in
the 21st Century
The Department of Health and Human Services (DHHS) estimates
that 56 million Americans have a diagnosable mental illness. The
term Revolving door effect is used to explain how people with
severe and persistent mental illness have shorter hospital stays,
but they are admitted more frequently. People with severe and
persistent mental illness may show signs of improvement in a few
days but are not stabilized. Thus, they are discharged into the
community without being able to cope with community living.
Substance abuse issues cannot be dealt with in the 3-5 days typical
for admissions in the current managed care environment. Many
providers believe todays clients are to be more aggressive than
those in the past. Between 4% and 8% in clients seem in Psychiatric
ERs are armed. People not receiving adequate mental health care
commit about 1,000 homicides each year. In state prisons, 1 in 10
prisoners take psychotropic medications and 1 in 8 receives
counseling or therapy for mental health issues. 85% of the homeless
population has a psychiatric illness and/or a substance abuse
problem. The United States has the largest percentage of mentally
ill citizens (29.1%) and provided care for only 1 in 3 people who
needed it (Bijl et al., 2003). Persons with minor or mild cases are
most likely to receive treatment while those with severe and
persistent mental illness were least likely to be treated. Cost
containment and managed care
Managed Care is a concept designed to purposely control the
balance between the quality of care provided and the cost of that
care. In a managed care system, people receive care based on need
rather than request. Case management or management of care on a
case-by-case basis represented an effort to provide necessary
services while containing costs. The client is assigned a case
manager, a person who coordinates all types of care needed by the
client. In 1996, Congress passed the Mental Health Parity Act,
which eliminated annual and lifetime dollar amounts for mental
health care for companies with more than 50 employees. However,
substance abuse was not covered by this law, and companies could
limit the number of days in the hospital or the number of clinic
visits per year. Thus, parity did not really exist. Psychiatric
Nursing Practice
In 1873, Linda Richards improved nursing care in psychiatric
hospitals and organized educational programs in state mental
hospitals in Illinois. Richards is called the first American
psychiatric nurse.
The first training of nurses to work with persons with mental
illness was in 1882. The care focused on nutrition, hygiene and
activity. Nurses adapted medical-surgical principles to the care of
clients with psychiatric disorders and treated them with tolerance
and kindness. Treatments such as insulin shock therapy (1935),
psychotherapy (1936), and electroconvulsive therapy (1937) required
nurses to use their medical skills more extensively. John Hopkins
was the first school of nursing to include a course on psychiatric
nursing in its curriculum. In 1950, the National League for Nursing
(which accredits nursing programs) required schools to include an
experience in psychiatric nursing. In 1973, the ANA developed
Standards of care, which states the responsibilities for which
nurses are accountable. Psychiatric nursing practice has been
profoundly influenced by Hildegard Peplau and June Mellow, who
wrote about the nurse-client relationship, anxiety, nurse therapy,
and interpersonal nursing therapy. Psychiatric Mental Health
Nursing Phenomena of Concern
The maintenance of optimal health and well-being and the
prevention of psychobiologic illness.
Self-care limitations or impaired functioning related to mental
and emotional distress.
Deficits in the functioning of significant biologic, emotional,
and cognitive symptoms. Emotional stress or crisis components if
illness, pain, and disability.
Self-concept changes, developmental issues, and life process
changes.
Problems related to emotions such as anxiety, anger, sadness,
loneliness, and grief. Physical symptoms that occur along with
altered psychological functioning.
Alterations in thinking, perceiving, symbolizing, communicating,
and decision making.
Difficulties relating to others
Behaviors and mental states that indicate the client is a danger
to self or others or has a significant disability.
Interpersonal, systemic, sociocultural, spiritual, or
environmental circumstances or events that affect the mental or
emotional well-being of the individual, family, or community.
Symptom management, side effects/toxicities associated with
psychopharmacologic intervention, and other aspects of the
treatment regimen. Standards of Psychiatric mental health clinical
nursing practice.
Standard I. Assessment
The psychiatric-mental health nurse collects health data
Standard II. Diagnosis
The psychiatric-mental health nurse analyzes the data in
determining diagnoses.
Standard III. Outcome identification.
The psychiatric-mental health nurse identifies expected outcomes
individualized to the client.
Standard IV. Planning.
The psychiatric-mental health nurse develops a plan of care that
prescribes interventions to attain expected outcomes.
Standard V. Implementation The psychiatric-mental health nurse
implements the interventions identified in the plan of care.
Standard Va. Counseling
The psychiatric-mental health nurse uses counseling
interventions to assist clients in improving or regaining their
previous coping abilities, fostering mental health, and preventing
mental illness and disability.
Standard Vb. Milieu Therapy
The psychiatric-mental health nurse provides structures, and
maintains a therapeutic environment in collaboration with the
client and other health care practitioners. Standard Vc. Self-care
activities.
The psychiatric-mental health nurse structures interventions
around the clients activities of daily living to foster self-care
and mental and physical well-being.
Standard Vd. Psychobiologic Interventions.
The psychiatric-mental health nurse uses knowledge of
psychobiologic interventions and applies clinical skills to restore
the clients health and prevent further disability.
Standard Ve. Health teaching.
The psychiatric-mental health nurse, through health teaching,
assists clients in achieving, satisfying, productive, and healthy
patterns of living.
Standard Vf. Case Management.
The psychiatric-mental health nurse provides case management to
coordinate comprehensive health services and ensure continuity of
care.
Standard Vg. Health promotion and maintenance. The
psychiatric-mental health nurse employs strategies and
interventions to promote and maintain mental health and prevent
illness.
Areas of practice
Counseling
Interventions and communication techniques
Problem solving
Crisis intervention
Stress management
Behavior modification
Milieu therapy
Maintain therapeutic environment
Teach skills
Encourage communication between clients and others
Promote growth through role modeling
Self-care activities
Encourage independence
Increase self-esteem
Improve function and health
Psychobiologic interventions
Administer medications
Teaching Observations
Health teaching
Case management
Health promotion and maintenance
Advanced level functions
Psychotherapy
Prescriptive authority for drugs (in many states)
Consultation
Evaluation
Self-awareness issues
Self-awareness is the process by which the nurse gains
recognition of his or her own feelings, beliefs, and attitudes.
Chapter Two
Neurobiologic Theories and Psychopharmacology
The Nervous system and how it works
The cerebrum is the center for coordination and integration of
all information needed to interpret and respond to the
environment.
The cerebellum is the center for coordination of movements and
postural adjustments.
The brain stem contains centers that control cardiovascular and
respiratory functions, sleep, consciousness, and impulses. The
limbic system regulates body temperature, appetite, sensations,
memory, and emotional arousal.
Neurotransmitters
Neurotransmitters are the chemical substances manufactured in
the neuron that aid in the transmission of information throughout
the body. They either excite or stimulate an action in the cells
(excitatory) or inhibit or stop an action (inhibitatory). After
neurotransmitters are released into the synapse (point of contact
between the dendrites and the next neuron) and relay the message to
the receptor cells, they are either transported back from the
synapse to the axon to be stored for later use (reuptake) or are
metabolized and inactivated by enzymes, primarily monoamine oxidase
(MAO). Dopamine, a neurotransmitter located primarily in the brain
stem. Dopamine is generally excitatory and is synthesized from
tyrosine, a dietary amino acid. Antipsychotic medications work by
blocking dopamine receptors and reducing dopamine activity.
Norepinephrine and Epinephrine
Norepinephrine, the most prevalent neurotransmitter, is located
primarily in the brain stem. It plays a role in mood
regulation.
Epinephrine is also known as noradrenaline and adrenaline.
Epinephrine has limited distribution in the brain but controls the
fight-or-flight response in the peripheral nervous system.
Serotonin
A neurotransmitter found only in the brain, is derived from
tryptophan, a dietary amino acid. The function of serotonin is
mostly inhibitory, involved in the control of food intake, sleep
and wakefulness, temperature regulation, pain control, sexual
behavior, and regulation of emotions. Some antidepressants block
serotonin reuptake, thus leaving it available longer in the
synapse, which results in improved mood.
Histamine
The role of histamine in mental illness is under investigation.
Acetylcholine
Acetylcholine is a neurotransmitter found in the brain, spinal
cord, and peripheral nervous system. It can be excitatory or
inhibitory. It is synthesized from dietary choline found in red
meat and vegetables and has been found to affect the sleep-wake
cycle and to signal muscles to become active. Studies have shown
that people with Alzheimers disease have decreased acetylcholine
secreting neurons.
Glutamate
Glutamate is an excitatory amino acid that at high levels can
have major neurotoxic effects. Gamma-Aminobutyric Acid (GABA)
GABA is a major inhibitory neurotransmitter in the brain and has
been found to modulate other neurotransmitter systems rather than
to provide a direct stimulus. Drugs that increase GABA function
such as benzodiazepines are used to treat anxiety and to induce
sleep.
Neurobiologic causes of mental illness
Current theories and studies indicate that several mental
disorders may be linked to a specific gene or combination of genes
but that the source is not solely genetic; nongenetic factors also
play important roles. Two genetic links to Alzheimers disease are
chromosomes 14 and 21. The Human Genome Project, funded by NIH and
the US Department of Energy, is the largest of its kind. It has
identified all human DNA. In addition, the project also addresses
the ethical, legal, and social implications of human genetics
research. Stress and the Immune system (Psychoimmunology)
This is a relatively new field of study, which examines the
effect of psychological stressors on the bodys immune system.
Infection as a possible cause
Some researchers are focusing on infection as a cause of mental
illness. Studies such as this are promising in discovering a link
between infection and mental illness. The Nurses role in research
and education
The nurse must ensure that clients and families are well
informed about progess in these areas and must also help them to
distinguish between facts and hypotheses. The nurse can explain if
or how new research may affect a clients treatment or prognosis.
The nurse is a good resource for providing information and
answering questions.
Psychopharmacology
Efficacy refers to the maximal therapeutic effect that a drug
can achieve.
Potency describes the amount of the drug needed to achieve that
maximum effect; low-potency drugs require higher doses to achieve
efficacy, whereas high-potency drugs achieve efficacy at lower
doses.
Half Life is the time it takes for half of the drug to be
removed from the bloodstream. Drugs with shorter half-life may need
to be given three or four times a day, but drugs with a longer
half-life may be given once a day.
The FDA may issue a black-box warning when a drug is found to
have serious or life-threatening side effects. This means that
package inserts must have a highlighted box, separate from the
text, which contains a warning about the serious side-effects.
Antipsychotic drugs
Also known as neuroleptics, are used to treat the symptoms of
psychosis, such as the delusions and the hallucinations seen in
schizophrenia, schizoaffective disorder, and the manic phase of
bipolar disorder.
Antipsychotics work by blocking receptors of the
neurotransmitter, dopamine. Dopamine receptors are classified into
subcategories (D1, D2, D3, D4, and D5) and D2, D3, and D4 have been
associated with mental illness. The typical antipsychotic drugs are
potent antagonists (blockers) of D2, D3, and D4. This makes them
effective in treating target symptoms but also produces many
extrapyramidal side effects because of the blocking of the D2
receptors. Newer, atypical antipsychotic drugs such as clozapine
(Clozaril) are relatively weak blockers of D2, which may account
for the lower incidence of extrapyramidal side effects. The newer
antipsychotics also inhibit the reuptake of serotonin, increasing
their effectiveness in treating the depressive aspects of
schizophrenia. Extrapyramidal Side Effects (EPS) are the major side
effects of antipsychotic drugs. They include acute dystonia
(prolonged involuntary muscular contractions that may cause
twisting of the body parts, repetitive movements, and increased
muscular tone), pseudoparkinsonism, and akathisia (intense need to
move about). Blockage of the D2 receptors in the midbrain region of
the brain stem is responsible for the development of EPS. Included
in the EPS are:
Torticollis: twisted head and neck
Opisthotonus: tightness of the entire body with head back and an
arched neck. Oculogyric crisis: eyes rolled back in a locked
position. Immediate treatment with anticholinergic drugs usually
brings rapid relief.
Pseudoparkinsonism, or drug-induced Parkinsonism if often
referred to by the generic label of EPS. Symptoms include a stiff,
stooped posture; mask-like facies; decreased arm swing; a
shuffling. festinating gait; drooling; tremor; bradycardia; and
coarse pill rolling movements of the thumb and fingers while at
rest. Treatment of these symptoms can include adding an
anticholinergic agent or amantadine, which is a dopamine agonist
that increases transmission of dopamine blocked by the
antipsychotic drug.
Neuroleptic Malignant syndrome
(NMS) is a potentially fatal idiosyncratic reaction to an
antipsychotic. Death rates have been reported at 10% to 20%.
Symptoms include rigidity, high fever; autonomic instability such
as unstable blood pressure, diaphoresis, and pallor; delirium; and
elevated levels of enzymes, particularly creatine and
phosphokinase. Clients with NMS are confused and often mute; they
may fluctuate from agitation to stupor. Dehydration, poor
nutrition, and concurrent medical illness all increase the risk of
NMS. Treatment includes immediate discontinuation of the
antipsychotic and the institution of supportive medical care to
treat dehydration and hyperthermia. Tardive Dyskinesia
(TD) is a syndrome of permanent involuntary movements. This is
most commonly caused by the long-term use of antipsychotic drugs.
There is no treatment available. The symptoms of TD include
involuntary movements of the tongue, facial, and neck muscles,
upper and lower extremities, and truncal musculature. Tongue
thrusting and protruding, lip smacking, blinking, grimacing, and
other excessive unnecessary facial movements are characteristic.
One TD has developed, it is irreversible. Agranulocytosis
Some antipsychotics produces agranulocytosis. This develops
suddenly and is characterized by:
Fever
Malaise
Ulcerative sore throat
Leucopenia
The drug must be discontinued immediately if the WBC drops by
50% or to less that 3,000. Antidepressant drugs
Although the mechanism of action is not completely understood,
antidepressants somehow interact with the two neurotransmitters,
norepinephrine and serotonin. Antidepressants are divided into four
groups:
Tricyclic and the related cyclic antidepressants
Selective serotonin reuptake inhibitors (SSRIs)
MAO inhibitors (MAOIs)
Other antidepressants such as venlafaxine (Effexor), bupropion
(Wellbutrin), duloxetine (Cymbalta), trazodone (Desyrel), and
nefazodone (Serzone). MAOIs have a low incidence of sedation and
anticholinergic effects, they must be used with extreme caution for
several reasons:
A life-threatening side effect, hypertensive crisis, may occur
if the client ingests food containing tyramine (an amino acid)
while taking MAOIs. Mature or aged cheeses
Aged meats (sausage, pepperoni)
Tofu
ALL tap beers and microbrewery beer. Sauerkraut, soy sauce, or
soybean condiments
Yogurt, sour cream, peanuts, MSG
MAOIs cannot be given in combination with other MAOIs, tricyclic
antidepressants, Demerol, CNS depressants, and hypertensives, or
general anesthetics. MAOIs are potentially lethal in overdose and
pose a potential risk for clients with depression who may be
considering suicide. SSRIs, venlafaxine, nefazodone, and bupropion
are often better choices for those who are potentially suicidal or
highly impulsive because they carry no risk of lethal overdose in
contrast to the cyclic compounds and the MAOIs. However, SSRIs are
only effective for mild to moderate depression. The major actions
of antidepressants are with the monoamine neurotransmitter systems
in the brain, particularly norepinephrine and serotonin.
Norepinephrine, serotonin, and dopamine are removed from the
synapses after release by reuptake into presynaptic neurons. After
reuptake, these three neurotransmitters are reloaded for subsequent
release or metabolized by the enzyme MAO. The SSRIs block the
reuptake of serotonin; the cyclic antidepressants and venlafaxine
block the reuptake of norepinephrine primarily and block serotonin
to some degree; and the MAOIs interfere with enzyme metabolism.
Mood stabilizing drugs
Mood stabilizing drugs are used to treat bipolar disorder by
stabilizing the clients mood, preventing or minimizing the highs
and lows that characterize bipolar illness, and treating acute
episodes of mania. Lithium is considered the first-line agent in
the treatment of bipolar disorder. Lithium normalizes the reuptake
of certain neurotransmitters such as serotonin, norepinephrine,
acetylcholine, and dopamine. It also reduces the release of
norepinephrine through competition with calcium. Lithium produces
its effects intracellularly rather than within neuronal synapses.
Lithium serum levels should be about 1.0 mEq/L. Levels less than
0.5 mEq/L are rarely therapeutic, and levels of more than 1.5 mEq/L
are usually considered toxic. If Lithium levels exceed 3.0 mEq/L,
dialysis may be indicated. The mechanism of action for
anticonvulsants is not clear as it relates to their off-label use
as mood stabilizers. Valporic acid and topiramate are known to
increase the levels on the inhibitatory neurotransmitter, GABA.
Both are thought to stabilize mood by inhibiting the kindling
process. The kindling process can be described as the snowball-like
effect seen when minor seizure activity seems to build up into more
frequent and severe seizures. In seizure management,
anticonvulsants raise the level of the threshold to prevent these
minor seizures. It is suspected that this same kindling process may
occur in the development of full-blown mania with stimulation by
more frequent, minor episodes. Antianxiety drugs (Anxiolytics)
Benzodiazepines mediate the actions of the amino acid GABA, the
major inhibitory neurotransmitter in the brain. Because GABA
receptor channels selectively admit the anion chloride into
neurons, activation of GABA receptors hyperpolarizes neurons and
thus is inhibitory. Benzodiazepines produce their effects by
binding to a specific site on the GABA receptor.
Stimulants
Today, the primary use of stimulants is for ADHD in children and
adolescents, residual attention deficit disorder in adults, and
narcolepsy. Stimulants are often termed indirectly acting amines
because they act by causing release of the neurotransmitters
(norepinephrine, dopamine, and serotonin) from presynaptic nerve
terminals as opposed to having direct agonist effects on the
postsynaptic receptors. They also block the reuptake of these
neurotransmitters. By blocking the reuptake of these
neurotransmitters into neurons, they leave more of the
neurotransmitter in the synapse to help convey electrical impulses
in the brain. Cultural considerations
Im not going to go much into this. Just know that clients from
various cultures may metabolize medication at different rates and
therefore require alterations in standard dosages. Psychosocial
Theories and Therapy
Sigmund Freud, the Father of Psychoanalysis
Founded the personality components; Id, Ego, and Superego
Id: The part of ones nature that reflects basic or innate
desires such a pleasure seeking behavior, aggression, and sexual
impulses. The id seeks instant gratification, causes impulsive
thinking behavior, and has no rules or regard for social
convection.
Superego: The part of ones nature that reflects moral and
ethical concepts, values, parental and social expectations;
therefore, it is the directional opposite to the id.
Ego: The balancing or mediating force between the id and the
superego. The ego represents mature and adaptive behavior that
allows a person to function successfully.
Psychosexual development
Oral (birth to 18 months)
Anal (18 to 36 months)
Phallic/Oedipal (3 to 5 years)
Latency (5 to 11 or 13 years)
Genital (11 or 13 years)
Transference and Countertranference
Transference occurs when the client onto the therapist/nurse
attitudes and feelings that the client previously felt in other
relationships.
Countertranference occurs when the therapist/nurse displaces
onto the client attitudes or feelings from his or her past.
Developmental Theorists; Erikson and Piaget
Erikson focused on personality development across the life span
while focusing on social and psychological development in life
stages.
Trust vs. Mistrust (infant)
Autonomy vs. Shame and Doubt (toddler)
Initiative vs. guilt (preschool)
Industry vs. Inferiority (school age)
Identity vs. Role confusion (adolescence)
Intimacy vs. isolation (young adult)
Generativity vs. stagnation (middle adult)
Ego integrity vs. despair (maturity)
Erikson believed that psychosocial growth occurs in sequential
stages, and each stage is dependent on the completion of the
previous stage/life task.
Piaget explored how intelligence and cognitive functioning
develop in children.
Sensorimotor (birth to 2 years): The child develops a sense of
self as separate from the environment and the concept of object
permanence. Begins to form mental images.
Preoperational (2-6 years): Child begins to express himself with
language, understands the meaning of symbolic gestures, and begins
to classify objects.
Concrete operations (6-12 years): Child begins to apply logical
thinking, understands reversibility, is increasingly social and
able to apply rules; however, thinking is still concrete.
Formal operations (12 to 15 years and beyond): Child learns to
think and reason in abstract terms, further develops logical
thinking and reasoning, and achieves cognitive maturity.
Harry Stacks Sullivan: Interpersonal Relationships and Milieu
therapy
The importance and significance of interpersonal relationships
in ones life was Sullivans greatest contribution to the field of
mental health.
Sullivan developed the first therapeutic community or milieu
with young men with schizophrenia in 1929. He found that within the
milieu, the interactions among clients were beneficial, and then
the treatment should emphasize on the roles of the client-client
interaction.
Milieu therapy is used in the acute care setting; one of the
nurses primary roles is to provide safety and protection while
promoting social interaction.
Hildegard Peplau: Therapeutic nurse-patient relationship (The
bomb-diggity of nursing)
Developed the concept of the therapeutic nurse-patient
relationship, which includes 4 phases: orientation, identification,
exploitation, and resolution.
The orientation phase is directed by the nurse and involves
engaging the client in treatment, providing explanations and
information, and answering questions. During this time the nurse
would orient the patient to the rules and expectations (if in an
acute setting).
The identification phase begins when the client works
interdependently with the nurse, expresses feelings, and begins to
feel stronger. This phase can begin either within a few hours to a
few days; the patient can identify the nurse and environment on his
own. They come together. Kinky.
In the exploitation phase, the client makes full use of the
services offered. He moves toward independence.
In the resolution phase, the client no longer needs professional
services and gives up dependent behavior.
Keep in mind that after the resolution phase, the client can
regress and move back into the above mentioned phases.
Paplau defined anxiety as the initial response to a psychic
threat, describing 4 levels of anxiety: acute, moderate, severe,
and panic.
Acute anxiety is a positive state of heightened awareness and
sharpened senses, allowing the person to learn new behaviors and
solve problems. The person can take in all available stimuli
(perceptual field).
Moderate anxiety involved a decreased perceptual field (focus on
immediate task only); the person can learn new behavior or solve
problems only with assistance. Another person can redirect the
person to the task. Remember, this is the ideal anxiety state for
teaching a client regarding health concerns such as diabetes, as
Cathy says so. (
Severe anxiety involves feelings of dread or terror. The person
CANNOT be redirected to a task; he focuses only on scattered
details and has physiologic symptoms such as tachycardia,
diaphoresis, and chest pain. The client may go to the ER thinking
he is having a heart attack. In lecture, Cathy stated that this
person can still be talked down. The first priority is to move the
person away from all stimuli, and then attempt to talk with them to
calm down.
Panic anxiety can involve loss of rational thought, delusions,
hallucinations, and complete physical immobility and muteness. The
person my bolt and run aimlessly, often exposing himself and others
to injury.
Humanistic Theories; Maslows Hierarchy of needs. Everyone should
know this one. It is outlined on page 56 in your book.
He used a pyramid to arrange and illustrate the basic drives or
needs to motivate people.
The most basic needs, physiologic needs, need to be met first.
This includes food, water, shelter, sleep, sexual expression, and
freedom of pain. These MUST be met first.
The second level involves safety and security needs, which
involve protection, security, freedom from harm or threatened
deprivation.
The third level is love and belonging needs, which include
enduring intimacy, friendship, and acceptance.
The fourth level involves esteem needs, which includes the need
for self-respect and esteem from others.
The highest level is self-actualization, the need for beauty,
truth, and justice. Few people actually become self-actualized.
Remember, traumatic life experiences or compromised health can
cause a person to regress to a lower level of motivation.
Pavlov: Classic conditioning (Behavior theory)
Pavlov believed that behavior can be changed through
conditioning with external or environmental conditions or
stimuli.
Crisis Intervention
Maturational crises, sometimes called developmental crises, are
predictable events in the normal course of a life, such as leaving
home for the first time, getting married, having children, etc.
Situational crises are unanticipated or sudden events that
threaten an individuals integrity; such as a death of a loved one
and loss of a job.
Adventitious crises, sometimes called social crises, include
natural disasters like floods, earthquakes, or hurricanes; war,
terrorist attacks; riots; and violent crimes such as rape or
murder.
Non-violent crisis interventionThe heart of crisis intervention
is: Care Welfare Safety (#1!) SecurityPeople in crisis need care
and welfare.Staff responses should be safety and security.Anxiety:
Increase or change in behavior. Can be anything different from
usual behavior (excitement, pacing). Nursing interventions: Ask
Whats going on? Give supportive care and let the patient know that
youre there.Defensive: Loss of rationality. Nursing interventions:
Direct approach to setting limits. Take away privileges. Give the
patient some control and choices.Acting out person: Loss of
rational control. Nursing interventions: Everything Cathy showed us
on non-violent physical crisis interventionTension-Reduction:
Subsiding of energy. Nursing interventions: Establish therapeutic
rapport Prime time to talk and teach about preventions of
behavior.What if the patient simply refuses? Set limits! Make the
limits reasonable and enforceable. Releasing Venting Mad as heck!
Allow the patient to do this! Just stay calm as a nurse While
theyre venting, theyre also releasing. This is a good
thing.Intimidation: This is NOT A GOOD THING. What if the patient
tells you? I know what car you drive. I know your last name. I know
you have 2 dogs and Im going to kill them. Nursing interventions:
Get a witness! Do not be by yourself with this patient!Non-verbal
behavior that affect proxemics Factors that affect: Size, gender,
disability, environment, agitation, history, and speed. 18-36 is
personal space (usually how wide ones arm length is). Always be the
closest to the door. Kinesics (Body language) Facial expressions,
stance, posture, breathing, hand gestures When approaching a
client, stand at 45 degree angle Stand with hands to side
(especially when with a paranoid client) Move when the patient
moves. Be as calm as possible.Paraverbal communication 55%
nonverbal 7% verbal 38% paraverbal( its not what you say; its how
you say it! TVC (total voice control) Tone Volume CadenceAlways
remember not to lose eye contact.If youre being grabbed Gain
physiologic advantage Know where the weak point of grab is
Leverage- use what you have! Momentumit comes in handy ( Gain
psychological advantage Stay calm Have a plan Dont forget the
element of surpriseNon-Violent physical control and restraint
should be used as a LAST RESORT.
Mood disorders
Categories of Mood disorders
Unipolar
Major depression
Bipolar
Mania
Depression
Period of normalcy
Unipolar: Major depression
Sad mood or lack of interest in life for 2 or more weeks
Another 4 symptoms must also be present
Change in appetite (increase or decrease)
Change in sleep patterns (too much or too little)
Unable to concentrate and make decisions
Loss of self-esteem (guilt- how you were raised; how worthy a
person perceives themselves). Those at risk:
PMS/PMDD
Suffering from anxiety and irritability
PP depression
Chronic illness (dialysis)
PTSD
Grief and loss
Can be observed by others, or the depression is just in ones
head
Incidence
Major depression occurs at least twice as often in women
Single and divorced people have the highest rates of
depression
Treatments
Psychotherapy (groups, counselor)
Psychopharmacology (Meds)
ECT
Electroconvulsive therapy
The biggest concern is memory loss. Patient is pre-medicated,
much like a pre-op patient
Elders are treated for depression with ECT more frequently than
younger persons.
Elder persons have increased intolerance of side effects of
antidepressants ECT produces a more rapid response
Suicidal Ideation
Safety is primary concern
Watch for overt cues of suicide (Obvious) ( active
Covert cues are more subtlepassive People who suddenly are
happier are of great concern; may have made the suicidal plan are
content with their decision.
People whose meds are finally workinghave enough energy to carry
out the act
Clients Affect
Compare verbal with non-verbal behaviorsdo they match up?
Asocial: Withdrawal from family and friends
Anhedonic: Lose sense of pleasure
When confronting these clients about their behavior, use I
statements
I really wish youd join the group
Judgment
Feel overwhelmed with normal activities
Difficulty with task completion
Always exhausted
Self Concept
Ruminate: Worry to excess. Lack energy for normal activities
(always tired)
Interventions
Assess safety for client (PRIORITY!)
Perform suicide lethality assessment
Orient client to new surroundings (they need structure)
Offer explanations of unit routine (again, need structure)
Start to promote a therapeutic relationship; schedule short
interaction times.
Patient and Family teaching
Stress importance of follow-up carekeep it structured; make
appointment for them.
Stress importance of continuing medications; assess if they can
afford them
Make phone number lists of how to get help if they need it.
Bipolar disorder
Condition with cyclic mood changes
Person has manic episodes, periods of profound depression, and
times of normal behavior in-between
Occurs equally in men and women; often seen in highly educated
people.
Clinical course of mania
Episode of unusual, grandiose, or agitated mood lasting at least
one week with three or more of the following symptoms:
Exaggerated self-esteem
Sleeplessness
Pressured speech
Flight of ideas
Reduced ability to filter out stimuli
Distractibility
More activities with increased energy
Drug treatment
Lithium
Lithium is not metabolized; rather, it is reabsorbed by the
proximal tubule and excreted in the urine.
Thought to work in the synapse to increase destruction of
dopamine and norepinephrine; decreases sensitivity to postsynaptic
receptors (Basically- when a person is in a manic phase, they are
synapsing super fast. Lithium helps slow this synapsing down).
Onset of action is 5-14 days; other drugs must be used during
the acute phases to reduce symptoms of mania or depression.
Maintenance lithium level is 0.5-1.0 mEq/L. 3 is toxic! Duh.
Lithium is a salt contained in the human body. It not only competes
for salt receptor sites but also affects calcium, potassium, and
magnesium ions as well as glucose metabolism.
MUST complete an electrolyte blood panel (focus on
Chloride).
Having too much salt in the diet can cause the lithium level to
be too low.
Not having enough dietary salt can cause the lithium levels to
be too high.
Persistent thirst and diluted urine can indicate the need to
call the MD; lithium dosage may need to be reduced. Anticonvulsant
drugs: mechanism is unclear, but they raise the brains threshold
for dealing with stimulation; this prevents the person from being
bombarded with external and internal stimuli. Tegretol
Huge concern about agranulocytosis (a decrease in WBC).
Need serum levels monitored 12 hours after last dose.
Depakote
Need to monitor serum level, CBC with platelets, liver function
including ammonia level (ammonia is a by-product of liver
metabolism)
Klonopin
Anticonvulsant and benzodiazepine
Drug dependence can occur
Monitor CBC, liver function
Withdrawal drug slowly to prevent GI issues
Cannot be used alone to manage bipolar; must be used in
conjunction with lithium or another mood stabilizer.
Helpful hints to care for bipolar clients
You cant teach a manic client
Safety is a huge issue because their judgment is poor.
Only spend short periods of time with patient
Must be flexible in taking intake assessment; may need to obtain
data in several short sessions as well as talking to family
members. Ask the client to explain any coded speech
Assist the client to meet socially accepting behaviors. Kathy,
you are too close to my face. Please stand back two feet.
Feed them finger foods high in calories while in a manic phase;
provide nutritional support!
Use simple sentences when communicating. It is also helpful to
ask client to repeat brief messages to ensure they have heard and
incorporated them. Please speak more slowly. Im having trouble
following you.
Avoid becoming involved in power struggles over who will
dominate the conversation. Suicide
4 out of 5 who actually commit suicide have made at least one
prior attempt
In a majority of cases, there are clear indicators hat the
person was very troubled.
Few than 15% of suicide victims leave suicide notes
The suicide risk is greatest in the 90 days following a major
depressive episode. survivor guilt happens when 1 or more family
members feel guilty that they are still living
Separation anxiety may cause they surviving to join the beloved
deceased
Make the patient sign a contract for life
Crisis interventionmay need 1:1 care. The client is no more than
2-3 feet away from a staff member at any time, including going to
the bathroom. Anxiety disorders & Substance abuse
Incidence
Most common emotional disorder in the U.S.
Prevalent in women; age