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ATI Mental

Terms in this set (85)

Beneficence
› This relates to the quality of doing good and can be described as charity.
› Ex. A nurse helps a newly admitted client who has psychosis feel safe in the environment of the mental health facility.
Autonomy
This refers to the client's right to make her own decisions. But the client must accept the consequences of those decisions. The client must also respect the decisions
of others.
› Ex. Rather than giving advice to a client who has difficulty making decisions, a nurse helps the client explore all alternatives and arrive at a choice.
Justice
This is defined as fair and equal treatment for all.
Ex. During a treatment team meeting, a nurse leads a discussion regarding whether or not two clients who
broke the same facility rule were treated equally.
Fidelity
› This relates to loyalty and faithfulness to the client and to one's duty.
› Ex.A client asks a nurse to be present when he talks to his mother for the first time in a year. The nurse remains with the client during this interaction.
Veracity
This refers to being honest when dealing with a client.
›Ex. A client states, "You and that other staff member were talking about me, weren't you?" The nurse truthfully replies, "We were discussing ways to help you relate
to the other clients in a more positive way."
Voluntary commitment
client has the right to apply for release at any time. This client is considered competent, and so has the right to refuse medication and treatment.
Involuntary (civil) commitment
The client enters the mental health facility against her will for an indefinite period of time. The commitment is based on the client's need for psychiatric treatment, the risk of harm to self or others, or the inability to provide self-care.
Clients admitted under involuntary commitment are still considered ____ and have the right to ____ treatment, unless they have gone through a legal competency hearing and have been judged incompetent. The client who has been judged incompetent has a temporary or permanent _____ , usually a family member if possible, appointed by the court.
competent, refuse, guardian
In general, seclusion and/or restraint should be:
ordered for the shortest duration necessary, and only if less restrictive measures are not sufficient. They are for the physical protection of the client and/or the protection of other clients and staff.
Restraints can be either _____ or _____, such as neuroleptic medication to calm the client.
physical or chemical
Seclusion and/or restraint must never be used for:
◯ Convenience of the staff
◯ Punishment of the client
◯ Clients who are extremely physically or mentally unstable
◯ Clients who cannot tolerate the decreased stimulation of a seclusion room
The following must occur in order for seclusion or restraint to be used:
ordered by the primary care provider in writing.
◯ The order must specify the duration of treatment.
◯ The provider must rewrite the order, specifying the type of restraint, every 24 hr or the frequency of time specified by facility policy.
Clients in restraints must be:
Assessed (including for safety and physical needs), and the client's behavior documented
■ Offered food and fluid
■ Toileted
■ Monitored for vital signs
Documentation for restraints must include:
Precipitating events and behavior of the client prior to seclusion or restraint
■ Alternative actions taken to avoid seclusion or restraint
■ The time treatment began
■ The client's current behavior, what foods or fluids were offered and taken, needs provided for, and vital signs
■ Medication administration
Emergent restraint use allows:
an emergency situation must be present for the charge nurse to use seclusion or restraints without first obtaining a provider's written order. If this treatment is initiated, the nurse must obtain the written order within a specified period of time (usually 15 to 30 min).
False imprisonment
Confining a client to a specific area, such as a seclusion room, is false imprisonment if the reason for such confinement is for the convenience of the staff.
Assault
Making a threat to a client's person, such as approaching the client in a threatening manner with a syringe in hand, is considered assault.
Battery
Touching a client in a harmful or offensive way is considered battery. This would occur if the nurse threatening the client with a syringe actually grabbed the client and gave an injection.
Intrapersonal communication
communication that occurs within an individual. Also identified as "self-talk."
Interpersonal communication
communication that occurs between two or more people in a small group
Public communication
communication that occurs within large groups of people
Transpersonal communication
communication that addresses an individual's spiritual needs and provides interventions to meet those needs
Essential Components of Therapeutic Communication
Time, Attending behaviors or active listening - These are:
■ Eye contact, Body language, Vocal quality, Verbal tracking; Caring attitude, Honesty, Trust, Empathy, Nonjudgmental attitude
Communicating with children
Use simple, straightforward language.
☐ Be aware of own nonverbal messages, as children are sensitive to nonverbal communication.
☐ Enhance communication by being at the child's eye level.
☐ Incorporate play in interactions.
Communicating with adults
Recognize that the client may require amplification.
☐ Minimize distractions, and face the client when speaking.
☐ Allow plenty of time for the client to respond.
☐ When impaired communication is assessed, ask for input from caregivers or family to determine the extent of the deficits and how best to communicate.
Clarifying techniques
This technique is used to determine if the message received was accurate:
» Restating - uses the client's exact words.
» Reflecting - directs the focus back to the client in order for the client to examine his feelings.
» Paraphrasing - restates the client's feelings and thoughts for the client to confirm what has been communicated.
» Exploring - allows the nurse to gather more information regarding important topics mentioned by the client.
Presenting reality
This technique is used to help the client focus on what is actually happening and to dispel delusions, hallucinations, or faulty beliefs.
Offering self
Use of this technique demonstrates a willingness to spend time with the client. Limited personal information may be shared, but the focus should return to the client as soon as possible. Relevant self-disclosure by the nurse allows the client to see that his experience is shared by others
and understood.
Barriers to Effective Communication
● Asking irrelevant personal questions
● Offering personal opinions
● Giving advice
● Giving false reassurance
● Minimizing feelings
● Changing the topic
● Asking "why" questions
● Offering value judgments
● Excessive questioning
● Responding approvingly or disapprovingly
Altruism
Dealing with anxiety by reaching out to others
Ex. A nurse who lost a family member in a fire is a volunteer firefighter.
Sublimation
› Dealing with unacceptable feelings or impulses by unconsciously substituting acceptable forms
of expression
Ex. A person who has feelings of anger and hostility toward his work supervisor sublimates those feelings by working out vigorously at the gym during his lunch period
Suppression
Voluntarily denying unpleasant thoughts and feelings
›Ex. A person who has lost his job states he will worry about paying his bills
next week.
Repression
› Putting unacceptable ideas, thoughts, and emotions out of conscious awareness
Ex.› A person who has a fear of the dentist's drill continually "forgets" his dental appointments.
Undoing
› Performing an act to make up for prior behavior
›Ex. An adolescent completes his chores without being prompted after having
an argument with his parent.
Displacement
› Shifting feelings related to an object, person, or situation to another less threatening object, person, or situation
›Ex. A person who is angry about losing his job destroys his child's favorite toy.
Reaction formation
› Overcompensating or demonstrating the opposite behavior of what is felt
› Ex. A person who dislikes her sister's daughter offers to babysit so that her sister can go out of town.
Dissociation
Temporarily blocking memories and perceptions from consciousness
›Ex. An adolescent witnesses a shooting and is unable to recall any details of
the event.
Splitting
Demonstrating an inability to reconcile negative and positive attributes of self or others
› Ex. A client tells a nurse that she is the only one who cares about her, yet the following day, the same client refuses to talk to the nurse.
Levels of Anxiety: MILD
› Mild anxiety occurs in the normal experience of everyday living.
› It increases one's ability to perceive reality.
› There is an identifiable cause of the anxiety.
› Other characteristics include a vague feeling of mild discomfort, restlessness, irritability, impatience, and apprehension.
› The client may exhibit behaviors such as finger- or foot-tapping, fidgeting, or lip-chewing as mild tension-relieving behaviors.
Levels of Anxiety: MODERATE
› Moderate anxiety occurs when mild anxiety escalates.
› Slightly reduced perception and processing of information occurs, and selective
inattention may occur.
› Ability to think clearly is hampered, but learning and problem solving may still occur.
› Other characteristics include concentration difficulties, tiredness, pacing, change in voice pitch, voice tremors, shakiness, and increased heart rate and respiratory rate.
› The client may report somatic complaints including headaches, backache, urinary urgency and frequency, and insomnia.
› The client with this type of anxiety usually benefits from the direction of others.
Levels of Anxiety: SEVERE
› Perceptual field is greatly reduced with distorted perceptions.
› Learning and problem-solving do not occur.
› Functioning is ineffective.
› Other characteristics include confusion, feelings of impending doom, hyperventilation, tachycardia, withdrawal, loud and rapid speech, and aimless activity.
› The client with severe anxiety usually is not able to take direction from others.
Panic-level
Levels of Anxiety: PANIC LEVEL
› Panic-level anxiety is characterized by markedly disturbed behavior.
› The client is not able to process what is occurring in the environment and may lose touch
with reality.
› The client experiences extreme fright and horror.
› The client experiences severe hyperactivity or flight.
› Immobility can occur.
› Other characteristics may include dysfunction in speech, dilated pupils, severe shakiness, severe withdrawal, inability to sleep, delusions, and hallucinations.
NURSING INTERVENTIONS FOR THE CLIENT WITH SEVERE TO PANIC LEVELS OF ANXIETY
Set limits by using firm, short, and simple statements. Repetition may be necessary.
Direct the client to acknowledge reality and focus on what is present in the environment
Management of the milieu refers to
the management of the total environment of the mental health unit in order to provide the least amount of stress, while promoting the greatest benefit for all the clients.
Orientation Phase (nurse)
› Introduce self to the client and state purpose.
› Set the contract: meeting time, place, frequency, duration,
and date of termination.
› Discuss confidentiality.
› Build trust by establishing expectations and boundaries.
› Set goals with the client.
› Explore the client's ideas, issues, and needs.
› Explore the meaning of testing behaviors.
› Enforce limits on testing or other inappropriate behaviors.
Working Phase (nurse)
› Maintain relationship according to the contract.
› Perform ongoing assessment to plan and evaluate
therapeutic measures.
› Facilitate the client's expression of needs and issues.
› Encourage the client to problem-solve.
› Promote the client's self-esteem.
› Foster positive behavioral change.
› Explore and deal with resistance and other defense mechanisms.
› Recognize transference and countertransference issues.
› Reassess the client's problems and goals, and revise plans as necessary.
› Support the client's adaptive alternatives and use of new coping skills.
› Remind the client about the date of termination.
Termination Phase (nurse)
› Provide opportunity for the client to discuss thoughts and feelings about termination and loss.
› Discuss the client's previous experience with separations and loss.
› Elicit the client's feelings about the therapeutic work in the nurse-client relationship.
› Summarize goals and achievements.
› Review memories of work in the sessions.
› Express own feelings about sessions to validate the experience with the client.
› Discuss ways for the client to incorporate new healthy behaviors into life.
› Maintain limits of final termination.
TRANSFERENCE
Description
› Transference occurs when the client views a member of the health care team as having characteristics of another person who has been significant to the client's personal life.
Example
› A client may see a nurse as being like his mother, and thus may demonstrate some of the same behaviors with the nurse as he demonstrated with his mother.
Nursing Implications
› A nurse should be aware that transference by a client is more likely to occur with a person in authority.
COUNTERTRANSFERENCE
Description
› Countertransference occurs when a health care team member displaces characteristics of people in her past onto a client.
Example
› A nurse may feel defensive and angry with a client for no apparent reason if the client reminds her of a friend who often elicited those feelings.
Nursing Implications
› A nurse should be aware that clients who induce very strong personal feelings may become objects of countertransference.
Set up the following provisions to prevent client self-harm or harm by others
■ No access to sharp or otherwise harmful objects
■ Restriction of client access to restricted or locked areas
■ Monitoring of visitors
■ Restriction of alcohol and illegal substance access or use
■ Restriction of sexual activity among clients
■ Deterrence of elopement from facility
■ Rapid de-escalation of disruptive and potentially violent behaviors through planned interventions by trained staff
Factors that will affect the future of mental health care include the following:
◯ An increase in the aging population
◯ An increase in cultural diversity within the United States
◯ The expansion of technology, which may provide new settings for client care, as well as new ways to treat mental illness more effectively
Criteria to justify admission to an acute care facility include:
◯ A clear risk of the client's danger to self or others
◯ The failure of community-based treatment
◯ A dangerous decline in the mental health status of a client undergoing long-term treatment
◯ A client having a medical need in addition to a mental illness
In acute care mental health facilities nursing roles include the following:
■ Overall management of the unit, including client activities and therapeutic milieu
■ Ensuring safe administration and monitoring of all client medications
■ Implementation of individual client treatment plans, including client teaching
■ Documentation of the nursing process for each client
■ Managing crises as they arise
› Primary prevention promotes health and prevents mental health problems from occurring
Ex.› A nurse leads a group for parents of toddlers, discussing normal toddler behavior and ways to
promote healthy development.
› Secondary prevention focuses on early detection of mental illness.
› A nurse screens parents of children who have developmental disorders
› Tertiary prevention focuses on rehabilitation and prevention of further problems in clients previously diagnosed.
› A nurse leads a support group for clients who have completed a substance use disorder program.
COMMUNITY-BASED MENTAL HEALTH PROGRAMS Partial hospitalization programs
› These programs provide intense short-term treatment for clients who are well enough to go home every night and who have a responsible person at home to provide support and a safe environment.
› Certain detoxification programs are a specialized form of partial hospitalization for clients who require medical supervision, stress management, substance use disorder counseling, and relapse prevention.
COMMUNITY-BASED MENTAL HEALTH PROGRAMS
Assertive community treatment (ACT)
› This includes nontraditional case management and treatment by an interprofessional team for clients who have severe mental illness and are noncompliant with traditional treatment.
› ACT helps to reduce reoccurrences of hospitalizations and provides crisis intervention, assistance with independent living, and information regarding resources for necessary support services.
COMMUNITY-BASED MENTAL HEALTH PROGRAMS Community mental health centers
› These facilities provide a variety of services for a wide range of community clients, including: » Educational groups
» Medication dispensing programs
» Individual counseling programs
COMMUNITY-BASED MENTAL HEALTH PROGRAMS Psychosocial rehabilitation programs
› These programs provide a structured range of programs for clients in a mental health setting, including: » Residential services
» Day programs for older adults
COMMUNITY-BASED MENTAL HEALTH PROGRAMS Home care
› Home care provides mental health assessment, interventions, and family support in the client's home. This is implemented most often for children, older adults, and clients with medical conditions.
Behavioral therapy is based on the theory that
behavior is learned and has consequences. Abnormal behavior results from an attempt to avoid painful feelings. Changing abnormal
or maladaptive behavior can occur without the need for insight into the underlying cause of the behavior.
MODELING
Definition
› A therapist or others serve as role models for a client, who imitates this modeling to improve behavior.
Use in Mental Health Nursing
› Modeling can occur in the acute care milieu to help clients improve interpersonal skills. The therapist demonstrates appropriate behavior in a stressful situation with the goal of having the client imitate the behavior.
OPERANT CONDITIONING
Definition
› The client receives positive rewards for positive behavior (positive reinforcement).
Use in Mental Health Nursing
› As an example: a client receives tokens for good behavior, and he can exchange them for a privilege or other items.
SYSTEMATIC DESENSITIZATION
Definition
› This therapy is the planned, progressive, or graduated exposure to anxiety-provoking stimuli in real-life situations, or by imagining events that cause anxiety. During exposure, the client uses relaxation techniques to suppress anxiety response.
Use in Mental Health Nursing
› Systematic desensitization begins with the client mastering relaxation techniques. Then, the client is exposed to increasing levels of the anxiety-producing stimulus (either imagined or real) and uses relaxation to overcome anxiety. The client is then able to tolerate a greater and greater level of the stimulus until anxiety no longer interferes with functioning.
AVERSION THERAPY
Definition
› Pairing of a maladaptive behavior with a punishment or unpleasant stimuli to promote a change in the behavior.
Use in Mental Health Nursing
› A therapist or treatment team may use unpleasant stimuli, such as bitter taste or mild electric shock, as punishment for behaviors such as alcohol use disorder, violence, self-mutilation, and thumb sucking.
MEDITATION, GUIDED IMAGERY, DIAPHRAGMATIC BREATHING, MUSCLE RELAXATION, AND BIOFEEDBACK
Definition
› This therapy uses various techniques to control pain, tension, and anxiety.
Use in Mental Health Nursing
› As an example, a nurse can teach diaphragmatic breathing to a client having a panic attack, or to a female client in labor.
Which age group benefits the most from group therapy?
Adolescent - it is especially valuable, as this age group typically has strong peer relationships
Healthy Families
› There are clear, understandable messages between family members, and each member is encouraged to express individual feelings and thoughts.
General adaptation syndrome (GAS) is
the body's response to an increased demand. The first stage is the initial adaptive response, also known as the "fight or flight" mechanism. If stress is prolonged, maladaptive responses can occur.
ACUTE STRESS (FIGHT OR FLIGHT)
› Apprehension, Unhappiness or sorrow, Decreased appetite, Increased respiratory rate, heart rate, cardiac output, blood pressure, Increased metabolism and glucose use, Depressed immune system
PROLONGED STRESS (MALADAPTIVE RESPONSE)
› Chronic anxiety or panic attacks, Depression, chronic pain, sleep disturbances,Weight gain or loss, increased risk for myocardial infarction, stroke, Poor diabetes control, hypertension, fatigue, irritability, decreased ability to concentrate, increased risk for infection
Cognitive reframing
The client is helped to look at irrational cognitions (thoughts) in a more realistic light and to restructure those thoughts in a more positive way.
Electroconvulsive therapy (ECT)
■ ECT uses electrical current to induce brief seizure activity while the client is anesthetized.
Indications for ECT
MDD (unresponsive to other therapies), Schizophrenia (unresponsive to meds), Acute Mania (Bipolar with rapid cycling)
Contraindications for ECT
◯ Recent myocardial infarction
◯ History of cerebrovascular accident
◯ Cerebrovascular malformation
◯ Intracranial mass lesion
◯ Increased intracranial pressure
The typical course of ECT treatment
treatment is three times a week for a total of six to 12 treatments
BEFORE ECT can be done
■ Any medications that affect the client's seizure threshold must be decreased or discontinued several days before the ECT procedure.
■ MAOIs and lithium should be discontinued 2 weeks before the ECT procedure.
◯ Severe hypertension should be controlled because a short period of hypertension occurs immediately after the ECT procedure.
◯ Any cardiac conditions, such as dysrhythmias, should be monitored and treated before the procedure.
◯ The nurse monitors the client's vital signs and mental status before and after the ECT procedure.
◯ The nurse also assesses the client's and family's understanding and knowledge of the procedure and provides teaching as necessary.
◯ Thirty minutes prior to the beginning of the procedure, an IM injection of atropine sulfate or glycopyrrolate (Robinul) is given to decrease secretions and counteract any vagal stimulation.
◯ An IV line is inserted and maintained until full recovery
Selective Serotonin Reuptake Inhibitors (SSRIs)
» Citalopram (Celexa)
» Fluoxetine (Prozac)
» Sertraline (Zoloft)
› Advise the client that adverse effects may include nausea, headache, and CNS stimulation (agitation, insomnia, anxiety).
› Instruct the client that sexual dysfunction may occur and to notify provider if effects are intolerable.
› Advise the client to observe for manifestations of serotonin syndrome. If any occur, instruct the client to withhold the medication and notify the provider.
› Instruct the client to avoid the concurrent use of
St. John's wort, which can increase the risk of serotonin syndrome.
› Instruct the client to follow a healthy diet because weight gain can occur with long-term use.
› Tricyclic Antidepressants » Amitriptyline (Elavil)
› Advise the client to change positions slowly to minimize dizziness from orthostatic hypotension.
› To minimize anticholinergic effects, advise the client to chew sugarless gum, eat foods high in fiber, and increase fluid intake to 2 to 3 L/day from food and beverage sources.
› Monoamine Oxidase Inhibitors (MAOIs)
» Phenelzine (Nardil)
› Due to the risk for hypertensive crisis, advise the client to avoid foods with tyramine (ripe avocados or figs, fermented or smoked meats, liver, dried or cured fish, most cheeses, some beer and wine, and protein dietary supplements).
› Due to the risk of medication interactions, instruct
the client to avoid all medications, including over-the-counter, without first discussing them with the provider.
Atypical Antidepressants
» Bupropion (Wellbutrin)
› Advise the client to observe for headache, dry mouth, GI distress, constipation, increased heart rate, nausea, restlessness, or insomnia, and to notify the provider if they become intolerable.
› Monitor the client's food intake and weight due to appetite suppression.
› Avoid administering to clients at risk for seizures.
› Serotonin Norepinephrine Reuptake Inhibitors
» Venlafaxine (Effexor)
» Duloxetine (Cymbalta)
Adverse effects include nausea, weight gain, and sexual dysfunction.
Positive symptoms - The manifestation of things that are not normally present. These are the most easily identified symptoms.
› Hallucinations › Alterations in speech › Delusions
› Bizarre behavior, such as walking backward constantly
Negative symptoms - The absence of things that are normally present. These symptoms are more difficult to treat successfully than positive symptoms.
› Affect - usually blunted (narrow range of normal expression) or flat (facial expression never changes)
› Alogia - poverty of thought or speech; the client may sit with a visitor but may only mumble or respond vaguely to questions.
› Anergia - lack of energy
› Anhedonia - lack of pleasure or joy; the client is indifferent to things that often make others happy, such as looking at beautiful scenery.
› Avolition - lack of motivation in activities and hygiene; for example, the client completes an assigned task, such as making his bed, but is unable to start the next common chore without prompting.
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