N4 Exam 1

Mental health influencing factors: Individuals

• Biologic makeup: genetic

• Intolerable or unrealistic worries or fears: can cause someone to miss events, nonfunctional

Mental health influencing factors: interpersonal

• Ineffective communication

• Inadequate social support

Social/Cultural

• Unwarranted negative view of the world (sometimes the negative view is warranted)

• Discrimination (stigma, racism, classism, etc.)

Imposter syndrome

when someone doubts their abilities and feels undeserving of their accomplishments, even when they have evidence of competence

For example:

A nursing student passes difficult exams but thinks:

"I only passed because I got lucky. Everyone else is smarter than me."

Who experiences an imposter syndrome at a higher rate

showing minorities who have more “triggers” experience it at high/different levels

SOCIAL DETERMINANTS

Access to resources Income

Protection
Food security
Not feeling that your diversity is supported Violence
Negative view of the world
Sexism
Racism
Classism

DSM stands for

The Diagnostic and Statistical Manual of Mental Disorders

what is the DSM used for

o Major psychiatric disorders
o Medical conditions
o Psychosocial and environmental problems

Does everyone follow the DSM

Some reject the DSM

Alternatives in Mental Health Treatment

Magnetic Therapy: magnetic pulses to stimulate specific areas of the brain (rTMS)

Neurofeedback: providing feedback about brain activity while a person practices regulating certain patterns

Red Light Treatment to reduce anxiety and tension

What is the age range of mental health disbaility in the US and Canda

15 to 44 years old

The revolving door effect due to

• deinstitutionalization: moving from psychiatric inpatient care to outpatient community based care

• without outpatient, it can cause psych patients to go back into institutionalization without proper therapy and meds

What causes dual problems of both mental illness and substance abuse

• Shorter hospital stays

• decompensation

• rehospitalization

where are pts boarded when waiting for inpatient beds

ED

Mental health help number

988

can be slow to respond

5150

involuntary 72 hr hold for a danger to self or others

5250

involuntary psychiatric detention that lasts for up to 14 days of intensive treatment following an initial 72-hour 5150 hold

what percentage of chronically homeless have a psychiatric illness

30%

The 4 Rs for difficult interviews

• Restart

• Restate

• Refocus

• Reassess

Interview and Environment

• comfortable, quiet, private, safe environment with few distractions that does not compromise safety

Patient interview questions

– Open-ended to initiate assessment(Examples/role play)

– Focused if patient cannot organize thoughts or has difficulty answering open-ended questions

Chat: if having SI should used focused direct questions such as are you thinking of harming urself

WHAT IS IN THE ASSESSMENT?

• History
• General Appearance and motor behavior • Mood & Affect
• Thought process & Content
• Sensorium& Intellectual process
• Judgement & Insight
• Self concept
• Roles & Relationships
• Physiologic & Self Care concerns

• Spiritual beliefs

Assessment: Developmental stage

Erik Erikson's psychosocial stages

Assessment: Cultural Considerations

no assumptions/stereotypes should be made-about anything

Assessment: Appearance/motor behavior

• Hygiene/grooming
  Appropriate dress

• Posture

• Eye contact
  Unusual movements/mannerisms

• Automatisms

• Waxy flexibility

• Speech: Neologisms

Automatisms

uncontrolled body movement

ex. repeated movement

Waxy flexibility

keeping an awkward posture

ex. if u put a pt arm up it stays there like in catatonia

Neologisms

• made up words by the pt

• ex. in schizophrenic ppl using a made up word to describe something

Assessment: Mood and Affect

• Mood: emotional state reported by pt

• Affect: how the pt emotional state is externally expressed (objective)

• Assess for consistency

• Blunted

• Broad

• Flat

• Inappropriate

• Restricted

Blunted

little or slow to respond facial expression

ex. Shows only a slight reaction to emotional news

Broad

full range of expression
ex. Smiles when happy and looks sad when discussing a loss

Flat

no expression

ex. Face and voice remain almost expressionless

Inappropriate

situation doesn’t match mood

ex. Laughs while discussing a painful event

Restricted

• one sole expression-serious/somber- doesn’t change

• ex. Shows mainly one narrow range of expressions

Assessment: Thought process and content

though process: how the pt thinks such as disorganized thinking

though content: what the pt says

• Circumstantial thinking

• Delusion

• Flight of ideas

• Ideas of reference

• Loose associations

• Tangential thinking

• Thought broadcasting, insertion, blocking, withdrawal

• Word salad

Circumstantial thinking

patient gives too many unnecessary details but eventually answers the question.

Memory trick: CIRCUMSTANTIAL = Circles around, but comes BACK.

Tangential thinking

The patient moves away from the topic and never returns to answer the question.

Example:

Nurse: "What did you eat for breakfast?"

Patient: "Breakfast reminds me of my mother. My mother loved gardening. Gardens need sunlight. The sun is very hot."

The patient never answers.

Flight of ideas

The patient rapidly moves from one idea to another, often with superficial associations.

Example:

"I need to go to school! Schools have buses! Buses have wheels! Wheels go round! Round and round!"

Commonly associated with manic episodes.

Loose associations

Thoughts jump between ideas without clear logical connections.

Example:

"I went shopping. The moon is purple. My shoes are talking."

The statements do not connect logically.

Memory trick: LOOSE = Logical links are LOOSE.

Word salad

Speech is so disorganized that it becomes largely incomprehensible.

Delusions

held false belief that is not explained by the person's cultural or religious context and persists despite contrary evidence.

Ideas of reference

The patient believes ordinary external events have special personal meaning directed toward them.

Example:

"The news anchor is sending me a secret message."

Memory trick: REFERENCE = Everything refers to ME.

Thought broadcasting

The patient believes other people can hear or access their thoughts.

Thought insertion

The patient believes someone or something is putting thoughts into their mind.

Thought withdrawal

The patient believes someone or something is removing their thoughts.

Example:

"The government keeps stealing thoughts from my brain."

Thought blocking

The patient's train of thought suddenly stops.

Example:

Patient: "Yesterday I went to the store and then..."

Assessment: Suicide or harm toward others

– Ask patient directly
– Anger, hostility, or threats toward another person

– Specific threats or plans to harm someone

• Duty to warn for homicidal ideation

SUICIDE RISK ASSESSMENT

• Are you thinking about it? • Do you have a plan?
• How would you do it?
• Do you have access?

• When?

• Time of day?

Assessment: Sensorium/intellectual processes

– Orientation(oriented x4)
– Memory(see sample questions)

Type	Meaning	Nurse's question
Immediate	Remembers something just told to them (right now)	"Repeat these three words: apple, table, penny."
Recent	Remembers something from a little while ago (earlier)	"What did you eat for breakfast?"
Remote	Remembers something from long ago (long ago)	"Where did you go to elementary school

– Ability to concentrate
– Abstract thinking and intellectual abilities: Example:

"What does the saying 'Don't judge a book by its cover' mean?"

An abstract response:

"You shouldn't judge someone only by appearance."

– Abnormal sensory experiences or misperceptions

Sensory–perceptual alterations

They may describe these to you

• Hallucination = Perception without the object.

• Illusion = Incorrect interpretation of a real object.

Judgment and insight

Ability to interpret environment

Ability to understand true nature of one’s situation

Insight = I UNDERSTAND the situation. Judgment = I DECIDE the action I want to take.

Assessment: Self-concept

• Personal worth and dignity

• Description of physical characteristics/body image

• Emotions the patient frequently experiences

• Self-concept = Your overall picture of yourself.

  Self-esteem = How you value yourself.

  Example:

  Self-concept: "I'm a nursing student, a parent, and someone who enjoys helping others."

  Self-esteem: "I feel proud of what I've accomplished."

Assessment: Roles and relationships

• Current roles

• Ability to fulfill roles

• Changes in roles

• Satisfaction with relationships

• Online activity/social media

• Categories of family assessment (see Box 8.3)

Assessment: Physiological and self-care considerations

mental health RNs are RNs and must perform physiological skills, assessment and have knowledge

– Eating habits
– Sleep patterns
– Major or chronic health problems
– Use of drugs and/or alcohol
– Noncompliance with prescribed medications

Assess patient’s cognitive abilities

• –  Orientation to person, time, place, date, season, day

  of the week

• – Interpretation of proverbs: abstract thinking

• –  Math calculations: attention span

• –  Memorization,short-termrecall

• –  Identification of common objects

• –  Ability to follow multistep commands

• – Ability to write or copy a simple drawing

Self-Awareness Issues

Gather all information needed.

• • Judgments are not part of the assessment process. We may have them, but we don't document as data or information. "appeared" "Stated"

• Be open, clear, direct when asking about personal or uncomfortable topics. ROLE/PLAY - (set of questions)

• Examine own beliefs; gain self-awareness (growth-producing experience)

• Do not allow personal beliefs to interfere with the nurse-patient relationship and assessment process.

Suicidal ideation

• thinking about killing oneself

Attempts vs completed suicides

• ”Attempts” at suicide are higher in number than “completed suicides”

SUICIDE MYTHS

1. People who talk about it never do it

2. Suicidal people only want to hurt themselves

3. There is no way to help a suicidal person

4. Do not mention “suicide” around a to a person you suspect to be suicidal

5. Ignoring threats or challenging a suicidal person will reduce risk

6. Once suicidal always suicidal

These conditions can all lead to suicide

• Depression
• Bipolar disorder

• Schizophrenia
• PTSD

• HIV&AIDS
• Spinal cord Injury • Sickle Cell Anemia • Cancer

Suicide: Environmental Risk

• Isolation

• Loss (describe your definition)

• Unemployment

• PANDEMIC/ AFTERMATH OF PANDEMIC

• Family history of depression or suicide

• Bullying (amongst youth) Cyber bullying =bullycide

what is “bullycide” and what is it a form of

• form of violence

• used to describe suicide as the result of bullying

Suicide Assessment

• Previous suicide attempts (the first 2 years after is the highest risk period, especially the first 3 months);

•  relative who committed suicide

• Warnings of suicidal intent

• Risky behavior

• Lethality assessment: what do you ask?: potential for an action or method to cause death

• - "Have you made a plan?"

• "Do you intend to act on those thoughts?"

• "Do you have access to what you would use?"

• "Have you attempted suicide before?"

• "Do you feel able to stay safe right now?"

Suicide Assessment Questions

Ideation: “Are you thinking about killing yourself?”

Plan: “Do you have a plan to kill yourself?”

Method: “How do you plan to kill yourself?”

Access: “How would you carry out this plan? Do you have access to the means to carry out the plan?”

Where: “Where would you kill yourself?”

When: “When do you plan to kill yourself?”

Timing: “What day or time of day do you plan to kill yourself?”

Suicide interventions

• Anything that can be used to harm self should not be in patient’s possession

• Providing a safe environment (describe) • Creating a support system list

Family response to suicide

– Suicide as ultimate rejection of family and friends

– Families react with guilt, shame, and anger.
– Families can disintegrate.
The blame game
Guilt
Horror
Rumination of what you could have done[

5 V’s

validation, venting, values, vision, vitals

Nurses reponse to suicide

• –  Need for unconditional positive regard for person

• – Avoidance of patient blame

• – Nonjudgmental approach, tone

• – Belief that one person can make a difference in another’s life

• – Possible devastation of staff if patient commits suicide

  Devastation or desensitization- must be addressed amongst nursing staff

  Nurse burnout: we move on too quickly...

Where was the first state to adopt assisted suicide

Oregon

What is the nurses role in assisted suicide

• provide supportive care for patients and family as they work through decision-making process

Elder Considerations of mental health

• depression higher especially in medical ill pts

• psychotic features more frequent than younger people with depression

• Increased intolerance of side effects of medications

• Suicide increasing among elderly

Successful treatment of depression in community by

psychiatrists, psychiatric advanced practice nurses, and primary care physicians

Screening for early detection of risk factors

– Family strife
– Parental alcoholism or mental illness
– History of fighting

– Access to weapons in the home

Self-Awareness Issues- Look Inward

Importance of dealing with own feelings about suicide

Frustration possible when working with depressed or manic patients

Exhaustion possible when working with manic

patients

Journaling to help deal with own feelings

Talking with colleagues is often helpful.

ANGER LEADS TO

Hostility and Aggression

Hostility

– Expressed through verbal abuse, lack of cooperation, violation of rules or norms, threatening behavior

– May be expressed when a person feels threatened or powerless: especially when a nurse is controlling ur regime

anger = normal emotion

hostility = expressed toward another person through negative or threatening behavior

Physical aggression

• attack on or injury to another person or destruction of property

• Meant to harm or punish another person or force into compliance

• Sudden, unexpected

• Identifiable stages or phases

how can a nurse help the pt express their anger in a healthy way

• Encourage use of "I" statements ("I feel - when you

"I am trying to_)

• "Cathartic" activities: punching in a pillow or yelling is contraindicated in some patients: due to it inciting more physical aggression

• Cry

Walking, going for a walk...

Role-playing = practicing with pt healthy responses

Modeling = showing healthy reactions by staying calm

CBT

challenges thoughts assumptions to improve behavior. 6 months weekly is

great!

• Changing one’s perspective

• Reframing

• helps with anger

HINT: challenging negative assumptions, identifying distorted thinking, or replacing unhelpful thoughts, think CBT

Anger suppression happens for what reason and what gender is it more common in

• occurs due to stigma/punishment

• more common in women

Mileu

means psychiatric environment

be aware of factors influencing aggression

Individual pts assessment of psychiatric environment is very important for

• History of violent or aggressive behavior in the past

• How patient handles anger

• Beliefs about anger

Five phase aggression cycle

• Triggering phase

• Escalation phase

• Crisis

• Recovery

• Postcrisis

Escalation phase

movement towards loss of control

Crisis

loss of control

Recovery

regain of control

Postcrisis

attempt of reconciliation

Nursing Dx

• Risk for other-directed violence

• Ineffective coping

Nursing outcome goals

• Not harm self or threaten others

• Refrain from intimidating/frightening behaviors

• Describe feelings and concerns without aggression

• Comply with treatment

When is intervention best implemented in the aggression cycle?

Most effective and least restrictive when implemented early in the aggression cycle

Interventions for aggresion

• Planned activities

• Scheduling one-to-one interactions

• Offer opportunity for problem-solving or conflict
  resolution

• Consider safety of other patients

Managing aggressive behavior: triggering phase

• Approach in a nonthreatening, calm manner

• Convey empathy

• Encourage verbal expression of angry feelings

• Use clear, simple, short statements

• Allow patient time for self-expression

• Suggest patient go to a quieter area

• Offer PRN medications if ordered

• Suggest physical activity, such as walking, quick meditation

Managing aggressive behavior: escalation phase

• Take control

• Provide directions in a firm, calm voice

• Direct patient to time-out in quiet room or area

• Communicate that aggressive behavior is not acceptable

• Offer medication if refused in triggering phase

Management of aggressive behavior: crisis phase

• Take charge of situation for safety

• Restraint

• Only staff with training should participate in restraint. (students do not participate )

• Four to six trained staff members are needed.

• Inform patient that behavior is out of control and staff is taking measures for safety.

"Take down"

Management of aggressive behavior: recovery phase

• Talk about situation or trigger

• Help patient relax or sleep

• Help patient explore alternatives to aggressive behavior

• Assess and document any injuries

• Debrief staff

• Encourage other patients to talk about feelings

• Do not discuss aggressive patient in detail with other patients

Management of aggressive behavior: postcrisis phase

• Remove patient from restraint or seclusion as soon as criteria met

• Calmly discuss behavior (no lecturing or chastising)

• Give patient feedback for regaining control

• Reintegrate patient as soon as he or she is able to participate

The Brain: Cerebrum

2 hemispheres

lobs: parietal (touch), temporal (hearing), occipital (vision), frontal (judgement)

memories, behavior

The BrainP: Cerebellum

below cerebrum

movements

CereBELLum = BALANCE.

The Brain: Brain stem

midbrain: eye movements/alertness

pons: regulates breathing/sleep

medulla: vital breathing/cardio

extrapyramidal system: coordination, spinal nerves from antipsychotics blocking dopamine

The brain: Limbic system

Thalamus and hypothalmus

regulators of appetite, feelings, anger, rage,

excitement

disturbance here contribute to mental illness