Mental Health Nursing - Exam 2

self awareness

the process of understanding one’s own belief’s, thoughts, motivations, biases, and limitations and recognizing how they affect others

biopsychosocial framework

consists of three separate interdependent domains

1. biologic

2. social

3. psychological

biologic approach

• biological theories related to mental health plus the biologic activities related to other health problems

• also related to exercise, sleep, nutrition, plus neurobiologic theories

psychological approach

theoretical basis of the psychological processes (thoughts, feelings, and behaviors) that influence one’s emotion, cognition, and behavior

social approach

• theories that account for the influence of social forces encompassing the patient, family, and community within cultural settings

• social settings do not cause psychiatric illness, but manifestations and treatment can be affected

effective communication

this includes verbal communication, nonverbal communication, and therapeutic communication…actions speak louder than words

verbal communication

spoken word, underlying emotion, context, connotation

nonverbal communication

gestures, expressions, body language

therapeutic communication

ongoing process of interaction through which meaning emerges

principles of therapeutic communication

• patient is the primary focus

• professional attitude

• self-disclosure only for therapeutic purpose

• no advice or social relationship with patients

• patient confidentiality

• assessment of patient’s intellectual competence

• interventions based on theory

• nonjudgmental attitude

• guiding patient to reinterpret experiences rationally

• clarification to track the patient’s verbal interaction

• avoid changing the subject unless in the patient’s best interest

self disclosure

• telling the patient personal information

• generally is not a good idea

• the conversation should focus on the patient, not the nurse

passive listening

• involves sitting quietly and letting the patient talk

• allows the patient to ramble and does not focus or guide the thought process

• this form of listening does not foster a therapeutic relationship

• body language usually communicates boredom or indifference

active listening

• focuses on what the patient is saying, interprets the underlying meaning, and responds to the message objectively

• the nurse usually responds indirectly using techniques such as open-ended statements, reflection, and questions that elicit additional responses from the patient

• the nurse should avoid changing the subject and instead follow the patient’s lead

blocks to communication

• advice

• agreement

• challenges

• reassurance

• disapproval

strength based communication

• should be supportive

• focuses on the patient’s strengths instead of potential deficits

• language that promotes acceptance and respect should be favored over language that distracts from acceptance of the person

advice

• telling the patient what to do

• the nurse solves the patient’s problem, which implies that the nurse knows best and may not be the appropriate solution

• it also encourages dependency on the nurse

agreement

• agreeing with a particular viewpoint of a patient

• the patient is denied the opportunity to change their view now that the nurse agrees

challenges

• disputing the patient’s beliefs with arguments, logical thinking, or direct order

• the nurse belittles the patient and decreases the patient’s self-esteem

• the patient will avoid relating to the nurse who challenges.

reassurance

• telling a patient that everything will be okay

• the nurse makes a statement that may not be true

• the patient is blocked from exploring their feelings

disapproval

• judging the patient’s situation and behavior

• the nurse belittles the patient

• the patient will avoid the nurse

considerations for effective communication

• rapport

• empathy

• recognition of empathic linkages

• boundaries and body space zones

defense mechanisms

• also known as coping styles

• psychological mechanisms that help an individual respond to and cope with difficult situations, emotional conflicts, and external stressors

• use may be conscious or unconscious

defense mechanisms examples

acting out, affiliation, altruism, anticipation, autistic fantasy, denial, devaluation, displacement, help-rejecting complaining, humor, idealization, intellectualization, isolation of affect, omnipotence, passive aggression, projection

devaluation

defense mechanism where an individual exaggerates or makes things bigger than they are/need to be

displacement

defense mechanism where an individual transfers feelings from one thing or person to another

symbolism

• the use of a word or phrase to represent an object, event, or feeling

• often is used universally

• common in children and older adults

communication blocks

• identified by topic changes that either the nurse or the patient makes

• the nurse should attempt to redirect the conversation back to the topic at hand unless the particular topic is too uncomfortable for the patient at that point in time

nurse patient relationship

based on Peplau’s model

• introduction

• orientation phase

  • first meeting

  • confidentiality

  • testing the relationship

• working phase

  • identification of problems

  • problem solving

• resolution phase

  • problems resolve

  • relationship ends

non therapeutic relationships

• the nurse and the patient both feel very frustrated and keep varying their approach with each other in an attempt to establish a meaningful relationship

• involves frustration, struggle to reach common ground, mutual withdrawal, and broken foundation of trust

patient interviews

1. introduce yourself

2. state the purpose

3. use open ended questions and closed ended questions

4. clarify your own words

5. summarize the interview to allow the patient to correct the nurses interpretation

synchronous communication

• real-time tele health interactions between nurse and patient such as a video

• clinical information is transmitted from patient to clinician or clinician to patient and stored for review at a later point

asynchronous communication

• include emails, text message, and video recordings

• use of mobile health applications (mHealth) is useful for history taking, interviewing, assessment, and treatment as well as clinician support for decision-making and up-to-date treatment

physical examination

includes body system review, neurologic status, lab results, elimination, activity and exercise, sleep, appetite and nutrition, hydration, sexuality, and self care

mental status examination

includes general observations, orientation, mood and affect, speech, and thought process

insight

a person’s awareness of their own thoughts and feelings and ability to compare them with the thoughts and feelings of others

clinical judgement

the ability to reach a logical decision about a situation and to choose a course of action after examining and analyzing various possibilities

self concept

• develops over a lifetime

• represents the total beliefs about three interrelated dimensions of the self: body image, self-esteem, and personal identity

body image

represents a person’s beliefs and attitudes about their body and includes such dimensions as size (large or small) and attractiveness (pretty or ugly)

self esteem

the person’s attitude about the self

personal identity

knowing “who I am”

suicide screening

every mental health assessment should include this

assaultive or homicidal ideation

Do you intend to harm someone? If yes, who?

Do you have a plan? If yes, what are the details of the plan?

Do you have the means to carry out the plan? (If the plan requires a weapon, is it readily available?)

social well being

involves developing a sense of connection and a well-developed support system

occupational well being

involves personal satisfaction and enrichment derived from one’s work

guided imagery

the purposeful use of imagination to achieve relaxation or direct attention away from undesirable sensations

cognition

defined as an internal process of perception, memory, and judgment through which an understanding of self and the world is developed

Milieu therapy

• provides a stable and coherent social organization to facilitate an individual’s treatment

• the design of the physical surroundings, structure of patient activities, and promotion of a stable social structure and cultural setting enhance the setting’s therapeutic potential

• promotes personal growth

• key concepts include containment, validation, structured interaction, and open communication.

direct care

performing interventions when you’re physically with the patient

indirect care

nursing interventions and communication done on behalf of the patient

nursing intervention systems

• Nursing Interventions Classifications (NIC)

• Clinical Care Classification system

• Omaha nursing model

biologic nursing interventions

• promotion of self care activities

• activity and exercise interventions

• sleep interventions

• nutrition interventions

• relaxation interventions

• hydration interventions

• thermoregulation interventions

• pain management

• medication management

psychological nursing interventions

• counseling interventions

• conflict resolution and cultural brokering

• bibliotherapy and webotherapy

• reminiscence

• behavior therapy

• psychoeducation

• health teaching

• spiritual interventions

social nursing interventions

• social behavior and privilege systems

• Milieu therapy

• promotion of patient safety

• home visits

• community action

target symptoms

measurable, specific symptoms expected to improve with treatment

side effects

unwanted effects of medications

adverse reactions

unwanted effects with serious physiologic consequences

boxed warnings

• serious adverse effects

• use with extreme caution

food and drug administration

FDA, responsible for assuring safety, efficacy, and security of drugs

pharmacodynamics

• WHY

• how a drug affects the body, including its mechanism of action and the resulting physiological effects

• includes four sites of action

  • receptors

  • ion channels

  • enzymes

  • carrier proteins

receptors

• first site of action in pharmacodynamics

• agonists or antagonists either initiate or block a response

• A drug’s ability to interact with a given receptor is based on three factors:

  • selectivity

  • affinity

  • intrinsic activity

selectivity

the degree to which a drug works on a given site relative to other sites

affinity

chemical forces that cause a substance to bind to its receptor

intrinsic activity

maximal possible effect that can be produced by a drug

ion channels

• second site of action in pharmacodynamics

• drugs block ion channels of nerve cell membrane

• ex. Valium

enzymes

• third site of action in pharmacodynamics

• proteins that act as catalyst for physiologic reactions and can be target site for drugs

• ex. MAO is an enzyme required to break down neurotransmitters associated with depression. An MAOI inhibitor prevents breakdown of these neurotransmitters

carrier proteins

• fourth site of action in pharmacodynamics

• also called uptake receptors

• membrane protein that transports a specific molecule across the cell membrane

• medications for this site block/inhibit transport and increase activity of neurotransmitter in the in the synapse

agonist

substances that initiate the same response as the chemical normally present in the body

antagonist

substances that block the response of a given receptor

efficacy

ability of drug to produce response (drug may fit receptor but not elicit a response)

desensitization

• rapid decrease in drug effects (often in minutes)

• rare with psychiatric medications

toxicity

drug concentration harmful to body

potency

• drug dose needed for effect

• a drug with a lower dosage may be more potent but have the same efficacy of another medication

tolerance

• gradual decrease in drug action

• days to months

• also called treatment refractoriness

therapeutic index

• ratio of maximum nontoxic dose to minimum effective dose

• goal is always the lowest dosage of a medication possible

ADME

• absorption and routes of administration

• distribution

• metabolism

• excretion

absorption

movement of the drug from the site of administration into the plasma

distribution

the amount of the drug found in various tissues, particularly the target organ at the site of drug action

metabolism

• also called biotransformation

• the process by which a drug is altered and broken down into smaller substances, known as metabolites

• occurs in the liver, kidneys, lungs, and intestines

excretion

the removal of drugs from the body either unchanged or as metabolites

half life

• time required for plasma concentrations to be reduced by 50%

• takes 4 half-lives (or more) for more than 90% of drug to be excreted by body

pharmacokinetics

• HOW/ACTION

• how the body affects a drug, involving absorption, distribution, metabolism, and excretion

pharmacogenomics

how a person’s genetic makeup affects their response to drugs

ethnopsychopharmacology

the study of how culture and genetic differences in human groups determine and influence the response to medications

phases of drug treatment

• initiation phase

  • psychiatric exam, nursing assessment, relevant labs

  • “Test” dose to watch for adverse effects

• stabilization phase

  • dose adjusted as needed

  • nurse provides patient education

  • *therapeutic drug monitoring*

• maintenance phase

  • after symptoms have improved, medications are continued to prevent relapse

  • nurses must provide patient education!

• discontinuation phase

  • some will be d/c’d…others not

  • never stop abruptly

augmentation

adding an additional medication when first medication only gives a partial response…ex. adding a mood stabilizer to an antidepressant

polypharmacy

using more than one group from a class of medication

major psychopharmacologic drug classes

• antipsychotic medications

• mood stabilizers

• antidepressants

• anti-anxiety and sedative–hypnotics

• stimulants

typical

conventional antipsychotic meds, older mediations

block dopamine receptors more potently than seratonin receptors

ex. Chlorpromazine, Fluphenazine, Haloperidol (Haldol), Loxapine (Adasuve), Molindone, Pimozide (ORAP), Thiothixene (Navane)

atypical

newer antipsychotic meds

block serotonin receptors more potently than dopamine receptors

ex. Aripiprazole (Abilify), Clozapine (Clozaril), Risperidone (Risperdal), Olanzapine (Zyprexa), Quetiapine (Seroquel), Ziprasidone (Geodon)

indications for antipsychotics

• schizophrenia

• mania

• autism

• symptoms of psychosis

  • hallucinations

  • delusions

  • bizarre behavior

  • disorganized thinking

  • agitation

antipsychotic metabolism

• metabolize in liver (except for paliperidone which is in kidneys; and Latuda which is excreted almost unchanged through the urine and feces)

• susceptible to numerous drug interactions

antipsychotic excretion

• slow

• half-life of 24 hours and metabolites with longer half-lives

• high lipid solubility

• drug levels can be found weeks after discontinuing a medication, which is hard if medication is stopped due to side effects

antipsychotics side effects

• orthostatic hypotension and prolonged QTC interval

• dry mouth

• urinary retention

• weight gain

• diabetes

• sexual side effects

• agranulocytosis

• severe and dangerous lowering of WBC—specifically leukopenia

• high fever

• sore throat

• mouth sores

• neuroleptic malignant syndrome (NMS)

• confusion

• variable BP

• sweating

• tachycardia

• photosensitivity

• lowered seizure threshold

dystonia

• acute medication related movement disorder

  • abnormal tonicity, difficulty maintaining posture

• onset within a few days of initiating therapy

• acytecycholine is overactive as dopamine is blocked

akathisia

• acute medication related movement disorder

  • intense, uncomfortable feeling of restlessness and an irresistible urge to move

• can be misdiagnosed as agitation or increased psychotic symptoms

tardive dyskinesia

• chronic medication related movement disorder

  • involuntary, repetitive, and persistent movements

• due to long-term antipsychotic use

• irreversible

• risk increases with age and is worse with typical antipsychotics

mood stabilizers

• also referred to as antimanic medications

• includes:

  • lithium

  • anti-convulsants

  • calcium channel blockers

  • adrenergic blocking agents

  • atypical antipsychotics

0.8-1.4 mEq/L

lithium therapeutic blood levels

lithium

• mood stabilizer

• indications: mania, depressive episodes of bipolar illness

• action: uncertain, crosses cell membranes, altering sodium transport, not protein bound…thought to exert multiple neurotransmitter effects

• naturally occurring and works in 40% of all patients

• onset: 5 to 7 days; may take as long as 2 weeks

• excretion: kidneys

• side effects: thirst, metallic taste, increased urinary frequency, fine head tremor, drowsiness, and mild diarrhea

• nursing implications: signs of lithium toxicity, routine lab monitoring (creatinine, thyroid, and CBC every 6 months), avoid during pregnancy (esp. first trimester)

• possible kidney damage and thyroid disfunction

anticonvulsants

• used as mood stabilizers

• reduce repetitive firing of action potentials in the nerves

• used when patients have not responded to lithium

• ex. Valproic acid (Depakote), carbamazepine (Equetro), Lamotrigine (Lamictal)