Clinical Reasoning and Personalized Nursing Care: Mental Health Exam 1

Discuss the bio-behavioral concepts and theories needed to design personalized nursing care for the promotion of mental health.

Biopsychosocial Model, Stress and Coping, Maslow's Hierarchy of Needs, Erikson's Psychosocial Stages, Peplau's Interpersonal Relations Theory, Self-Efficacy

What is Maslow's Hierarchy of Needs?

It is a conceptualization of human needs arranged in a pyramid, with basic needs at the bottom and higher-level needs at the top.

What are physiological needs in Maslow's Hierarchy?

They are the most basic needs, including food, oxygen, water, sleep, sex, and a constant body temperature.

What needs emerge once physiological needs are met in Maslow's Hierarchy?

Safety needs, which include security, protection, and freedom from fear and chaos.

What are safety needs according to Maslow's Hierarchy?

They include the need for security, protection, and freedom from fear, anxiety, and chaos.

What needs are associated with belonging and love in Maslow's Hierarchy?

The need for intimate relationships, love, affection, and belonging.

What are esteem needs in Maslow's Hierarchy?

The need for high self-regard and recognition from others, leading to feelings of confidence and value.

What is self-actualization in Maslow's Hierarchy?

The drive to realize one's full potential and become everything one is capable of becoming.

Correct order of Maslow's Hierarchy (Bottom of pyramid to top)

1. Physiological needs (food, water, sleep, etc.)

2. Safety needs (security, protection, stability)

3. Belongingness needs (love, affection, relationships)

4. Esteem needs (self-esteem, confidence, achievement)

5. Self-actualization needs (realizing one's full potential)

Erikson's Psychosocial Stages

1. Trust vs. Mistrust (Infancy)

2. Autonomy vs. Shame & Doubt (Early Childhood)

3. Initiative vs. Guilt (Play Age)

4. Industry vs. Inferiority (School Age)

5. Identity vs. Role Confusion (Adolescence)

6. Intimacy vs. Isolation (Young Adulthood)

7. Generativity vs. Stagnation (Adulthood)

8. Ego Integrity vs. Despair (Late Adulthood)

Each stage represents a psychosocial crisis that must be resolved to develop a healthy personality and progress successfully to the next stage. Erikson emphasized the importance of social experiences across the entire lifespan in shaping personality development.

Peplau's Interpersonal Relations Theory

Basis for developing a therapeutic relationship with a patient (especially useful for working with adult or child psychiatric patients). The relationship has certain parameters that are a major part of the treatment. The overlapping phases are orientation, identification, exploitation, and resolution.

Peplau's Four Levels of Anxiety

Mild, Moderate, Severe, Panic

Mild

seldom a problem

moderate

perceptual field diminishes

severe

perceptual field is so diminished that concentration centers on one detail only or on many extraneous details

Panic

the most intense state of anxiety

Define mental health

-The successful adaptation to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are age-appropriate and congruent with local and cultural norms.

-State of well-being in which individuals reach their own potential, cope with the normal stresses of life, work productively, and contribute to the community

Define mental illness

"Maladaptive responses to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are incongruent with the local and cultural norms and interfere with the individual's social, occupational, or physical functioning."

Describe the continuum of mental health and mental illness

-a concept that views mental health and mental illness not as distinct categories, but as points along a spectrum. On one end is optimal mental health and well-being, characterized by positive functioning, life satisfaction, and the ability to cope with life's stressors. The middle ground represents periods of mild distress or impairment that may be temporary. At the other end is severe, persistent mental illness involving significant disruptions in thinking, mood, and behavior.

-Everyone falls somewhere on the mental health-mental illness continuum and experience gradual or sudden shifts

-highlights that mental health is not simply the absence of mental illness, but a state of overall psychological wellness.

Discuss risk and protective factors for mental illness and mental health.

+Resilience

-Ability and capacity to secure resources needed to support well-being

-Characterized by

•Ability to secure needed resources

•Capacity for regulating one's own emotions and overcoming negative, self-defeating thoughts

-Essential to recovery

+Social and economic circumstances

-Family

-Schools and peer groups

-Socioeconomic status

-Educational advancement

+Environmental factors

-Political climate & cultural considerations

-Social & economic policies

Describe Stress Response Theories

Fight-or-Flight, General Adaptation Syndrome (GAS)

General Adaptation Syndrome (GAS)

a theory proposed by Hans Selye to describe the body's physiological response to stressors. It consists of three stages

1. Alarm stage

2. Resistance stage

3. Exhaustion stage

-Understanding GAS helps explain how chronic stress can overtax the body's coping mechanisms and contribute to physical and mental health problems over time.

Alarm or acute stress stage

•Activates sympathetic nervous system

•Activates HPA axis to stay on alert

Resistance or adaptation stage

•Sustained and optimal resistance to the stressor; recovery, repair, and renewal may occur.

Exhaustion stage

•Resources are depleted; the stress may become chronic

☆Sustained physical responses to stress promote susceptibility to many diseases☆

Fight-or-Flight

•Body prepares for situation that individual perceives as threat to survival

•Increased blood pressure, heart rate, respirations, and cardiac output

•New research indicates that men and women have different neural responses to stress

Describe the Physical Responses to Stress

•General Adaptation Syndrome (GAS)

•Links exist among stress (biopsychosocial), the immune system, and disease

-Activation of the sympathetic nervous system and the hypothalamic-pituitary-adrenal (HPA) axis.

-Triggers the release of hormones like cortisol, epinephrine, and norepinephrine which produce physiological changes:

- Increased heart rate, blood pressure, and breathing rate

- Dilated pupils and constricted blood vessels

- Elevated blood sugar levels

- Suppressed digestive and reproductive systems

- Tensed muscles

- Sweating and flushed skin

Describe the Psychological Responses to Stress

•ANXIETY!!!!!!!!

•A variety of thoughts, feelings, and behaviors are associated with an individual's response patterns.

•Adaptation is determined by the extent to which the thoughts, feelings, and behaviors interfere with an individual's functioning

Major primary psychological response pattern to stress.

ANXIETY

Ego defense mechanisms

•Some are more adaptive than others, but all are used either consciously or unconsciously as protective devices for the ego in an effort to relieve mild-to-moderate anxiety

+Sometimes they are appropriate to use - they do not necessarily denote "negative"

What is adaptation determined by?

the extent to which the thoughts, feelings, and behaviors interfere with an individual's functioning.

Define Anxiety as a Component of Stress

-primary psychological response pattern to stress

-A diffuse apprehension that is vague in nature and is associated with feelings of uncertainty and helplessness

-Extremely common in our society

-A MILD version is adaptive and can provide motivation for survival

-Becomes problematic when the individual is unable to prevent their response from escalating to a level that interferes with their ability to meet basic needs.

MILD Level of Anxiety

Individuals employ various coping mechanisms to deal with stress (e.g., sleeping; yawning; fidgeting; fingertapping;

MODERATE Level of Anxiety

•EGO DEFENSE MECHANISMS ACTIVATE:

Maladaptive when the defense mechanism interferes with ability to deal with reality as it is presented, with interpersonal relations or with occupational performance.

SEVERE ANXIETY

+If it remains unresolved over an extended period there is risk for development of physiological disorders, e.g., migraine headaches, irritable bowel syndrome, and cardiac arrhythmias.

•Extended periods of repression can result in psychoneurotic patterns of behaving, e.g., anxiety disorders and somatoform disorders.

Panic anxiety

•At this extreme level, an individual is not capable of processing what is happening in the environment and may lose contact with reality.

•Loss of contact with reality = psychosis

Psychosis

a significant thought disturbance in which reality testing is impaired, resulting in delusions, hallucinations, disorganized speech, or catatonic behaviour.

Describe Defense Mechanisms

•Sigmund Freud identified the ego as the reality component of the personality, governing problem solving and rational thinking

•As the level of anxiety increases, the strength of the ego is tested, and energy is mobilized to confront the threat

•Maladaptive use of defense mechanisms, on the other hand, promotes disintegration of the ego

Altruism

largely unconscious motivation to feel caring and concern for others and act for the well-being of others.

Compensation

used to counterbalance perceived deficiencies by emphasizing strengths.

Conversion

the unconscious transformation of anxiety into a physical symptom with no organic cause.

Denial

escaping unpleasant, anxiety-causing thoughts, feelings, wishes, or needs by ignoring their existence.

Displacement

is the transference of emotions associated with a particular person, object, or situation to another nonthreatening person, object, or situation.

Dissociation

disruption in consciousness, memory, identity, or perception of the environment that results in compartmentalizing uncomfortable or unpleasant aspects of oneself.

Identification

attributing to oneself the characteristics of another person or group. This may be done consciously or unconsciously.

Intellectualization

a process in which events are analyzed based on remote, cold facts and without passion, rather than incorporating feeling and emotion into the processing.

Projection

refers to the unconscious rejection of emotionally unacceptable features and attributing them to others.

Rationalization

justifying illogical or unreasonable ideas, actions, or feelings by developing acceptable explanations that satisfy the teller and the listener.

Reaction

when unacceptable feelings or behaviors are controlled and kept out of awareness by developing the opposite emotion or behavior.

Regression

reverting to an earlier, more primitive and childlike pattern of behavior that may or may not have been exhibited previously.

Repression

an unconscious exclusion of unpleasant or unwanted experiences, emotions, or ideas from conscious awareness.

Splitting

inability to integrate the positive and negative qualities of oneself or others into a cohesive image.

Sublimation

an unconscious process of transforming negative impulses into less damaging and even productive impulses.

Suppression

the conscious decision to delay addressing a disturbing situation or feeling. For example, Jessica has studied for the state board examination for a week. She says, "I won't worry about paying my rent until after my exam tomorrow."

Undoing

when a person makes up for a regrettable act or communication.

Mental illness versus physical illness

Root of most mental disorders lies in intercellular abnormalities

nature-plus-nurture argument

diathesis-stress model—in which diathesis represents biological predisposition and stress represents environmental stress or trauma—is the most accepted explanation for mental illness

-asserts that most psychiatric disorders result from a combination of genetic vulnerability and negative environmental stressors.

Diathesis

biological predisposition

Mental Health Parity Act

•passed in 1996.

-This legislation required insurers that provide mental health coverage to offer annual and lifetime benefits at the same level provided for medical/surgical coverage.

Parity

Equivalence

Incidence

number of new cases in a given time

Prevalence

number of cases regardless of when they began

Distress

•Negative draining energy that results in anxiety, depression, confusion, helplessness, hopelessness, and fatigue.

Eustress

Normal physiological positive energy that motivates individuals and results in positive feelings and purposeful movement

Maladaptive behavior

-refers to behaviors, thoughts, or emotions that are unhealthy, disruptive, or interfere with a person's ability to function effectively.

-considered harmful or counterproductive ways of coping with stress or challenges.

Adaptive behavior

refers to the ability to effectively adjust thoughts, emotions, and actions in response to changing situations and environments. It involves using constructive coping strategies and problem-solving skills to manage stress and challenges in a healthy, productive manner.

Clinical epidemiology

broad field that examines health and illness at the population level.

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition

(DSM-V)

-Official medical guidelines of the American Psychiatric Association for diagnosing psychiatric disorders

-Based on specific criteria influenced by multiprofessional clinical field trials

ICD-10-CM

Clinical descriptions of mental and behavior disorders

International Classification for Nursing Practice (ICNP)

+Provides standardized nursing diagnoses

+Nursing diagnoses are not DSM-V diagnoses

+Nursing diagnoses follow nursing assessment and guide the planning of nursing interventions to reach preferred patient outcomes

Basic Level Psych Nursing Interventions

1. Therapeutic nurse-patient relationship: Establishing a caring, trusting rapport to facilitate open communication and promote patient growth.

2. Milieu therapy: Creating a safe, structured therapeutic environment on the inpatient unit.

3. Patient education: Teaching patients and families about mental health conditions, treatments, coping strategies, and available resources.

4. Medication administration: Providing psychotropic medications as prescribed and monitoring for therapeutic effects and side effects.

5. Crisis intervention: Assisting patients through acute distress or dangerous situations using de-escalation techniques.

6. Supportive counseling: Offering empathetic listening, encouragement, and guidance to help patients develop insight and adaptive coping skills.

7. Monitoring and documentation: Closely observing patient behavior, mental status, and response to treatment, maintaining accurate records.

(Under supervision of advanced practice psychiatric nurses and psychiatrists.)

Who is certified to do psychotherapy?

psychiatric-mental health advanced practice registered nurse (PMH-APRN)

psychiatric clinical nurse specialist (CNS)

Describe the relevance of a therapeutic nurse-client relationship

Facilitate communication of distressing thoughts and feelings

Assist patient with problem solving

Help patient examine self-defeating behaviors and test alternatives

Promote self-care and independence

Provide education about disorders and treatments

what are the phases of relationship development

1. Preorientation phase

2. Orientation phase

3. Working phase

4. Termination phase

Preorientation Phase

Preparing for your assignment

Researching the patient's history

Recognizing one's own thoughts and

feelings about meeting this patient

Anticipating and setting ground rules

before the first meeting

Orientation Phase

Establishing rapport

Parameters of the relationship

Formal or informal contract

Confidentiality

Terms of termination (discuss termination during the first

meeting and again during the working stage at appropriate times)

Working Phase

Maintain relationship

Gather further data

Promote patient's

Problem-solving skills

Self-esteem

Use of language

Facilitate behavioral change

Overcome resistant behaviors

Evaluate problems and goals

Redefine them as necessary

Promote practice and expression

of alternative adaptive behaviors

Barriers in the working phase

Defense mechanisms (refer to module 1)

Transference and countertransference

(discussed in class in module 2)

Termination Phase

Summarize goals and objectives achieved

Discuss ways for patient to incorporate new coping strategies learned

Discuss plans for the future - (p. 131)

Review situations of relationship during nurse-patient relationship as

needed for reinforcement of patient growth and self-empowerment

Exchange memories - can help validate experience (p. 131)

Describe therapeutic communication techniques

´Silence

´Active listening

´Techniques to help improve clear communications

´Questions

´Open-ended

´Closed-ended

´Projective

´The miracle question - "caution"

Open-ended questions

encourage patients to share information about experiences, perceptions, or responses to a situation.

Closed-ended questions

Questions that can be answered in short or single word responses.

Projective questions

uses "what if" or similar questions to assist clients in exploring feelings and to gain greater understanding of problems and possible solutions

The miracle question

a goal-setting question that helps patients to see what the future would look like if a particular problem were to vanish.

Describe nontherapeutic communication techniques

´Excessive questioning

´Giving approval or disapproval

´Giving advice

´Asking "why" questions -Giving premature advice

-Minimizing feelings

-Falsely reassuring

-Making value judgments

-Changing the subject

Silence

Gives the person time to collect thoughts or think through a point.

Accepting

Indicates that the person has been understood. An accepting statement does not necessarily indicate agreement but is nonjudgmental.

Giving recognition

Indicates awareness of change and personal efforts. Does not imply good or bad, right or wrong.

Offering self

Offers presence, interest, and a desire to understand. Is not offered to get the person to talk or behave in a specific way.

Offering general leads

Allows the other person to take direction in the discussion. Indicates that the nurse is interested in what comes next.

Giving broad openings

Clarifies that the lead is to be taken by the patient. However, the nurse discourages pleasantries and small talk.

Placing the events in time or sequence

Puts events and actions in better perspective. Notes cause-and-effect relationships and identifies patterns of interpersonal difficulties.

Making observations

Calls attention to the person's behavior (e.g., trembling, nail-biting, restless mannerisms). Encourages patient to notice the behavior and describe thoughts and feelings for mutual understanding. Helpful with mute and withdrawn people.

Encouraging description of perception

Increases the nurse's understanding of the patient's perceptions. Talking about feelings and difficulties can lessen the need to act them out inappropriately.

Encouraging comparison

Brings out recurring themes in experiences or interpersonal relationships. Helps the person clarify similarities and differences.

Restating

Repeats the main idea expressed. Gives the patient an idea of what has been communicated. If the message has been misunderstood, the patient can clarify it.

Reflecting

Directs questions, feelings, and ideas back to the patient. Encourages the patient to accept personal ideas and feelings. Acknowledges the patient's right to have opinions and make decisions and encourages the patient to think of oneself as a capable person.

Focusing

Concentrates attention on a single point. It is especially useful when the patient jumps from topic to topic. If a person is experiencing a severe or panic level of anxiety, the nurse should not persist until the anxiety lessens.

Exploring

Examines certain ideas, experiences, or relationships more fully. If the patient chooses not to elaborate by answering no, the nurse does not probe or pry. In such a case, the nurse respects the patient's wishes.

Giving information

Makes facts the person needs available. Supplies knowledge from which decisions can be made or conclusions drawn. For example, the patient needs to know the role of the nurse, the purpose of the nurse-patient relationship, and the time, place, and duration of the meetings.

Seeking clarification

Helps patients clarify their own thoughts and maximize mutual understanding between nurse and patient.