mental health exam

recovery model

get patient back to optimal functioning level for them; emphasis on rehab and recovery

trauma informed care

treat everyone like they have been through something traumatic

patient-centered medical homes

provides access to physical health, behavioral health, and supportive community/social services; ranges from preventive care/acute medical problems to chronic conditions/end of life care

PCMH 5 key characteristics

comprehensive care, patient-centered care, coordinated care, accessible services, quality and safety

community mental health centers

regulated through state mental health departments

psychiatric rehab services

supports recovery and integration into society rather than accepting a medical model of dysfunction

intermediate steps between inpatient and outpatient

intensive outpatient programs and partial hospitalization programs

role of psych nurse in-patient

most intensive care in safe and structured setting

role of psych nurse out-patient

care for patient/family; develop/implement a plan of care along with multidisciplinary treatment team

therapeutic milieu

healthy environment combined with healthy social structure within inpatient setting or structured outpatient clinic

how nurses maintain therapeutic milieu

people test new behaviors/increase ability to interact with outside community; nurses lead community meetings with staff/patients to encourage engagement, and orient/introduce new members

where crisis intervention is provided

emergency departments of general hospitals and community based crisis intervention center

goal of crisis intervention

treat and psychoeducate in a short period of time

patient rights

right to treat, right to refuse treatment, right to informed consent, rights surrounding involuntary commitment and psychiatric directives, rights regarding restraint and seclusion rights after death 

voluntary admission

have the right to demand and obtain release at any time

involuntary admission

 person is in need of psychiatric treatment, presents danger to self/others, or unable to meet basic needs; right to inform consent and right to refuse medications

rights regarding restraints

free from physical/mental abuse/corporal punishment; not allowed if coercion, disciplined, convenience, or retaliation; only used to ensure immediate safety of patient, staff or others; must be discontinued ASAP

restraint orders/hours

• 4 hours for 18+

• 2 hours 9-17

• 1 hour 9 and under

environmental factors affecting communication

physical factors: background noise, lack of privacy, uncomfortable accommodations 

social determinants: sociopolitical, historical, economic factors, presence of others, expectation of others

personal factors that affect communication

emotional factors: mood, responses to stress, personal bias, relationship understandings 

social factors: previous experience, cultural differences, language differences, lifestyle differences 

cognitive factors: problem-solving ability, knowledge level, language use

active listening

strengthens patient’s ability to use critical thinking to solve problems 

techniques to enhance communication

silence, active listening, clarifying techniques

non-therapeutic communication techniques

asking excessive questioning, giving approval/disapproval, giving advice, asking “why” questions

therapeutic use of self

nurse-patient relationship is a creative process and unique to each person (a part of art of nursing)

evidence-based teaching

promotes adherence and positive outcomes and positive patient feedback

goals of nurse-client therapeutic relationship

meets patients needs; facilitating, assisting, helping, promoting

facilitates a client to engage more easily in a therapeutic relationship

nurse should offer leads/make statements of acceptance, showing interest to the patient 

roles nurse assumes in therapeutic relationship

teacher, counselor, socializing agent, liaison

establishing boundaries in a therapeutic relationship

provide a safe space where patient can explore feelings and treatment issues; patient needs separated from nurse’s needs and roles are defined and different

indication relationship is becoming non-therapeutic

nurse needs met at expense of patients, relationship slips into social context, overhelping, controlling, narcissism 

transference

process when a person unconsciously/inappropriately transfers patterns of behaviors/emotional reactions towards another person that originated from childhood; ex: desire for affection or resp

counter transference

tendency of the nurse to displace onto the patient feelings related to people in his/her past; stalls without recognition

phases of therapeutic relationship

preorientation, orientation, working, termination

helps build therapeutic relationship

needs of patient are identified/explored, alternate problem-solving approaches are take, new coping skills are developed, behavioral change is encouraged

2 factors that hamper development of therapeutic relationship

inconsistency and unavailability

tactics that should be avoided in interviewing client

argue with/minimization, false reassurance, advice, criticism of another nurse/staff, trying to sell patient on accepting treatment, question patient about sensitive areas

helpful guidelines in conducting interviews

speak briefly, don’t say anything if you don’t know something, focus on feelings, avoid advice, avoid relying on questions, pay attention to nonverbal cues, keep focus on patient

behaviors to keep in mind when conducting interview

culturally relevant and individually appropriate

palliative car

highly structured/organized system of care care intended to address needs of patients/family experiencing end of life; has a disease focused approach that’s changed to patient-centered philosophy

hospice

provided at end of life and is apart of palliative care trajectory

grief

response to loss of someone or something important and considered a normal and natural part of life

uncomplicated grief

experienced normally, cognitively, physically, socially, and spiritually

complicated grief

grief work is unresolved and occurs when individuals have difficulty coming to terms with loss and experience phenomena outside the normal grief reaction (can’t act socially or resume previous roles) 

phases of bereavement

denial and isolation, anger, bargaining, depression, acceptance

phenomena experienced bereavement

sensations of somatic distress, preoccupation with image of deceased, guilt, anger, changes in behavior like depression, disorganization, or restlessness

risk factors that complicate grieving

heavily dependent on deceased, unresolved/consistent conflicts with deceased, child was the one who is deceased, does bereaved have a support system/coping skills/difficulty resolving past significant losses/history of depression/drug/alcohol abuse, was the decreased a veteran

nursing diagnoses that may apply to complicated grief

dysfunctional grief, risk for dysfunctional grief, grief, risk for depressed moods

interventions for helping people in grief

full presence/eye contact/attentive listening, shared information about phenomena that occurs during normal grieving process, encourage family/support system, refer to community bereavement group, offer spiritual support, show understanding/support

guidelines for talking to bereaved person

educational component, encourage full expression of emotions/affect, help bereaved come to peace with new relationship to deceased

competencies/skills a nurse uses for terminally ill patients/families

communication and therapeutic presence

role of nurse in end of life conversations about AD

clarify goals and wishes by exploring values, beliefs, and priorities

how nurse helps people say goodbye

adjust to caregiver demands, gather information, finalize connection to dying person, forgiveness/love/gratitude/farewell

compassion fatigue

emotional pain or cost of working traumatized persons

what levels of anxiety can a person still solve problems

mild and moderate

levels of anxiety

mild, moderate, severe, panic level

mild anxiety

normal experience of everyday life

moderate anxiety

something needs attention, selective inattention, clear thinking is hampered, but learning/problem solving can still take place

severe anxiety

overly focused on 1 particular detail, can have difficulty noticing events occurring, hyperventilation, learning/problem solving is significantly affected at this level 

panic level anxiety

markedly disturbed behavior, not able to process events in the environment and loses touch with reality

when anxiety becomes pathological

when intensity of emotional response is out of proportion to threat, emotional response persists after threat is resolved, emotional response becomes generalized to benign situations

how nurse assists client to determine possible solutions to avoid escalating anxiety

establishing therapeutic relationship, active listening, assist patient with self-awareness and identifying potential solutions, introduce new coping strategies/activities, supporting the patient in carrying out the plan

healthy defense mechanisms

alturism, sublimation, humor, suppression

alturism

conflicts/stressors are addressed by meeting other’s needs

sublimation

unconscious process of substituting constructive/socially acceptable activity for strong impulses not considered acceptable

suppression

denial of a disturbing situation/feeling

intermediate defense mechanisms

repression, displacement, reaction formation, somatization, undoing, rationalization

repression

exclusion of unpleasant/unwanted experiences

displacement

transfer of emotions

reaction formation

unacceptable feelings/behaviors are kept out of awareness by developing opposite emotions and behaviors

somatization

indirect way to communicate the need for help in a more socially acceptable manner 

immature/unhealthy defenses

passive aggression, acting-out behaviors, dissociation, idealization, splitting, projection, denial

splitting

inability to integrate positive and negative qualities of oneself or others (switching back and forth)

denial

escaping unpleasant realities by ignoring their existence

unhealthy result of chronic stress

hypertension, heart attack/disease, stroke, atherosclerosis, diabetes, cancer, ulcers, chronic GI problems, allergies, eczema, autoimmune diseases, arthritis, headaches, reduced immunity, kidney and liver disease

physiologic responses in the alarm stage or fight or flight response

increased heart rate, respirations, plasma FFAs and sugar, triglycerides, platelet aggregation, blood to skeletal muscles, muscular tension, decreased kidney clearance

1980’s change for rehab/institution approaches

inpatient stays were at a peak, private/nonfederal general hospital psychiatric units multiplied, shift to a more independent focus

interpersonal theory

sullivan, psychodynamic theory, shorter, less expensive, become functional quicker, tertiary recovery model

cognitive behavior therapy

negative and self-critical thinking causes depression

classical conditioning

involuntary behavior can be conditioned to respond to neutral stimuli

operant conditioning

voluntary behaviors are learned through positive/negative reinforcement

behavioral therapy

corrects and eliminates maladaptive by rewording/reinforcing behavior

maslow hierarchy of needs

physiological, safety, love/belonging, esteem, self-actualization, self-transcendent

roger’s therapeutic model

person-centered therapy

levels of care

acute, tertiary, custodial

acute care

inpatient, detox, crisis stabilization

tertiary care

rehab and skilled care, day hospital

custodial care

independent

necessary loss

loss related to a change that is part of the cycle of life, anticipated but still can be intensely felt; this type of loss can be replaced by something different/better

actual loss

any loss of a valued person, item, or status (loss of a job) that others can recognize

perceived loss

anything clients define as loss but that is not obvious or verifiable to others

maturational or developmental loss

any loss normally expected due to the developmental processes of life; associated with normal life transitions and help people develop coping skills (a child leaving home for college)

situational loss

any unanticipated loss caused by an external event (a family loses their home during tornado)

anticipatory loss

experienced before the loss happens

normal grief

uncomplicated, negative emotions but should change to acceptance with time, some acceptance should be evident by 6 months after the loss, somatic complaints can include chest pain, palpitations, headaches, nausea, changes in sleep patterns, and fatigue

anticipatory grief

 implies the “letting go” of an object or person before the loss, as in a terminal illness, start grieving before the actual loss

complicated grief

chronic, exaggerated, masked, and delayed grief; client can develop suicidal ideation, intense feelings of guilt, and lowered self-esteem; somatic complaints persist for an extended period of time

Disenfranchised grief

grief entails an experienced loss that cannot be publicly shared or is not culturally acceptable (death of an incarcerated person, abortion)

manifestations of approaching death

decreased level of consciousness; loss of muscle tone, with obvious relaxation of the face; labored breathing, dyspnea, apnea, cheyne-Stokes respirations; audible respirations due to pulmonary secretions (“death rattle”); sense of touch is diminished, but client can feel the pressure of touch, mucus collecting in large airways; incontinence of bowel and/or bladder; mottling, cyanosis occurring with poor circulation; pupils no longer reactive to light; pulse slow and weak, blood pressure dropping; cool extremities; perspiration; decreased and dark urine output; inability to swallow

prolonged effects of stress

increased cortisol, cytokines, inflammation, hurts immune and circulatory system, hardening of arteries, stroke, diabetes, weight gain

what happens when a person encounters stress

glucose to muscles, muscles get a better blood supply, tense, fight/flight response