Psych Exam 1

Therapeutic Relationship/Communication - purpose

Pt centered, planned, directed by professional, meets pt needs, guides pt to explore personal issues and painful feelings, listen, information shared w/ health team

HELP

H = Hear pt’s story

E = Explore feelings

L = Listen actively

P = Put pt in charge

STOP

S = Solve problem

T = Tell what to do

O = Offer false reassurance

P = Pass judgement

Do’s

• Accepting

• Broad Openings

• Consensual validation

• Exploring

• Reflecting

• Silence

• Restating

Don’ts

• Advising

• Agree/disagree

• Challenging/argue

• Defending

• Disapproval/approval

Environment

• Privacy

• Furniture

• Temperature

• Noise level

• Proxemics: the way ppl perceive + use environmental, social, personal space during interactions

• Front-facing

• Arms length away

• Boundaries

Potential Impairments

• Hearing loss

• Developmental disabilities (problems comprehending + remembering)

• Speech impediments

• Pain interfering w/ ability to think clearly + concentrate

Nonverbal (Kinesics: nonverbal communication via body language)

• Culture based

• Body language:

  • Facial expressions, eye movement, eye contact

  • Gestures, mannerisms

• Might be incongruent w/ words

• Validate meaning

• Posture, looks, actions

HIPAA

• Know respecting the patient's rights to privacy + who gets to look at the information. Protects SSN + DOB. Pt has rights to their own records. Document what you see vs what you think. Protect the pt’s data. No grease board bc anyone can walk by and see info.

• HIPPA violation: I met a celebrity. Can’t say her name but I can’t wait to see her wedding pics

• I think you said..I think I heard you say..Tell me more..Table 8.1 (read it)

Features of the Therapeutic Milieu (Day Room) 35min

• Safety

• Structure (limited, simple rooms)

• Norms

• Balance

• Environmental modifications

Purpose of Mental Health Assessment

• Determine level of care needed

• Safety/Risk

• Intensity of Supervision Needed/Danger to self/others

• Severity of S/S, Level of Functioning (Gravely disabled/Acutely Psychotic)

Elements of the Continuum of Care (Hospital through Self Help Groups)

• Nurse role = assess + direct/escort pt to appropriate services

• Multidisciplinary team collab coordinates care

• Team includes professionals, pts, families, representatives from insurance companies, nursing homes, group homes, medical clinical

• Hospital:

  • 3-5 days

  • Crisis intervention + safety/stabilization

  • Pts = acutely symptomatic

  • Discharge planning on admission

  • Detoxification from substances/medications

  • Pts w/ medical illness w/ behavioral S/S or complicates existing psychiatric illness

• Long-Term Care: Residential Services; state-run facilities

  • State/Federal Forensic/Civil

  • Extended-care facility, nursing homes, group homes, half-way homes, supervised living apartment, foster care, shelters: homeless or safety d/t DV

• Traditional Outpatient Services:

  • Clinic/private practice

  • Appointments determined by individual need

  • Staff = psychiatrist, psychologist, NP, RN, social worker, LMHC, case manager

  • May receive services from >1 NP depending on need

• Day Treatment Program:

  • For Pts who need minimal supervision, but can’t stay in hospital any longer

  • Ongoing treatment that is structured

  • Care 4-8hrs/day for 1-5days/wk

  • Adult, child, adolescent

  • May specialize in specific populations (Ex. substance abuse)

• Self-Help Groups:

  • Meeting conducted by nonprofessionals (individuals who have experienced the mental illness)

    • Ex. AA, Narcotics Anonymous

    • Addiction, survivor, disorder, loss, medical, prevention based

Lobotomy

• Egas Moniz did first

• Make two holes in pt skull, inject etoh to cortex to kill part of brain

• Transorbital lobotomy: go in through eye

Benchmark I: 1790s

• Period of Enlightenment

• Asylum: two meanings

  • Protection, social support, sanctuary

  • Place of mistreatment, neglect

• Tuke - ensured moral treatment (England)

• Pinel - unchained + clothed pts, provided food + abolished abuse (France)

• Dix - developed concept of asylum, adequate shelter, nutritious food, warm clothing (USA 32 state hospitals + change in term asylum)

Benchmark II: mid-late 1800s

• Major scientists

  • Freud - described human behavior (talking, dreams, hidden meaning)

    • Psychoanalysis, defense mechanism, free association, lay on therapist chair..say words like “cat”

  • Kraepelin - classified mental disorders (schizophrenia)

  • Bleuler - coined word “schizophrenia” + added understanding to treatment -> positive outcome for schizo pts

Benchmark III: 1950s

• Period of psychotropic drugs

• Antipsychotics:

  • Chlorpromazine (Thorazine), Haloperidol (Haldol)

  • Tricyclic antidepressant: Imipramine (Tofranil)

  • Antimanic/mood stabilizer: Lithium (Gold standard for schizo)

• Insulin shock therapy -> Induces seizure -> Pt better; Thorazine reduced the need for electroshock therapy

  • Thorazine Shuffle = blank look on face

Benchmark IV: 1960s

• Period of Community Mental Health Centers Act, 1963 -> funding shift from institutions to community facilities; hospitals stopped mental health units bc no funding -> deinstitutionalization after 1955; SSI benefits; Commitment law changes

• Deinstitutionalization -> individuals w/ mental illness had to live in

  • Prisons/jails

  • Nursing homes, state hospitals

  • Homeless

  • Home w/ family, group home, own

Benchmark V: 1990s

• Box 2.1 p.10 + Box 2.2 p.17

• Decade of the Brain

• Brain research + public interest in explanations for mental disorders

• Diagnostic and Statistical Manual of Mental Health (DSM-5) revision*

  • DSM-5: tells S/S, diagnosis, treatment

• Nursing books include psychobiology + psychopharmacology

• Paradigm shift in psychiatric care

  • Homelessness

Recovery model

no cure, emphasizes hope and personal strengths

Mahoney

• 1st AA Licensed Nurse 1879

• Established Professional Nurses Organization 1949

Richards

• 1st Psychiatric nurse

  • Developed nursing care in psychiatric hospitals

  • Directed a school of psychiatric nursing

Peplau

• 1st Psychiatric nursing theorist

  • Developed 1st model for psychiatric nursing

  • Wrote Interpersonal Relations in Nursing; Interpersonal Theory

Common law

Derived from JUDICIAL decisions

Statuatory law

Created by FEDERAL + STATE LEGISLATURES

Administrative law

Developed by administrative agencies (STATE BOARDS OF NURSING)

Criteria for INVOLUNTARY Admission

• Refused voluntary admission (+ refused examination)

• Without care, will suffer from neglect -> harmful to person

• OR:

  • Without care, will cause harm to self/others in future

Baker Act (1971)

• Defines Mental Illness:

  • Impaired mental/emotional processes that exercise conscious control of actions/ability to perceive + understand reality

  • Interferes w/ ability to meet ordinary demands of living

  • NOT INCLUDED: developmental disability, intoxication, substance abuse, antisocial behavior

Who can initiate Baker Act?

• Law Enforcement Officer

  • Custody IF:

    • Refuses voluntary exam

    • Without care, will suffer neglect

    • Without care, will cause harm

• Authorized Mental Health Professional (MD, Psychologist, Psychiatric Nurse, LCSW, LMHC, Therapist)

  • Based on professional observation + exam within past 48hrs

  • Meets criteria for involuntary exam (above)

Ba 52

• Authorized 72hrs

  • Within 72hrs, person may:

    • Be released

    • Sign a voluntary Right to Release form; Within 24hrs:

      • Pt + MD agree on discharge

      • Pt rescinds request to leave

      • MD institutes involuntary placement if criteria met

    • Petition for involuntary treatment filed -> BA 32

• Examined within 24hrs of admission

Ba 32

• Initiated by Judge w/ Court Order, longer form treatment after 72hr

Ex Parte (Official court order = “form one side only”)

• Initiated by Circuit Court Judge

  • Based on sworn testimony (written/oral)

  • Law enforcement officer takes person into custody + transports to facility

Marchman Act (1993)

• Initiated by Family Court (Court order)

• Initial Hold: +/- 5 Days

• Addiction Treatment Law

• Lost power of self control of substance use AND EITHER:

  • Inflicted/threatened/attempted physical harm to self/others

  • OR

  • Needs substance abuse service d/t substance abuse impairment

Tarasoff Rule vs U Cali (1976)

“Duty to Warn”

Competency (adjudicated incompetent)

• legally determined by a court to be unable or unfit to manage their own affairs due to a mental condition

Guardian Advocate

• Person appointed by the court to make decisions regarding mental health treatment on behalf of a patient who has been found to be incompetent to consent to treatment.

CNS

brain & spinal cord

Frontal

planning, judgement, motor, language, personality

Parietal

somatic sensation, spatial awareness

Occipital

visual

Temporal

hearing, language, memory fn

PNS

neural pathways outside CNS

Somatic

voluntary (walking)

autonomic

involuntary (HR)

Schizophrenia

↑ Dopamine

Parkinson’s

↓ Dopamine

Depression

↓ Norepinephrine

↓ Serotonin

↑ Acetylcholine

Anxiety

↓ GABA

Motor Cortex

initiates voluntary movement

Corticospinal pathways

carry motor signals

Basal ganglia

regulate initiation / control of movement

Cerebellum

coordination, balance, posture (unlimited strength, but no coordination: CEREBELLUM ISSUE)

Sympathetic

ALERT ALERT

stress, arousal

prep for action

↑ HR, sweating/hyperalertness

Parasympathetic

Rest and digest :)

• Rest/recovery

• Energy conservation

• Return toward baseline

• Restorative fns

HPA Axis for stress

Hypothalamus -> CRH -> Anterior Pituitary -> ACTH -> Adrenal Cortex -> CORTISOL

Limbic system

ctrls emotion, memory, motivation (basic drives, hunger, thirst, sex)

Values

principles / standards someone lives by (what do i consider important, worth pursuing?)

Beliefs

shared convictions within a group that consists of norms, traditions, values; guides interactions (what do i think is true?)

Basic elements of cultural assessment

Assess:

• Communication

• Orientation

• Nutrition

• Significant others & family

• Health

• Education

• Spirituality and religion

• Bio & physio

More on that /\

• Communication — Language ability, fluency, need for interpreter, and cultural norms around touch or ethnic expression.

• Orientation — Length of residence, place of birth, ethnic/cultural identity, and adherence to traditional values and worldviews.

• Nutrition — Preferred foods, what they eat when sick, foods avoided for cultural or belief reasons.

• Significant others and family — Important relationships, decision-making patterns, family roles, household customs, and core personal values.

• Health — Reasons for seeking care, beliefs about recovery, past helpful or disliked treatments, preferred helpers, and views on causes of illness.

• Education — Preferred learning style, educational background, and payment preferences for treatment.

• Spirituality and religion — Spiritual or religious identity, preferences, and relevant practices or people involved in care.

• Biology and physiology — Family health history, avoided treatments, personal care preferences, current meds/supplements, and substance or dietary habits (smoking, alcohol, caffeine, sweets).

Cultural formulation tool

(DSM-5): assesses the pt + nurse’s cultural viewpoint for culturally responsible care.

Key components of spiritual issues

• Grief

• Transcendence

• Discovery

• Meaning

• Purpose

• Relationship

• Gratitude

HOPE

FICA

• F: Faith - what is your faith tradition?

• I: Importance - how important is your faith to you?

• C: Church/Community: what is your church or community of faith?

• A: Address: how might we address your spiritual needs?