Mental Health Exam 1

Science of nursing

finding the evidence for the practice

Art of nursing

developing the skills for the practice

* caring, attending, patient advocacy

Caring

* is evidenced by empathic understanding, actions, and patience
* is the most natural and fundamental aspect of human existence
* caring nurse = competent nurse

Attending

* being present
* therapeutic communication - verbal and on-verbal

Advocating

* ethical role
* speaking up for patients and families
* toward team members, patient family and friends, and/or policies
* nurses advocate for patients when they:
* advise patients of their rights
* provide accurate and current information

What do the formation of practice guidelines include?

* Evidence based practice
* research on biology and treatments
* constantly changing
* Recovery Model
* rehabilitation and recovery focus
* Trauma-informed care

What is evidence based practice?

* research on biology and treatments
* constantly changing

What is the recovery model’s principle?

believes that addicts can recover and lead on full lives

* social model of disability
* includes AA’s 12 steps

What does trauma-informed care provide?

provides guidelines for integrating an understanding of how trauma affects patients into clinical programming

* change from “what is wrong with you?” to “what has happened to you?”
* avoid retraumatizing the patient

What are the 6 steps of the evidence based practice process?

1. ask the clinical question using the PICOT format
2. search for the best evidence based on the clinical question
3. critically appraise and synthesize the evidence
4. implement the evidence in practice
5. evaluate the practice decision or change
6. share the outcomes of the decision or change

What are the elements of the PICOT question?

P - patients/population

I - intervention

C- comparison or comparison group

O - outcome

T - time (as applicable)

Hierarchy of evidence - Level 1

systematic review or meta-analysis of randomized control trial

Hierarchy of evidence - Level 2

one well-designed RCT

Hierarchy of evidence - Level 3

controlled trial without randomization (quasi-experimental study)

Hierarchy of evidence - Level 4

single, nonexperimental study (case-control, correlational, cohort study)

Hierarchy of evidence - Level 5

systematic reviews of descriptive or qualitative studies

Hierarchy of evidence - Level 6

single descriptive or qualitative study

Hierarchy of evidence - Level 7

opinion of authorities or reports of expert committees

Resources for clinical practice

1. internet resources
2. clinical practice guidelines
3. clinical algorithms
4. clinical/critical pathways

What is a clinical algorithm ?

step-by-step guidelines prepared in a flowchart or decision-tree format

What are clinical/critical pathways?

interprofessional care plans that outline the care and desired outcomes for a specific time for patients with a specific diagnosis. “road map” that patient and healthcare team should follow.

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common components include assessment guidelines, lab and diagnostic testing, medications, activity, diet, and teaching.

6 A’s of integrating EBP into clinical practice

1. Ask a question
2. Acquire the literature
3. Appraise the literature
4. Apply the evidence
5. Asses the performance

What is the research-practice gap?

It is a wide gap between the best evidence treatments and their effective translation into practice

What is the need for the research practice gap?

continued research on how best to apply the findings of clinically relevant issues

What is the recovery model?

* social model of disability
* believes that people can recover and lead full lives
* includes AA’s 12 steps
* individualized care plans

What is Quality and Safety Education for Nursing (QSEN)

National initiative toward safety and quality

What is the goal of QSEN?

equip nurses with knowledge, skills, and attitudes (KSAs) to improve quality and safety of their health care systems

What are the 6 QSEN competencies?

* patient-centered care
* teamwork and collaboration
* evidence-based practice
* quality improvement
* safety
* informatics

What are some factors that affect mental health?

* economics
* biological hormones genetics
* spirituality religion
* culture regional differences
* family, friends, community
* personality traits
* health practices and beliefs
* environmental experiences

What is the tool used to diagnose mental health disorders?

The DSM-5 - Diagnostic and Statistical Manual of Mental Disorders

What are the negative effects of stigma on mental health patients?

stigma of mental illness affects how an individual is viewed

* affects housing, employment, and health services
* has harmful effects on the patient and family

Mental health and mental illness exist on a

continuum

According to the CDC, what percent of people in the US will experience mental illness in their lifetime?

50%

What are the mental health intrapersonal factors?

What are the core determinants of health ?

* employment/working conditions
* education and literacy
* physical environments
* social support networks
* personal health practices and coping skills
* social environments
* healthy child development
* biology and genetic endowment
* culture
* financial and social status
* gender
* health services

DSM -5 details

* the current official guidebook for categorizing and diagnosing psychiatric mental health disorders in the United States
* classifies a disorder a patient has, not identifies the patient
* lists required symptoms that must be exhibited for patient to receive a medical diagnosis
* dual diagnosis = mental health and substance use problems

What is stigma ?

A “collection” of negative attitudes, beliefs, thoughts, and behaviors that influence the individual and general public

* it is a major barrier to mental health treatment and recovery over the last 13 to 14 years
* harmful effects on the individual and family

Mental Health Parity Act of 1996

U.S. insurers must offer same benefits at the same level of coverage for mental illness as for other medical and surgical conditions

Affordable Care Act of 2010

ACA banned annual dollar limits; eliminated pre-existing condition exclusions

What is the nursing process?

a 6 step problem-solving care approach

* it is the foundation for the standards of practice

How does the nursing process facilitate care?

* appropriate
* safe
* culturally competent
* developmentally relevant
* high quality

What are the 6 steps of the nursing process?

1. assessment
2. \

ASSESSMENT - what is the difference in objective vs subjective?

objective - what you can see

subjective - what the patient says

Who is the primary source?

the patient is always the primary course

* starts with the first sight of patient or history
* varies with age of patient

What does a psychiatric nursing assessment include?

* perform a mental status examination
* assess psychosocial status
* identify mutual goals for treatment
* formulate a plan of care that prioritizes the patient’s immediate condition and needs
* document data in a retrievable format

How can you gather data?

* lab data : can used to verify medications
* can perform MSE
* assess psychosocial status
* identify mutual goals
* prioritize patients needs
* awareness - “Do you know why you are here?”

What does the MSE consist of?

appearance - hygiene, facial expressions, etc

behavior - body movements, eye contact

speech - rate, volume, disturbances

affect and mood - angry, flat, bland, sad, euphoric

thought process - disorganized, coherent, delusions, obsessions

perceptual disturbances - hallucinations, illusions

insight/judgement - orientation, LOC, memory, attention,

What is a psychosocial assessment?

it provides more information along the MSE to help with the plan of care

What is included in a psychosocial assessment?

* previous hospitalizations
* educational background
* occupational background
* social patterns
* sexual patterns
* interests and abilities
* substance use and abuse
* coping abilities
* spiritual assessment
* cultural assessment

What is the standard nursing diagnosis?

* the problem (unmet need)
* the etiology (probable cause)
* the supporting data (signs and symptoms)

What is a risk diagnosis?

high probability of a future negative event for a vulnerable individual

what is health promotion diagnosis?

willingness to enhance specific health behaviors

What is outcomes identification?

S - specific

M - measurable

A - attainable

R - realistic/relevant

T - time based

What does planning include?

care plans, clinical pathways, and algorithms

* should include safety, appropriate, individualized, and evidence based

What is involved in implementation?

* coordinate of care
* health teaching and health promotion
* assess and teach pharmacological, biological, and integrative therapies
* therapeutic relationship and counseling

What is included in evaluation?

* systematic, ongoing, criterion-based
* include supporting data
* enables revisions to diagnoses, outcomes, and interventions

What is included in documentation?

EVERYTHING

* evaluation of stated outcomes
* all changes in patient condition
* record of informed consents
* medication reactions
* symptoms/concerns
* untoward incidents
* patient progress
* “nonadherence” is used for patients who refuse/noncompliant

what does SOAPIE stand for?

S - subjective data (patient statement)

O - objective data (nurse observations)

A - assessment (nurse interprets S and O and describes either a problem or a nursing diagnosis)

P - plan (proposed intervention)

I - intervention (nurse’s response to problem)

E - evaluation (patient outcome)

What is the importance of therapeutic communication?

respect, compassion, and empathy are essential to psychological healing, it is patient centered. 90% of communication is nonverbal and the receiver knows your intent

What are personal communication factors?

* emotional and social factors
* cultural and language differences
* lifestyle differences
* cognitive factors

What are environmental communication factors?

* physical factors (background noise, lack of privacy)
* societal factors (historical or economic factors; presence of others; expectations of others)

What is a symmetrical relationship?

it is equal: friends or colleagues

What is a complementary relationship?

it is unequal: difference in status and power such as between a nurse and patient or between and teacher and student

What is included in active listening?

* observing the patient’s nonverbal behaviors
* listening and understanding the patient’s verbal message
* listening and understand a person in the social context, and listening for incongruences in content
* providing feedback - most people want the other person to be there for them psychologically, socially, and emotionally

What are some cultural consideration barriers?

* communication styles
* use of eye contact
* perception of touch
* cultural filters

What are some therapeutic communication techniques?

* using silence
* accepting
* giving recognition
* offering self
* offering general leads
* giving broad openings
* placing the events in time and sequence
* making obersecations
* encouraging description of perception
* encouraging comparison
* restating
* reflecting
* exploring
* giving information
* seeking clarification
* presenting reality
* voicing doubt
* seeking consensual validation
* verbalizing the implied
* encouraging evaluation
* attempting to translate into feelings
* suggesting collaboration
* summarizing
* encouraging formulation of plan
* focusing

What should you do when your patient has hallucinations?

* assess for the presence and content
* express to patient that you do not share the hallucinations
* calm milieu
* keep the patient focused on something concrete
* avoid touching the patient

What do you do when your patient is having delusions?

* assess presence and content
* focus on the feeling, not content
* reality orientation
* do not argue

what are examples of NONtherapeutic communication techniques?

* asking excessive questions
* giving approval/agreeing
* disapproving/disagreeing
* giving premature advice
* asking “why” questions
* minimizing feelings
* being falsely reassuring
* making value judgements
* changing the subject

What are some de-escalation techniques?

* emphasize that you are on patients side
* stand at an angle to appear nonconfrontational
* assess or provide for personal safety
* appear calm and in control
* do not speak while person is yelling
* speak softly; nonprovocative, nonjudgemental
* demonstrate genuineness and concern
* do not treat individual in humiliating manner
* ask “what will help now?”

What is the goal of a mental health nurse?

* feel understood and comfortable
* identify and explore problems relating to others
* discover healthy ways of meeting emotional needs
* experience satisfying interpersonal relationships

What is included in a nurse-patient relationship ?

* it is complementary
* nurses should be safe, confidential, reliable, and consistent
* it should be a partnership
* should have clear and appropriate boundaries
* therapeutic use of self is an example of the art of nursing

What is included in a social relationship?

* includes friendship and socialization
* mutual needs are met
* may include giving advice
* basic needs are met
* content is superficial
* roles may shift
* little evaluation of interaction occurs

What are included in therapeutic relationships?

* focusing on patient needs
* nurses needs are not addressed
* language is straightforward

what are values?

abstract standards the represent ideal, either positive or negative

what is modeling?

presents a vivid example of values in action

What do we have to remember about values and beliefs?

* we understand and accept our own
* BUT we are sensitive and accepting to the unique values and beliefs of others

What is transference?

when a patient reacts to their nurse/counselor in a way associated with how they feel about someone in their past

“you remind me of my…”

What is countertransference?

what a nurse transfers to their patient - they remind you of someone you know

ex. nurse getting upset with an alcoholic because they remind them of their alcoholic mother

How much distance should you keep between yourself and a patient?

typically during conversations you should be between 1.4-4ft from a patient.

* be aware of being too close to a patient

What are the phases of a nurse-patient relationship?

preorientation

orientation

working

termination

What is included in preorientation?

planning and self-reflection

What is included in orientation?

introduction, collect data, set boundaries, discuss termination

What is included in working?

evaluation of problem, problem solving

What is included in termination?

evaluate progress, feelings on termination, strengths, next steps

what are features of a positive nurse-patient relationship?

* consistency
* pacing
* listening
* initial impressions
* comfort and control
* patient trust
* patient participation

what are features of a negative nurse-patient relationship?

* inconsistency
* unavailability
* nurses lack of self-awareness

guidelines for establishing therapeutic relationship

* genuineness
* positive regard (respect)
* empathy

What is empathy?

we understand the feelings of others

What is sympathy?

we feel the feelings of others; objectivity is lost

Helpful tips for communication

* speak briefly
* wen you do not know what to say, say nothing
* when in doubt, focus on feelings
* avoid giving advice
* avoid relying on questions
* note nonverbal cues
* keep the focus on the patient

ID

* pleasure principle
* reflex action
* primary process

Superego

* problem solver
* reality tester

Ego

* moral component

Level of awareness: conscious

thoughts, beliefs, and feelings

Level of awareness: preconscious

not currently the subject of our attention, but accessible

levels of awareness: unconscious

biggest chunk; seat of primitive feelings, drives, and memories, especially those that are unbearable and traumatic

Freud’s psychoanalytic theory

* experiences during the early stages of life determine an individual’s lifetime adjustment patterns and personality traits
* unconscious influences the conscious
* personality formation is associated with erogenous body zones
* noted the presence of transference and countertransference

what are examples of behavioral theories

* pavlov’s classical conditioning
* watson’s behaviorism - learned behaviors
* skinner’s operant conditioning - positive and negative reinforcement
* implications for nursing
* altering targeted behaviors and behavior management

Behavioral modification

positive reinforcement - addresses maladaptive behaviors by rewarding adaptive behaviors