Chapter 1-15 questions Mental health

Terms in this set (100)

• Theoretical models and therapeutic strategies provide a useful framework for the delivery of psychiatric nursing care.

• The psychoanalytic model is based on unconscious motivations and the dynamic interplay between the primitive brain (id), the sense of self (ego), and the conscience (superego). The focus of psychoanalytic theory is on understanding the unconscious mind.

• The interpersonal model maintains that the personality and disorders are created by social forces and interpersonal experiences. Interpersonal therapy aims to provide positive and repairing interpersonal experiences.

• The behavioral model suggests that because behavior is learned, behavioral therapy should improve behavior through rewards and reinforcement of adaptive behavior.

• The humanist model is based on human potential, and therapy is aimed at maximizing this potential. Maslow developed a theory of personality that is based on the hierarchical satisfaction of needs. Rogers's person-centered theory uses self-actualizing tendencies to promote growth and healing.

• The cognitive model posits that disorders, especially depression, are the result of faulty thinking. Cognitive behavioral therapy is empirically supported and focuses on the recognition of distorted thinking and the replacement with more accurate and positive thoughts.

• The biological model is currently the dominant model and focuses on physical causation for personality problems and psychiatric disorders. Medication is the primary biological therapy.

• A variety of nursing theories are useful to psychiatric nursing. Hildegard Peplau developed an important interpersonal theory for the provision of psychiatric nursing care.

• Group therapy offers the patient significant interpersonal feedback from multiple people.

• Groups transition through predictable stages, benefit from therapeutic factors, and are characterized by members filling specific roles.

• Family therapy is based on various theoretical models and aims to decrease emotional reactivity among family members and encourage differentiation among individual family members.
All actions of the brain— sensory, motor, intellectual— are carried out through the interactions of nerve cells involving impulse conduction, transmitter release, and receptor response. Alterations in these basic processes can lead to mental disturbances and physical manifestations.

• In particular, it seems that excess activity of dopamine, among other factors, is involved in the thought disturbances of schizophrenia, and deficiencies of norepinephrine, serotonin, or both underlie depression and anxiety. Insufficient activity of GABA also plays a role in anxiety.

• Pharmacological treatment of mental disturbances is directed at the suspected transmitter-receptor problem. Antipsychotic drugs decrease dopamine levels, antidepressant drugs increase synaptic levels of norepinephrine and/ or serotonin, and antianxiety drugs increase the effectiveness of GABA or increase 5-HT and/ or norepinephrine levels.

• Because the immediate target activity of a drug can result in many downstream alterations in neuronal activity, drugs with a variety of chemical actions may show efficacy in treating the same clinical condition. Thus, newer drugs with novel mechanisms of action are being used in the treatment of schizophrenia, depression, and anxiety.

• Unfortunately, agents used to treat mental disease can cause various undesired effects. Prominent among these can be sedation or excitement, motor disturbances, muscarinic blockage, α-adrenergic antagonism, sexual dysfunction, and weight gain. There is a continuing
• Compared to seeking care for physical disorders, finding care for psychiatric disorders can be complicated by a two-tiered system of care provided in the private and public sectors.

• Nonspecialist primary care providers treat a significant portion of psychiatric disorders.

• Psychiatric care providers are specialists who are licensed to prescribe medication and conduct therapy. They include psychiatrists, advanced practice psychiatric nurses, physicians' assistants, and, in some states, psychologists.

• Community mental health centers are state-regulated and state-funded facilities that are staffed by a variety of mental health care professionals.

• Other outpatient settings include psychiatric home care, intensive outpatient programs, and partial hospitalization programs.

• Inpatient care is used when less restrictive outpatient options are insufficient in dealing with symptoms. It can be provided in general medical centers, private psychiatric centers, crisis units, and state hospitals.

• Nurses provide the basis for inpatient care and are part of the overall unit milieu that emphasizes the role of the total environment in providing support and treatment.

• Specific populations such as children, veterans, geriatrics, and forensics benefit from treatment geared to their unique needs.

• Financing psychiatric care has been complicated by lack of parity, or equal payment for physical as compared to psychiatric disorders. Legislation has been proposed and passed to improve mental health parity.
• The nursing process is a six-step problem-solving approach to patient care to help secure safety and quality care for patients.

• The Institute of Medicine (IOM) and QSEN faculty have established mandates to prepare future nurses with the knowledge, skills, and attitudes (KSAs) necessary for achieving quality and safety as they engage in the six competencies of nursing: patient-centered care, teamwork and collaboration, evidence-based practice (EBP), quality improvement (QI), safety, and informatics.

• The primary source of assessment is the patient. Secondary sources of information include the family, neighbors, friends, police, and other members of the health team.

• The assessment interview includes gathering objective data (mental or emotional status) and subjective data (psychosocial assessment). A number of tools are provided in this textbook for the evaluation of cultural, spiritual/ religious, and mental status.

• Medical examination, history, and systems review complete a comprehensive assessment.

• An important part of planning patient-centered care is to understand how spiritual/ religious beliefs play a part in a person's life and how they deal with stress.

• Caregivers should also have an awareness of the person's cultural background and social attachments, and how these issues affect the way a person experiences healing in his or her culture.

• Assessment tools and standardized rating scales may be used to evaluate and monitor a patient's progress. Emphasis needs to be placed on further evaluation of progress and sharing of this information with other members of the health care team.

• Self-assessment is an important part of the assessment process. There are a number of ways that novice interviewers can gain valuable feedback, support, and supervision.

• Determination of the nursing diagnosis (NANDA-I) defines the practice of nursing, improves communication between staff members, and assists in accountability for care.

• A nursing diagnosis consists of (1) an unmet need or problem, (2) an etiology or probable cause, and (3) supporting data.

• Outcomes are variable, measurable, and stated in terms that reflect a patient's actual state. NOC provides 330 standardized outcomes. Planning involves determining desired outcomes.

• Behavioral goals support outcomes. Short- and long-term outcomes are measurable, indicate the desired patient behavior( s), include a set time for achievement, and are short and specific.

• Planning nursing actions (NIC or other sources) to achieve the stated outcomes include the use of the following specific principles: the plan should be (1) safe, (2) evidence based whenever possible, (3) realistic, and (4) compatible with other therapies. NIC provides nurses with standardized nursing interventions that areapplicable for use in all settings

• Practice in psychiatric nursing encompasses basic-level interventions: coordination of care; health teaching and health promotion; milieu therapy; and pharmacological, biological, and integrative therapies.

• Advanced practice interventions are carried out by a nurse who is educated at the master's level or higher. Nurses certified for advanced practice psychiatric mental health nursing may be additionally prepared to practice psychotherapy, prescribe certain medications, and perform consulting work.

• The evaluation of care is a continual process of determining to what extent the outcome criteria have been achieved. The plan of care may be revised on the basis of the evaluation.

• Documentation of patient progress through evaluation of outcome criteria is crucial. The patient's record is a legal document and should accurately reflect the patient's condition, medications, treatment, tests, responses, and any untoward incidents.

• Simply documenting a patient's noncompliance/ nonadherence to medical treatment no longer protects nurses, doctors, other health care professionals, and/ or institutions from lawsuits when further harm to the patient presents itself. Careful documentation of what has been done to help the individual understand the instructions, understand the reasons behind the medical advice, and follow-up on compliance issues should be included.
• Knowledge of communication and interviewing techniques is the foundation for development of any patient-centered partnership. Goal-directed professional communication is referred to as therapeutic communication.

• Communication is a complex process. Berlo's communication model has five parts: stimulus, sender, message, medium, and receiver. Feedback is a vital component of the communication process for validating the accuracy of the sender's message.

• Effective/ therapeutic communication in nursing points to "increased recovery rates, a sense of safety and protection, improved levels of patient satisfaction, and greater adherence to treatment options" (Neese, 2015). Poor communication skills (non-therapeutic) were responsible for 80% of 440,000 medical deaths in the United States in 2013.

• A number of factors can minimize or enhance the communication process. For example, differences in culture, language, and knowledge levels; noise; lack of privacy; the presence of others; and expectations can all influence communication.

• There are verbal and nonverbal elements in communication; the nonverbal elements often play the larger role in conveying a person's message. Verbal communication consists of all words a person speaks. Nonverbal communication consists of the behaviors displayed by an individual, in addition to the actual content of speech.

• Communication has two levels: the content level (verbal) and the process level (nonverbal behavior). When content is congruent with process, the communication is said to be healthy. When the verbal message is not reinforced by the communicator's actions, the message is ambiguous; we call this a double-bind (or mixed) message.

• Cultural background (as well as individual differences) has a great deal to do with what nonverbal behavior means to different individuals. The degree of eye contact and the use of touch are two nonverbal aspects that can be misunderstood by individuals of different cultures.

• There are a number of communication techniques that nurses can use to enhance their nursing practices. Many widely used communication enhancers are cited in Table 8-2.

• There are also a number of nontherapeutic techniques that nurses can learn to avoid to enhance their effectiveness with people. Some are cited in Table 8-3 along with suggestions for more helpful responses.

• Most nurses are most effective when they use nonthreatening and open-ended communication techniques. • Effective communication is a skill that develops over time and is integral to the establishment and maintenance of a therapeutic alliance.

• The application of information communication technologies in the psychosocial sciences is relatively new, but it is viewed as an invaluable tool for helping people with mental health and issues in behavioral health and medicine. It is particularly well suited for individuals in rural areas and for those to whom assessing health care/ mental health clinics is not possible either physically or financially. The emergence of apps for those with anxiety, depression, and other mental health issues (e.g., posttraumatic stress disorder, bipolar, etc.) can provide greater accessibility to psychiatric care. The one caveat is that an app should be approved and well accepted within the mental health community
• The nurse-patient relationship/ partnership is well defined, and the roles of the nurse and the patient must be clearly stated.

• It is important that the nurse be aware of the differences between a therapeutic relationship and a social or intimate relationship. In a therapeutic nurse-patient relationship, the focus is on the patient's needs, thoughts, feelings, and goals. The nurse is expected to meet personal needs outside this relationship in other professional, social, or intimate arenas.

• Genuineness, positive regard, and empathy are personal strengths in the helping person that foster growth and change in others.

• Although the boundaries of the nurse-patient relationship generally are clearly defined, they can become blurred; this blurring can be insidious and may occur on an unconscious level. Usually, transference and countertransference phenomena are operating when boundaries are blurred.

• It is important to have a grasp of common countertransferential feelings and behaviors and of the nursing actions to counteract these phenomena

. • Supervision aids in promoting the professional growth of the nurse as well as in the nurse-patient relationship, allowing the patient's goals to be addressed and met.

• The phases of the nurse-patient relationship include the orientation, working, and termination phases, which are in reality very fluid.

• The clinical interview is a key component of psychiatric mental health nursing. Presented are considerations needed for establishing a safe setting and planning for appropriate seating, introduction, and initiation of the interview.

• Attending behaviors (e.g., eye contact, body language, vocal qualities, and verbal tracking) are a key element in effective communication
. •
Cultural background (as well as individual values and beliefs) has a great deal to do with what nonverbal behavior means to different individuals. The degree of eye contact and the use of touch are two nonverbal aspects that can be misunderstood by individuals of different cultures.

• A meaningful therapeutic relationship is facilitated when values and cultural influences are considered. It is the nurse's responsibility to seek to understand the patient's perceptions.
• Some stress is useful in our lives; eustress is stress that makes us strive to reach our goals, repair important relationships, improve our work, and stimulate creative problem-solving processes and improve critical thinking.

• Stress is common in our lives, but when stress is prolonged and increased it may be experienced more as distress, which is a negative experience. When stress becomes chronic it can cause physiological harm and emotional difficulties.

When we are confronted with a serious stressor, our autonomic nervous system reacts with the fight-or-flight response. This response involves a complex network of nerve pathways, brain structures, and glands to help our bodies and mind deal with the stressor.

• The second part of the fight-or-flight response is caused by the hypothalamus-pituitary-adrenal (HPA) cortex, which activates the response.

• When the stress response is prolonged and becomes chronic, it can have damaging effects on the body by lowering the resistance of the immune system and contributing to both physical illness and mental trauma (e.g., depression, hopelessness, helplessness, increased sustained anxiety).


• Posttraumatic stress disorder (PTSD) usually occurs after a severe traumatic event (e.g., childhood abuse, torture/ kidnap, military combat, sexual assault, incest, natural disasters, and life-threatening illness). It is estimated that up to 20% of our combat veterans returning from combat have PTSD.

• If PTSD is not treated, serious consequences often result, including severe depression, alcohol/ substance abuse, suicide, inability to trust, and social and occupational disruptions, as well as a host of mentally damaging symptoms and/ or disorders.

• The major symptoms of PTSD and acute stress disorder have been addressed in this chapter.

• Pharmacological and therapeutic interventions that have proven successful with PTSD have been identified.

• Nurses, physicians, and first responders are cautioned to be alert for secondary traumatic stress and practice self-care since they also can be at risk for compassion fatigue/ posttraumatic stress disorder if not properly managed

. • Symptoms a health care worker might experience are included in this chapter. Health care workers who might be vulnerable to compassion fatigue stress/ compassion fatigue/ PTSD have been identified; however, this is not an exclusive list.
• A simple explanation for the difference between anxiety and fear is that anxiety has an unknown or unrecognized source, whereas fear is a reaction to a specific threat.

• Anxiety can be normal, acute, or chronic, as well as adaptive or maladaptive. • Peplau operationally defined four levels of anxiety. The patient's perceptual field, ability to learn, and physical or other characteristics are different at each level (see Table 11-1).

• Effective psychosocial interventions are different for people experiencing mild to moderate levels of anxiety and for individuals experiencing severe to panic levels of anxiety. Effective psychosocial nursing approaches are suggested in Tables 11-2 and 11-3.

• Defenses against anxiety can be adaptive or maladaptive. Defenses are presented in a hierarchy from healthy to intermediate to immature. Table 11-4 provides examples of adaptive and maladaptive uses of many of the more common defense mechanisms.

• Anxiety disorders are the most common psychiatric disorders in the United States and frequently co-occur with major depression and/ or substance use disorders; OCD and BDD also have high rates of co-occurring with major depression

. • Research has identified genetic and biological factors in the etiology of anxiety disorders and OCD. • Psychological theories, cultural influences, and socioeconomic status also are pertinent to the understanding of anxiety disorders.

• Patients with anxiety disorders suffer from panic attacks, irrational fears, excessive worrying, uncontrollable rituals, or severe reactions to stress.

• People with anxiety disorders and hoarding disorder are often too embarrassed or ashamed to seek psychiatric help. People with anxiety disorders may consult their primary care providers about multiple somatic complaints. • One form of psychotherapy that is effective for treating anxiety disorders, OCD, and milder forms of BDD is cognitive behavioral therapy (CBT) in conjunction with medication. • Interventions include counseling, milieu therapy, promotion of self-care activities, psychobiological intervention, and health teaching
• People with personality disorders (PDs) present with the most complex, difficult behavioral challenges for themselves and the people around them.

• People with PDs have inflexible and maladaptive ways of handling stress; demonstrate disabilities in both work and intimate relationships; evoke strong, intense personal conflict with those around them; and have difficulty managing impulses

. • PDs often co-occur with other mental health disorders (e.g., depression, substance use disorder, somatization, eating disorders, PTSD, anxiety disorders), other personality disorders, and general medical conditions.

• It is unlikely there is any single cause for any of the personality disorders— most seem to have genetic and environmental risk factors. • People with these disorders respond to stress (e.g., frustration, anger, loneliness) with more primitive defenses, resulting in outrageous behaviors unmodified by "normal" defenses.

• Needs are experienced as rage, and sexuality and dependency are confused with aggression.

• Self-assessment is an important part of assessment when working with a person with a PD. When personal feelings are not recognized or confronted, substantial interpersonal conflict will ensue.

• Determining if there is a history of suicide/ homicide/ self-mutilation, and if there are co-occurring disorders as well, is a vital part of the initial assessment interview. •

Nursing diagnoses are given and reflect the problematic behaviors of the PD at the time.

• Communication guidelines for manipulative and impulsive behaviors are outlined.

• Careful evaluation for antidepressants, anticonvulsants (for aggressive and impulsive behaviors), and antipsychotics (for stress-induced psychotic thinking) may offer the patient relief.

• Therapy has been used for patients with PDs; however, there is little evidence-based research comparing the efficacy of different therapies with different disorders, except for dialectical behavior therapy (DBT), which has been extremely effective in people with borderline PD.
• A number of theoretical models help explain risk factors for the development of eating disorders. • Neurobiological theories identify an association between eating disorders, depression, and neuroendocrine abnormalities.

• Psychological theories explore issues of control in anorexia and affective instability and poor impulse control in bulimia, but these are not considered causes of eating disorders.

• Genetic theories postulate the existence of vulnerabilities that may predispose people toward eating disorders, and increasingly twin studies confirm genetic liability, which perhaps interacts with environmental mechanisms.

• Sociocultural models look both at our present societal ideal of being thin and at the ideal feminine role model in general.

• Families may serve as important allies in treatment.

• Eating disorders are now appearing in populations in which they had been rare. The dynamics— the stress of acculturation versus identification with the new culture— are being examined.

• Anorexia nervosa is a possibly life-threatening eating disorder that includes being severely underweight; having low blood pressure, pulse rate, and temperature measurements; being dehydrated; and having low serum potassium level and dysrhythmias. Anorexia may be treated in an inpatient treatment setting— in which milieu therapy, psychotherapy (cognitive), development of self-care skills, and psychobiological interventions can be implemented.

• Eating disorders, thought to occur only in preteen or teen-age groups, are now being diagnosed in people ages 35 to 65.

• Long-term treatment is provided on an outpatient basis and aims to help patients maintain healthy weight; it includes treatment modalities such as individual therapy, family therapy, group therapy, psychopharmacology, and nutrition counseling.

• Individuals with bulimia nervosa are typically within the normal weight range, but some may be slightly below or above ideal body weight.

• Assessment of a patient with bulimia may show enlargement of the parotid glands, dental erosion, and dental caries if the patient has induced vomiting.

• Acute care may be necessary when life-threatening complications are present, such as gastric rupture (rare), electrolyte imbalance, and cardiac dysrhythmias.

• The primary goal of interventions for a patient with bulimia is to interrupt the binge/ purge cycle. • Psychotherapy as well as self-care skill training is included.

• Long-term treatment focuses on therapy aimed at addressing any coexisting depression, substance abuse, and/ or personality disorders that are causing the patient distress and interfering with quality of life. Self-worth and interpersonal functioning eventually become issues that are useful to target.

Other specified feeding or eating disorder (OSFED), formerly eating disorder not otherwise specified (EDNOS) in DSM-IV, includes a variety of subthreshold patterns that do not meet full criteria as set forth in DSM-5.

• Binge eaters report a history of major depression significantly more often than non- binge eaters.

• Effective treatment for obese binge eaters integrates modification of the disordered eating, improvement of depressive symptoms, and achievement of an appropriate weight for the individual. Applying Critical Judgment
• Depression is the most commonly seen psychiatric syndrome in the health care system.

• There are a number of subtypes of depression and depressive clinical phenomena. Two primary depressive disorders are major depressive disorder (MDD) and chronic depressive disorder (dysthymic disorder). Bipolar disorder is the third major depressive disorder and is covered in Chapter 16

. • The symptoms in MDD are usually severe enough to interfere with a person's social or occupational functioning (inability to experience pleasure [anhedonia], significant weight loss, insomnia or hypersomnia, extreme fatigue [anergia], psychomotor agitation or retardation, diminished ability to think or concentrate, feelings of worthlessness, recurrent thoughts of death).

• A person with MDD may or may not have psychotic symptoms, and the symptoms a person usually exhibits during a major depression are different from the characteristics of the normal premorbid personality.

• In persistent depressive disorder (PDD) the symptoms last for at least 2 years and are usually considered mild to moderate. Usually, a person's social or occupational functioning is not as greatly impaired as they are in MDD, although they may cause significant distress or some impairment in these areas. The symptoms in a chronic/ dysthymic depression (PDD) are often congruent with the person's usual pattern of functioning.

• Many theories exist about the cause of depression. The most accepted is the psychophysiological theory; however, cognitive theory, learned helplessness theory, and psychodynamic and life events issues help explain triggers to depression and maintenance of depressive thoughts and feelings. •

Nursing assessment includes the evaluation of affect, thought processes (especially suicidal thoughts), feelings, physical behavior, and communication. The nurse also needs to be aware of the symptoms that mask depression.

• Nursing diagnoses can be numerous. Depressed individuals are always evaluated for Risk for suicide. Some other common nursing diagnoses are Anxiety, Hopelessness, Impaired social interaction, Chronic low self-esteem, Imbalanced nutrition, Constipation, Disturbed sleep pattern,Ineffective coping, Spiritual distress, Disabled family coping, and others.

• Interventions with patients who are depressed involve several approaches, including using specific principles of communication, planning activities of daily living, administering or participating in psychopharmacological therapy, maintaining a therapeutic environment, and teaching patients about the biochemical aspects of depression and medication teaching.

• Several short-term psychotherapies are effective in the treatment of depression, including IPT, CBT, and some forms of group therapy.

• Electroconvulsive therapy (ECT) is an effective treatment for people with major depression with psychotic features and for patient's refractory to other treatments. Vagus nerve stimulation (VNS) can be a valuable adjunctive treatment in treatment-resistant depression. Light therapy is the first line of treatment for seasonal affective disorder.

• Evaluation is ongoing throughout the nursing process, and patients' outcomes are compared with the stated outcome criteria and short-term and intermediate goals. The care plan is revised by use of the evaluation process when desired outcomes are not being met.
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