Behavioral health

Psychiatric mental health nursing

specialty area of nursing committed to the promotion of mental health and the treatment of behavioral issues, psychiatric disorders, and substance use disorders

Mental health nursing care in all settings

All nurses are responsible for promoting the health, well-being, dignity, and humanity of all, including the individual client, family, and community

Goal of client care

Recovery

Therapeutic milieu

psychotherapeutic-based treatment focused on modifying or controlling the immediate environment in which the client is living

Components of therapeutic milieu

• Individualized client-centered treatment based on partnership and collaboration. ​

• Organized in a comprehensive environment that promotes well-being.​

• Therapeutic relationships, communication, and a trauma-informed approach.​

• A multidisciplinary team is essential in considering client needs.​

• Determine individual needs for support and services.​

• Implement an individual plan, including a program plan, and adherence to a therapeutic schedule of activities and therapies.​

• Ongoing evaluation of the effectiveness of treatment toward the goal of developing social and life skills

Nurse responsibilities

• Providing education ​

• Orienting client and family​

• Establishing a welcoming trauma-informed environment.​

• Selecting and advocating for activities ​

• Ensuring culturally sensitive care is provided.​

• Providing ongoing support and safety​

• Trauma-informed approach to care

Autonomy

refers to the right to make decisions about one’s own care without undue interference or coercion from others

Competence

A client’s ability to understand information, use reasonable thought processes, communicate their wishes, and understand the consequences of their decisions. ​​​​​

Compacity for decision making

Refers to a client’s ability or inability to make decisions about proposed medical treatments or aspects of their health care

Nonmaleficence

a principle based on the oath of nursing practice to “do no harm.

Beneficence

preventing harm by removing harmful conditions to benefit the client or others or ‘doing good” often defined by actions of kindness and compassion

Fidelity

principle rooted in keeping promises to clients and showing faithfulness while displaying integrity

Veracity

considers the importance of being truthful and authentic with clients during nurse-client interactions

Justice

Ensures that the element of fairness influences nursing decisions and care

Boundary violations

can be either intentional or unintentional, involving the crossing of established boundaries between client and nurse

informed consent

individuals voluntary agreement to participate in treatment or medical procedures based on their understanding of the risks and benefits as well as any alternative treatments

Burden of treatment

interventions, medications, and treatments that may complicate a clients conditions resulting in poor adherences, reduced self-care, and potentially worsening outcomes including increased hospitalizations and poor quality of life

Voluntary admission

• Request of client​

• Client recognition of need for care

Involuntary admission

• 24-72 hours

• Danger to self​

• Danger to others​

• Unable to meet basic self-care needs​

• Mental illness preventing recognition or need for care

Emergency admission

• Temporary admission​

• Client imminent danger to self or others​

• For evaluation of mental illness

Outpatient mental health clinic

Include a psychiatrist, psychologist, nurse practitioners, clinical nurse specialists, physician assistants with mental health training, nurses with mental health training, and therapists or counselors. ​

Case management

A case manager helps the client to coordinate their mental health treatment, such as medications, appointments, or arrange transportation ​

Home based services

a mental health care professional, such as a nurse or social worker, goes into the client’s home to provide services, such as assisting clients to take their medications and monitoring the client’s mental health status ​

Assertive community treatment

provides the services of an inpatient psychiatric treatment facility with medical staff trained in psychiatric care needs while the client is in their own home

Telehealth

uses virtual technology such as a computer or smartphone with a camera for health care professionals to meet with clients ​

Mobile mental health crisis teams

specially trained mental health professionals who provide emergency psychiatric care onsite at the client’s location.

Day treatment

provides mental health care and nonclinical support, such as job training

Family services

equips the client’s family and other caregivers with the tools and support to care for the client

Peer services

pair clients with others who have similar symptoms of mental illness, and they are trained to provide support

Process of neurotransmission

A presynaptic neuron interacting with a postsynaptic neuron.​

1) Neurotransmitter is released from the

presynaptic neuron​

2) Neurotransmitter binds to a specific receptor ​

3)Returns to presynaptic cleft – reuptake channel ​

a)Stored for later use​

b)Deactivated – enzyme degrades neurotransmitter​

c)Diffused away from synaptic connection​

4) Binds to specific receptor on presynaptic

neuro for feedback regulation

Dopamine

is an excitatory neurotransmitter that is responsible for transmitting information about emotional responses, complex movements, and cognition. Is responsible for an individual experiencing pleasure and reward from behaviors and its neurotransmission can be affected by stress

Serotonin

an inhibitory neurotransmitter that is responsible for emotional regulations, sexual behaviors, temperature regulation, sleep, and pain management

Norepinephrine

an excitatory neurotransmitter that is responsible for learning, sleep, mood, memory, and attention. ​

Histamine

• has a unique role in neuromodulation.

• The pre and postsynaptic receptors for histamine regulate the release of histamine, glutamate, serotonin, and gamma amino butyric acid (GABA). The known postsynaptic receptors for histamine in the brain mediate the effects of alertness and wakefulness

Gama Amino Butyric Acid (GABA)

• an amino acid that serves as an inhibitory neurotransmitter.

• Similar to histamine, GABA modulates other neurotransmitters.​

Glutamate

• an amino acid that serves as an excitatory neurotransmitter.

• Helpful with memory.

Acetylcholine

• a neurotransmitter that has inhibitory and excitatory properties. With receptors found throughout the body particularly in the skeletal muscles.​

• Regulates the sleep-wake cycle and is a primary neurotransmitter for muscle functioning.

Neurobiology

• Mental health is associated with genetics or that mental illness can be inherited. ​

• Family Study: A type of study that seeks to understand the cause of behaviors among those who share a genetic history.​

• Adoptive Study: A type of study that seeks to understand the cause of behaviors when comparing those who share and do not share a genetic history but are raised in identical environmental conditions.​

• Twin Study: A type of study that seeks to understand the cause of behavior when comparing genetically identical people

Psychiatric pharmacogenomic testing

strategy that a health care provider may choose to use that improves the likelihood of selecting an effective psychotropic medication based on the client’s genes. ​

Stress and psychoimmunology

field of science that attempts to expand knowledge related to the impact of psychosocial stress on the body’s immune system

Infection r/t mental illness

• mental illness can be described according to previous or current infection

• It is theorized that viral infection possibly alters genetic composition in the central nervous system leading to the presentation of mental illness.

  • There is a causal association. however, none of these studies are conclusive

Neuroplasticity

• refers to the brain’s ability to adapt synaptic connections, particularly in response to stress or learning or after experiencing an injury.​

• Explains why some manifestations of mental illness increase in severity over time, such as Major Depressive Disorder, and cannot be cured through a single dose of medication

Stressor

• An event, situation, or condition that results in psychological or physical stress

• can be internal (in the individual) or external (outside the individual)

Stress response

The human body is designed for experiencing. It is a survival response that helps an individual respond quickly to a threatening situation. ​

Acute response

results in physiological changes such as an make your heart rate increase, muscles tense, and your breathing increase. Following acute stress response, the individual returns to a state of equilibrium)

Repeated or excessive response

there is a risk that a sequence of physiological and hormonal changes or repeated stress experiences can result in an overreaction to the stressors.​

​

Biological and physiological response

Perceived (thinking about the stress) or experienced stress (actual occurrence)

Maladaptive stress

A type of stress response that includes characteristics both biological and behavioral that are detrimental and interfere with optimal functioning and coping with life.​

Resilience

ability to successfully adapt to difficult or challenging life experiences that are mentally and emotionally challenging, requiring flexibility in behaviors to adapt to external and internal demands.​

Chronic stress

when stress becomes a problem when an individual is repeatedly exposed to stress, or stressors continue over a period of time, leaving the individual no opportunity for recovery

Stress system pathway

1) Stressful Event Experienced​

2) amygdala (command center)

3) Hypothalamus (CRH) begins Hypothalamic-Pituitary-Adrenal (HPA) Axis (ACTH)​

4) Autonomic Nervous System (ANS) & Central Nervous System (CNS)​

5) Stress Response Communicated Throughout the Body​

Physiological effects of stress

• endocrine system: releases cortisol, adrenaline and noradrenaline. Resulting constriction of blood vessels. Less growth hormone is released, and fewer sex hormones are produced.

• heart: beats more rapidly, pumping more blood. Increased blood flow t mussels while blood flow to organs decreases. Blood pressure rise. ​

• Lungs: More oxygen is consumed, and more carbon dioxide is expelled. Breathing is faster and shallower​

• Skin: Sweating

• Pancreas: Releases glucagon, produces less insulin and blood glucose rises

Fight-Flight-Freeze-Faint-Fawn

• Fight: Facing the stressor or situation ready to confront or flight​

  • Anger, aggression, stomping, kicking punching, stomach in knots, nausea, vomiting​

• Flight​: Running away from or fleeing the stressor​

  • Anxiety and feeling trapped, tension, wide eyes, restlessness (feet, legs), fidgeting​

• Freeze​: Unable to respond or react against the stressor or situation​

  • Dread, heart pounding and numbness, pallor, holding breath​

• Fawn​: Attempting to please or give in to the stressor or situation​

  • Self-directed anger, lack of boundaries, feeling no identity, trying to please aggressor, ignoring own desires​

• Faint​: Limiting exposure to stress by physically fainting or experiencing syncope​

  • Changes in vision, feeling lightheaded, blacking out, falling

General adaptation syndrome

Explanation was based on physical responses and the Selye model explains how the body wants to adapt (reduce stress) and that the body has limits and can run out of energy

Alarm (acute) stage

when the sympathetic nervous system is activated, resulting in two substages:​

• Shock—resulting in a decrease in blood pressure, temperature, muscle tone, and a loss of bodily fluid—​

• Countershock, where the adrenal glands release the catecholamine adrenaline resulting in increased sympathetic nervous system (SNS) activity ​

• Resistance Stage also described as the adaptation stage, is when the body attempts to adapt to the stressor. An individual remains on alert and prepared to respond for self-protection as it did in the alarm stage​

• If the stressor diminishes, the individual can return to homeostasis.​

• If stressor does not diminish, the individual moves into the final stage of exhaustion ​

Exhaustion stage

the body has depleted its resources and can no longer adapt to the stressor. Internally, the body’s tissues and organs are depleted, and the result can lead to illness, disease, or death.​

Prolonged or chronic stress response system

• Body learns experiences of stress, fear, or trauma are normal​ occurrence​

• Any age but particularly harmful during childhood

Experience of sustained stressors

• Physical or emotional maltreatment, chronic neglect, exposure to violence, family economic hardship, or a caregiver's substance use disorder or mental health disorder.​

• Often referred to as adverse childhood experiences (ACES)

Long term/lifelong complications r/t toxic stress

• Stress-related disorders​

• Cognitive impairment and complications in learning ​

• Physical health issues​

• Mental illness

Psychological and behavioral manifestations of stress

• Anxiety​

• Irritability​

• Depression​

• Panic attacks​

• Increased sadness​

• Excessive worry​

• Eating disorders

• Substance use disorders or addictive behaviors such as gambling​

• Alterations in executive functioning, including language and problem-solving​

• Delayed development or regression​

• Compulsive behaviors such as shopping and sex

Stress response risk factors

• Feeling a lack of control, ​

• hopelessness, ​

• negative self-talk, ​

• internalizing/externalizing problems/situation, ​

• racism, ​

• reduced social interaction or negative interactions, ​

• previous or repeated exposure to trauma, ​

• poverty, ​

• adverse childhood experiences, ​

• discrimination, ​

• genetics,

Protective factors

• Perception of control, ​

• hardiness, ​

• realistic expectations, ​

• healthy lifestyle ​

• positive- safe-secure work, ​

• home, and school environment, ​

• positive-secure relationships, ​

• parental bonding, ​

• connection to culture, ​

• beliefs, ​

• spiritual practices​

Problem focused coping

• requires adjusting or managing the problem that has caused the stress. It is action-focused. ​

  • Example: A client who creates a list or a plan on how to tackle the issue and reduce stress.

Emotion focused coping

• styles vary and are action-focused. These coping styles reduce the negative emotions associated with stress. ​

  • Example: A client who seeks out support and resources that nurture their emotional health.

Avoidant coping

• described as cognitive and behavioral efforts directed toward diminishing, ignoring, or denying stressful situations in an effort to avoid dealing with the stressor and is a passive way of coping that focuses on ignoring the stressor. ​

  • Example: A client who avoids the stressor by drinking or

sleeping.

Anxiety

• Feelings of worry or fear or nervousness when stressed or threatened​

• Temporary anxiety can be motivational​

• Persistent or excessive can interfere with function

• Normal response to stress and a common human experience

• physiologic expression of anxiety optimally serves an adaptive function to protect an individual from dange

When does anxiety become a disorder

when it interferes with function

• Feelings of anxiety occur at inappropriate times or situations.​​

• Frequency of anxiety increases.​​

• Intensity of anxiety affects a person’s ability to function.​​

• Duration of anxiety becomes increasingly prolonged.

Separation anxiety disorder

The client experiences excessive fear or anxiety when separated from an individual to which the client is emotionally attached

Social anxiety disorder

The client experiences excessive fear of social or performance situations

Specific phobias

The client experiences an irrational fear of a certain object or situation. Specific clinical names are used to refer to specific phobias

Panic disorder

The client experiences recurrent panic attacks

Agoraphobia

The client experiences an extreme fear of certain places (the outdoors or being on a bridge) where the client feels vulnerable or unsafe

Generalized anxiety disorder (GAD)

The client exhibits uncontrollable, excessive worry for at least 6 months

Anxiety risk factors

• Most anxiety disorders are more likely to occur in females (same with OCD except for hoarding) Anxiety and obsessive-compulsive disorders have a genetic and neurobiological link.​

• Clients can experience anxiety due to an acute medical condition, (hyperthyroidism or pulmonary embolism).

  • important to assess the manifestations of anxiety in a medical facility to rule out a physical cause. ​

• Adverse effects of many medications can mimic anxiety disorders.​

• Trauma or negative life experiences such as adverse childhood experiences.​

• Lifestyle choices including poor diet, exercise, and substance use.​

• Substance-induced anxiety is related to current use of a chemical substance or to withdrawal effects from a substance (alcohol).​

Anxiety cycle

 trigger → anxious thoughts → feelings/emotions (fear, worry, dizziness) → physiological response → behavioral response

Separation anxiety disorder expected findings

• The client exhibits excessive levels of anxiety and concern when separated from someone to whom they have an emotional attachment, fearing that something tragic will occur resulting in permanent separation.​

• The client’s anxiety disrupts the ability to participate in routine daily activities.​

• Physical manifestations of anxiety develop during the separation or in anticipation of the separation and include headaches, nausea and vomiting, and sleep disturbances.

Specific phobias expected findings

• The client reports a fear of specific objects (spiders, snakes, or strangers).​

• The client reports a fear of specific experiences, (flying, being in the dark, riding in an elevator, or being in an enclosed space).​

• The client might experience anxiety manifestations just by thinking of the feared object or situation and might attempt to decrease the anxiety through the use of alcohol or other substances.​

Agoraphobia expected findings

• The client avoids certain places or situations that cause anxiety. This avoidance might disrupt the client’s ability to maintain employment or participate in routine activities of daily life.​

• The client’s fear and manifestations of anxiety are out of proportion with the actual danger of the place or situation.​

Social anxiety disorder expected findings

• The client reports difficulty performing or speaking in front of others or participating in social situations due to an excessive fear of embarrassment or poor performance. ​

• The client might report physical manifestations (actual or factitious) in an attempt to avoid the social situation or need to perform.​

Panic disorder expected findings

• Panic attacks typically last minutes but may occasionally continue for longer periods.​

• Four or more of the following manifestations are present during a panic attack:​

  • Palpitations​

  • Shortness of breath​

  • Choking or smothering sensation​

  • Chest pain​

  • Nausea​

  • Feelings of depersonalization​

  • Fear of dying or insanity​

  • Chills or hot flashes ​

• The client might experience behavior changes and/or persistent worries about when the next attack will occur

Generalized anxiety disorder

• The client exhibits uncontrollable, excessive worry for the majority of days over at least 6 months.​

• GAD causes significant impairment in one or more areas of functioning (work-related duties).​

• Manifestations of GAD include the following:​

  • Restlessness​

  • Muscle tension​

  • Avoidance of stressful activities or events​

  • Increased time and effort required to prepare for stressful activities or events​

  • Procrastination in decision making​

  • Sleep disturbance​

Low anxiety

More restless

Moderate anxiety

Trouble sleeping fr

Severe

• Overwhelmed

• Acting out

  • Unsure what to do

Panic

• Feels terror

• Exhausted

• No longer responding to stimuli

Obsessive compulsive disorder

• occurs when one experiences obsessions, which are persistent and recurrent thoughts or urges that are unwanted and become intrusive.​

• Compulsions are repetitive behaviors that are performed by the client with OCD to lessen or prevent anxiety brought on by their obsessions.​

• These obsessions and compulsions become time-consuming and interfere with the client’s ability to perform daily tasks.​

• precipitated by anxiety.​

• can be diagnosed in children and adults.​

Examples of obsessions

• Thoughts about being harmed or harming someone else​

• Fears for safety ​

• Concern for cleanliness or germs​

• Fear that they are offending a higher power or deity​

• Fear of forgetting something important​

• Worry about how tidy or neatly arranged items are ​

Examples of compulsions

• Checking and rechecking that a door is locked​

• Ritualistic order for handwashing ​

• Repeating specific words of phrases ​

• Hurting self, such as hair pulling ​

• Counting objects, items, or actions​

• Repeating an activity a specific number of times

Hoarding disorder

the client has difficulty parting with possessions, resulting in extreme stress and functional impairments.​

Body dysmorphic disorder

client has a preoccupation with perceived flaws or defects in physical appearance.​

Manifestations of OCD

• Experiencing a pattern of uncontrollable obsessive thought and associated compulsive behaviors or rituals.​​

• Cleaning​​

• Washing hands​​

• Ordering or counting objects or behaviors​​

• Taboo or forbidden thoughts​

Manifestations of hoarding disorder

• Demonstrating a persistent difficulty or inability to discard or part with possessions.​​

• Differs from collecting as symptoms result in excess accumulation of possessions that clutter and overwhelm living areas. ​

Manifestations of body dysmorphic disorder

• Persistent preoccupation with perceived defects or flaws in one’s appearance.​​

• Mirror checking ​​

• Excessive grooming ​​

• Skin picking ​​

• Seeking reassurance about looks​​

• Possible eating disorder​

Manifestations of trichotillomania

• Demonstrating a pattern of ritualized behavior defined by serially and intentionally pulling out one’s hair.​​

• Behaviors are triggered by boredom and/or anxiety ​​

• Results of behavior reduce tension, lead to form of gratification, and pleasure or a sense of relief ​​

Manifestations of excoriation disorder

• Pattern of behavior defined by the recurrent picking at one’s skin, resulting in lesions​​

• Physical manifestations commonly found on hands, face, arms, or multiple body sites ​​

• May pick pimples, scabs, or previous picked areas of skin​​

• Extensive time daily is spent picking ​​

• Often client attempts to cover with clothing or makeup​​

Nursing care for anxiety

• Providing trauma-informed care considers the client’s experience and requires the nurse to be aware, sensitive, and responsive.​

• Provide a structured interview to keep the client focused on the present.​

• Assess for comorbid condition of substance use disorder.​

• Provide safety and comfort to the client during the crisis period of these disorders, as clients in severe- to panic-level anxiety are unable to problem solve and focus. Clients experiencing panic-level anxiety benefit from a calm, quiet environment.​

• Remain with the client during the worst of the anxiety to provide reassurance.​

• Perform a suicide risk assessment. ​

• Provide a safe environment for other clients and staff

• use relaxation techniques with the client as needed for relief of pain, muscle tension, and feelings of anxiety.​

• Instill hope for positive outcomes (but avoid false reassurance).​

• Enhance client self-esteem by encouraging positive statements and discussing past achievements.​

• Assist the client to identify defense mechanisms that interfere with recovery.​

• Postpone health teaching until after acute anxiety subsides. Clients experiencing a panic attack or severe anxiety are unable to concentrate or learn.​

• Identify counseling, group therapy, and other community resources for clients who have anxiety.​

Non-pharmacologic interventions

• Psychotherapy​

  • Talk therapy focused on the client’s specific anxiety​

• Cognitive Behavioral Therapy (CBT)​

  • Psychotherapy directed at how the client thinks, behaves, and reacts to causes and feeling of anxiety​

• Cognitive therapy​

  • Similar to CBT, it is focused on identifying the cause of anxiety and eliminating thoughts that are distorted or unhelpful regarding anxiety or stressors​

• Exposure therapy​

  • The client is exposed to the underlying cause of anxiety that they are avoiding, such as driving in traffic or riding in an elevator, to gradually become more comfortable with the activity ​

• support groups​

  • Groups focusing on sharing and achieving goals related to anxiety management​

• Complimentary-integrative approaches​

  • Therapy that focuses on relieving anxiety in specific situations, such as during a medical procedure. Practices include relaxation techniques (deep breathing, guided imagery, progressive body relaxation), hypnosis, massage therapy, mindfulness meditation, and music​

• Lifestyle management​

  • Helping the client make better choices, including nutritional strategies (healthy diet), exercise, and avoiding excessive caffeine or substance use​

Sedative hypnotic anxiolytics

Benzodiazepines: ​Alprazolam, Diazepam, Lorazepam

Sedative hypnotic anxiolytics MOA

Enhance Inhibitory effects of gamma-aminobutyric acid (GABA) in the CNS. Short-term use recommended due to dependence.

Sedative hypnotic anxiolytics therapeutic uses

• GAD​

• PTSD, Hyperarousal, Insomnia, Muscle Spasms, ETOH withdrawal.