Exhaustive Guide to Psychiatric-Mental Health Nursing Principles

Priority Outcomes and Suicidal Ideation in Nursing

• Initial Nursing Outcomes for Suicidal Ideation: When a patient is admitted with suicidal ideation (having thoughts of suicide), the primary and most obvious outcome is that the patient will not harm himself.
• Nursing Interventions for Safety:     * Observing the patient's behavior constantly.     * Listening actively for any suicidal statements.     * Prioritizing safety as the immediate clinical goal.
• Evaluation of Nursing Care: Success is evaluated by the patient remaining safe and unharmed. The aspirational goal is the complete cessation of suicidal ideations.
• Longevity of Suicidal Thoughts: While most people stop having intrusive thoughts once the inciting event is overcome, a minority of patients may experience these thoughts for extended periods (e.g., documented cases of patients having these thoughts for $30$ years).

Questions & Discussion

• Student Question: A student mentioned difficulty reaching out to group members because the online platform did not display last names, making it impossible to find their emails.
• Doctor Manning's Response: He instructed any students facing this issue to email him. He will then send a group email and CC the members.
• Expectation for CC replies: The professor requested that if a student replies to such an email, they must remove him (CC) from the reply to prevent unnecessary inbox traffic.
• Contact Information: Dr. Manning's email follows the format: first initial, last name, at the domain "manning $3$". He noted there were two others with his name before him.

The Three Levels of Prevention in Nursing Care

• Primary Care (Prevention): This is the earliest level of care, designed to prevent an illness or disorder from occurring before it ever starts.     * Specific Example: Education in grade schools about drugs.     * The DARE Program: A drug prevention program that utilized binders and merchandise (sweatshirts).     * Brooklyn-style Commercial: A famous primary prevention campaign featured an egg (symbolizing the brain) being thrown into a frying pan with the catchphrase: "This is your brain on drugs."
• Secondary Care (Screening): The focus is on screening for the illness to catch it as soon as it happens so resources can be provided immediately.     * Examples:         * An advisor in high school asking a student about drug use during a meeting.         * A doctor’s appointment involving direct questions about potential abuse or neglect.
• Tertiary Care (Maintenance and Prevention of Worsening): This involves stopping an existing illness from getting worse or preventing a recurrence.     * Example: Recovery groups for a patient who has suffered an MI (Myocardial Infarction) to monitor diet, exercise, and general health to prevent a second heart attack.

The Value and Economics of Prevention

• The Adage: "An ounce of prevention is worth a pound of cure."
• Cost-Benefit Analysis: The cost of prevention (healthy eating and exercise) is immeasurably lower in terms of money and man-hours compared to the cost of resuscitation.
• Emergency Interventions: Acute interventions—such as using epinephrine, the paddles (defibrillation), and open thoracic cavity surgery—are exponentially more expensive and resource-intensive than early prevention.
• Destigmatization: Vital for effective mental health care. Historically, mental illness was discussed in euphemisms.     * Personal Anecdote: Dr. Manning's family described a relative's suicide as "walking into the lake" or having a "nervous breakdown."     * Direct Assessment: Destigmatization allows nurses to ask direct, caring questions about suicide without "beating around the bush."

Maslow’s Hierarchy of Needs and NCLEX Strategies

• Foundational Needs: When answering NCLEX-type questions where multiple answers seem correct, the intervention that is lower (more foundational) on Maslow's hierarchy is usually the priority.
• ABC Priority: Airway, Breathing, and Circulation issues always take precedence over higher-level needs.
• NCLEX Strategy Tips:     * Nearest, Dearest, and Clearest: The NCLEX prefers answers that are clear rather than vague.     * Immediate Capability: The NCLEX favors interventions that can be performed in the next minute rather than long-term goals.
• Self-Actualization: Maslow's highest level, defined as actualizing your potential and becoming the "highest version of yourself."
• Self-Transcendence: An updated, higher tier where a person transcends the notion of self.
• The Problem of Depression: Depression often leads to "deconstruction into oblivion," where a patient questions the value of all goals (e.g., getting grades leading to a job they don't want). Nurses must help patients find their version of "who they are supposed to become."

Defining Psychiatric-Mental Health Nursing

• Formal Definition: A specialized area of nursing practice employing theories of human behavior as its science and the purposeful use of self as its art.
• Professional Certification: Nurses can be psychiatric-certified (requiring a specialized exam). This certification must be renewed every $6$ years.
• The Art vs. Science:     * Science: Utilizing theories of human motivation and behavior (e.g., Maslow, Erikson, Skinner).     * Art: The intentional use of the nurse's personality and communication as instruments for healing.

Theoretical Foundations of Psychiatric Care

• Orthopedics Comparison: In the past (e.g., $1883$), orthopedic patients were kept on bed rest for months. Modern theories changed this to emphasize mobility.
• Sigmund Freud: Credited with the groundbreaking discovery of the unconscious mind.     * Before Freud (e.g., $1783$), the prevailing belief was that humans were in conscious control of every decision.     * Freud introduced the idea of a "pool of unconscious resonance" containing repressed thoughts and childhood traumas that surface to cause traumatic responses.
• B.F. Skinner: Known for operant conditioning and the "Skinner Box" experiments with rats and food pellets.
• Hildegard Peplau: Often referred to as the mother of psychiatric nursing. She championed the idea of the nurse as a tabula rasa (blank slate), where the nurse reflects the patient's experience back to them rather than inserting their own personal life.

The Purposeful Use of Self and Boundaries

• Therapeutic vs. Social Communication: Social communication involves sharing personal experiences to build rapport; therapeutic communication keeps the spotlight on the patient.
• Boundary Violations: Sharing personal life info can lower boundaries, leading to an abuse of power or improper relationships. Serious violations can result in criminal charges or licensing actions.
• Self-Awareness: A nurse must be aware of their physical presence.     * Example: A tall person (e.g., $6$ feet or $5$ foot $11$ inches) might be triggering to an assault victim. Nurses should sit to appear "smaller" and use open body language.     * The "Baseball Coach" Stance: Crossing arms or standing authoritatively can be perceived as an attempt to control the patient.

Transference and Countertransference

• Transference (Patient to Nurse): A subconscious reaction where the patient perceives the nurse as having traits of a significant person from their past (e.g., an authority figure, a friend, or an archetype) and responds accordingly.     * Example: A patient became explosive because the nurse's stance reminded her of a figure skating coach who was controlling.
• Countertransference (Nurse to Patient): When the nurse subconsciously projects feelings regarding an important person in their life onto the patient.     * The Case of "Rosie": A sweet nurse who became a "tyrant" with young male patients with addiction. It was revealed her son had died of a drug overdose at age $27$. She was trying to "save" her son through these patients.

Standards of Nursing Practice (Standard 5: Implementation)

• 5A: Coordination of Care: managing holistic issues like housing, insurance, and job consequences.
• 5B: Health Teaching and Health Promotion:     * Teaching sleep hygiene and medication adherence.     * The Journaling Model: The nurse acts as the "patient's journal," helping them organize non-narrative, stormy thoughts.     * Problem Management: Helping the patient realize they don't have a "million problems" but perhaps four manageable ones.
• 5C: Milieu Therapy: Management of the "vibe" or environment.     * Derived from French: Milieu means environment/norms/rules.     * Safety Requirements: Reducing sharp objects, sharable surfaces, and flammable items.     * Ligature Points: Door handles on psych units are often non-load bearing or designed to prevent asphyxiation (hanging).     * Balance: Balancing sterile safety with a stimulating environment (e.g., art or color) to prevent boredom without causing overstimulation in manic patients.     * No TVs in Rooms: TV is kept in common areas to force patients to interact and negotiate social conflicts, which is a form of therapy.
• 5D: Pharmacological and Biological Therapies: Including medications, Ketamine infusions, and ECT.     * ECT (Electroconvulsive Therapy): Described as a "miracle" in psychiatry; it does not involve the physical contortions or "skeleton appearance" depicted in cartoons.
• Scope of Practice Limitations (What RNs cannot do):     * Prescribe: Only APRNs, Docs, and PAs can prescribe.     * Psychotherapy: Deep, billable, targeted psychological treatment (RNs perform therapeutic dialogue, not psychotherapy).     * Consultation: RNs cannot go to other units (like ortho) to perform official psych consults.

Professional Performance and Ethics

• License Renewal: Nurses must renew their licenses roughly every other year, requiring continuing education credits (typically $20$ credits).
• Shared Governance: A model where nurses manage unit infractions among peers rather than through management.
• Resource Utilization: Responsible stewardship of hospital resources (e.g., not wasting catheters costed at $16$ dollars each).

Building the Therapeutic Relationship

• Rapport: A feeling of comfort and ease. It begins with learning the patient's name.
• Trust: Built solely through consistent, trustworthy actions. Breaking a promise (e.g., forgetting a requested blanket for an hour) destroys trust instantly.
• Respect: Acknowledging that the nurse’s authority is situational, not inherent.
• Genuineness: Responding as a human, not an algorithm. Patients can sense a lack of genuineness.
• Empathy: Feeling "with" the patient.     * The "Sample Scoop" Analogy: Use empathy like a sample spoon at "Jenny's" ice cream. Feel a "sample" of the patient's pain to show care, but do not take the "whole double cone" or you will be overwhelmed.     * Empathy Sounds: Non-verbal cues (e.g., "oh") that signal you are feeling with the patient.
• Positive Regard: Moving for the patient's best interest regardless of their history.

Peplau’s Four Phases of the Nurse-Patient Relationship

1. Pre-orientation: Gathering data from charts, receiving reports, and identifying personal biases before meeting the patient.
2. Orientation: Admitting the patient, performing the assessment phase, establishing a boundary "contract" (e.g., no violence), and setting outcomes.
3. Working Phase: The primary period of treatment where the patient may exhibit "resistance behaviors" or "regress" due to fear of change.
4. Termination: Discussing the discharge plan (which must be scheduled within $30$ days by law), evaluating work achieved, and stating goodbyes.

Physical Touch in Psychiatric Settings

• Risk vs. Benefit: While touch can be healing, in psychiatry, it is often violative.
• Initiation: Nurses should rarely initiate touch unless required for assessment (e.g., blood pressure) because the risk of triggering the patient usually outweighs the benefit.
• Personal Space: Nurses must maintain boundaries even if they come from physically affectionate families.