NSG3233 Mental Health Nursing Flashcards

Clinical Judgment Framework and Exam Structure

• Exam Weighting and Content Distribution

  • Understand and Remember ($5-20\%$): Focuses on basic definitions, diagnostic criteria, and classification of medications.

  • Apply ($25-40\%$): Involves selecting the first action in a clinical scenario or matching specific interventions to a diagnosis.

  • Analyze and Evaluate ($30-50\%$): Centers on prioritization, clinical judgment, and complex item types like unfolding case studies and Next Gen NCLEX (NGN) formats.

  • Clinical application and analysis take precedence over simple memorization. Priority is determined by identifying the most critical findings and deciding on the immediate nursing response.

• Next Gen NCLEX (NGN) Item Types

  • Multiple Response/Select All That Apply (SATA): Evaluated as individual true/false statements; modern scoring often lacks partial credit for specific matrix-style versions.

  • Sequencing/Word Banks: Used for ordering steps, such as those in a suicide risk assessment, or filling in blanks.

  • Matrix Multiple Response: Grids used to categorize actions as indicated, contraindicated, or nonessential, frequently applied to complex clinical scenarios.

  • Bowtie and Trend Items: Require identifying a primary condition, determining appropriate actions, and establishing parameters for monitoring clinical changes.

• Prioritization Models

  • NCSBN Clinical Judgment Measurement Model: Recognizes cues, analyzes cues, prioritizes hypotheses, generates solutions, takes action, and evaluates outcomes.

  • Standard Prioritization Hierarchy: Airway, Breathing, and Circulation (ABC) $\rightarrow$ Safety (regarding self and others) $\rightarrow$ Maslow’s Hierarchy of Needs $\rightarrow$ The Nursing Process (Assessing before acting).

Foundations of Mental Health and Illness

• Definitions and Concepts

  • Mental Health: Defined by the World Health Organization as a state of well-being where an individual realizes their potential, can cope with normal life stressors, works productively, and contributes to their community.

  • Mental Health–Mental Illness Continuum: A spectrum along which individuals move; illness is characterized by significant distress and impairment ranging from moderate to disabling.

  • Risk Factors: Genetic predisposition, family history, traumatic events or Adverse Childhood Experiences (ACEs), poverty, substance misuse, chronic medical conditions, and social isolation.

  • Protective Factors/Resilience: Includes robust social support networks, effective coping strategies, spirituality, and a clear sense of purpose.

  • Diathesis-Stress Model: Onset of a disorder occurs through a combination of biological predisposition (diathesis) and environmental stressors.

• Epidemiological Terms

  • Prevalence: The total count of existing cases at a specific point in time.

  • Incidence: The number of new cases diagnosed within a specific period.

• Clinical Standards

  • DSM-5-TR: Diagnostic system that includes the specific disorder along with psychosocial and contextual factors and severity specifiers. It no longer uses the multiaxial system.

  • Stigma Management: Distinguishes between public stigma and self-stigma. Nurses must utilize person-first language (e.g., "a person with schizophrenia" rather than "a schizophrenic").

Theoretical Models in Psychiatric Care

• Major Theorists and Applications

  • Psychoanalytic (Freud): Focuses on the unconscious, defense mechanisms, and the division of the mind into the Id, Ego, and Superego. Therapies include free association and psychoanalysis.

  • Psychosocial (Erikson): Identifies eight stages of development, each defined by a specific crisis (e.g., trust vs. mistrust). Fixation at a stage provides insight into current clinical presentations.

  • Interpersonal (Sullivan, Peplau): Suggests anxiety stems from relationship dynamics. This model serves as the foundation for the phases of the nurse-patient relationship.

  • Behavioral (Pavlov, Skinner): Utilizes classical and operant conditioning. Applications include behavior modification and token economies.

  • Cognitive (Beck): Addresses automatic negative thoughts and cognitive distortions. The primary application is Cognitive Behavioral Therapy (CBT).

  • Humanistic (Maslow, Rogers): Focuses on the hierarchy of needs and unconditional positive regard in client-centered therapy.

  • Biological: Attributes psychiatric conditions to neurotransmitter imbalances or genetic factors, addressed primarily through pharmacotherapy.

  • Dialectical Behavior (Linehan): Developed for Borderline Personality Disorder, balancing acceptance and change through mindfulness, distress tolerance, and interpersonal effectiveness.

Defense Mechanisms and Behavioral Concepts

• Common Defense Mechanisms

  • Denial: Refusing to acknowledge a painful reality.

  • Repression: Unconscious exclusion of unpleasant experiences.

  • Suppression: Conscious denial of a disturbing situation or feeling.

  • Projection: Attributing one’s own unacceptable traits to others.

  • Displacement: Transferring emotions from their original object to a less threatening one.

  • Regression: Reverting to an earlier developmental level of behavior.

  • Rationalization: Justifying illogical ideas or feelings with acceptable explanations.

  • Sublimation: Channeling negative impulses into socially acceptable activities.

  • Reaction Formation: Acting in a way that is the exact opposite of one’s true feelings.

  • Undoing: Performing an act to make up for a prior behavior or thought.

• Group and Milieu Dynamics

  • Tuckman’s Stages of Group Development: Forming $\rightarrow$ Storming $\rightarrow$ Norming $\rightarrow$ Performing $\rightarrow$ Adjourning.

  • Milieu Therapy: The intentional use of the clinical environment (structure, safety, and norms) to facilitate healing.

Legal and Ethical Standards in Psychiatric Nursing

• Admission and Patient Rights

  • Voluntary Admission: The patient consents to treatment and retains rights, including the right to request discharge (though a temporary hold of $24-72\,\text{hours}$ may occur if they pose a danger).

  • Involuntary Admission: Court-ordered or provider-ordered based on evidence of danger to self/others or grave disability.

  • Least Restrictive Environment: Interventions must escalate from least to most restrictive based on safety requirements.

• Restraints and Seclusion

  • Considered a last resort. Requires a time-limited provider order (never PRN).

  • Requires a face-to-face assessment within a specific window and documented checks (frequently every $15\,\text{minutes}$).

• Ethical and Legal Principles

  • Confidentiality: Generally protected by HIPAA, with exceptions for the duty to warn (Tarasoff), suspected abuse (child/elder), or court orders.

  • Ethical Terms: Autonomy (self-determination), Beneficence (doing good), Nonmaleficence (doing no harm), Justice (fairness), Veracity (truthfulness), and Fidelity (maintaining loyalty).

  • Torts: False imprisonment (unjustified restraint), battery (unconsented touching), and negligence.

  • Malpractice Elements (DBCD): Duty, Breach of duty, Causation, and Damages.

Treatment Settings and Levels of Prevention

• Continuum of Care

  • Ranges from acute inpatient units to partial hospitalization (PHP), intensive outpatient (IOP), and community-based services like Assertive Community Treatment (ACT) teams.

• Prevention Levels

  • Primary: Education and prevention of illness onset.

  • Secondary: Early detection, screening, and crisis intervention.

  • Tertiary: Rehabilitation and prevention of relapse.

The Therapeutic Relationship and Communication

• Peplau’s Phases of the Nurse-Patient Relationship

  1. Pre-interaction: The nurse reviews data and explores personal biases or feelings before meeting the patient.

  2. Orientation: Establishing trust, setting the contract (parameters of time, place, and purpose), and defining confidentiality limits.

  3. Working: Identifying problems and facilitating behavioral change. Includes problem identification and exploitation subphases.

  4. Termination: Summarizing progress and discussing feelings regarding the end of the relationship.

• Boundaries and Qualities

  • Transference: Patient projects feelings about others onto the nurse.

  • Countertransference: Nurse projects personal feelings onto the patient. Requires self-monitoring.

  • Therapeutic Qualities: Genuineness, empathy (distinct from sympathy), unconditional positive regard, and self-awareness.

• Communication Techniques

  • Therapeutic: Broad openings, silence, restating, reflection, presenting reality without argument, and offering self.

  • Nontherapeutic: Giving advice, false reassurance, asking "why" questions, judging, or minimizing feelings.

  • Special Populations: Use simple sentences for psychosis; use concrete language for cognitive impairment; acknowledge delusions as the patient's reality without validating the false belief.

Neurobiology and Psychopharmacology

• Neurotransmitter Associations

  • Serotonin: Deficits linked to depression and anxiety; excess leads to Serotonin Syndrome.

  • Dopamine: Deficits linked to Parkinsonism; excess linked to psychosis, mania, and positive schizophrenia symptoms.

  • Norepinephrine: Deficits linked to depression; excess linked to mania and panic.

  • GABA: Primary inhibitory transmitter; deficits linked to anxiety and seizures.

  • Acetobylcholine: Deficits linked to Alzheimer's; excess associated with cholinergic equilibrium.

  • Glutamate: Implicated in neurotoxicity and schizophrenia.

• Antidepressant Classes

  • SSRIs: First-line for depression. Potential for GI upset, sexual dysfunction, and increased suicide risk in young adults (<25 years). Full effect takes $4-6\,\text{weeks}$.

  • SNRIs: Similar to SSRIs; require blood pressure monitoring due to norepinephrine impact.

  • TCAs: High anticholinergic effects and cardiotoxicity risk in overdose.

  • MAOIs: Require a tyramine-free diet (no aged cheese, red wine, cured meats) to prevent hypertensive crisis. Require a $2\text{-week}$ washout period before starting other serotonergics.

• Mood Stabilizers

  • Lithium: Therapeutic range is $0.6-1.2\,mEq/L$. Toxic at levels >1.5\,mEq/L. Requires adequate sodium and fluid intake. Avoid NSAIDs.

  • Valproic Acid: Requires monitoring of liver function tests (LFTs), platelets, and ammonia levels.

  • Lamotrigine: Potential for Stevens-Johnson Syndrome (severe rash).

• Antipsychotics

  • Typical (First-Gen): High risk for Extrapyramidal Symptoms (EPS) and Neuroleptic Malignant Syndrome (NMS).

  • Atypical (Second-Gen): Risk of metabolic syndrome (weight gain, dyslipidemia, hyperglycemia). Clozapine requires weekly Absolute Neutrophil Count (ANC) monitoring due to agranulocytosis risk.

  • EPS Recognition: Acute dystonia (muscle spasms), Akathisia (restlessness), Pseudoparkinsonism (tremor/shuffling), and Tardive Dyskinesia (involuntary tongue/lip movements; use AIMS scale).

Stress, Somatic Symptoms, and Factitious Disorders

• Stress Responses

  • General Adaptation Syndrome (Selye): Alarm $\rightarrow$ Resistance $\rightarrow$ Exhaustion.

• Somatic and Related Disorders

  • Somatic Symptom Disorder: Excessive anxiety regarding physical symptoms.

  • Illness Anxiety Disorder: Preoccupation with having a serious disease despite no evidence.

  • Conversion Disorder: Neurological symptoms (e.g., blindness) lacking organic cause, often following stress levels. May show "la belle indifference."

  • Factitious Disorder: Intentional production of symptoms to assume the sick role (may be imposed on self or others).

  • Nursing Care: Validate the symptoms as real to the patient but redirect focus to coping and stress management; minimize secondary gain.

Mood Disorders: Bipolar and Depression

• Bipolar Disorders

  • Bipolar I: At least one full manic episode.

  • Bipolar II: Hypomania plus major depression.

  • Mania Presentation (DIGFAST): Distractibility, Indiscretion, Grandiosity, Flight of ideas, Activity increase, Sleep deficit, Talkativeness.

  • Nursing Priorities: Safety, finger foods for nutrition during mania, low-stimulation environment, and consistent limits.

• Depressive Disorders

  • Major Depressive Disorder: Presence of $5$ out of $9$ symptoms (SIGECAPS: Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor, Suicidal ideation) for at least $2\,\text{weeks}$.

  • ECT (Electroconvulsive Therapy): Used for treatment-resistant depression. Requires NPO status and informed consent. Temporary memory loss/confusion is expected post-procedure.

Crisis Intervention, Suicide, and Physical Safety

• Suicide Assessment and Intervention

  • High-Risk Indicators: Previous attempt (strongest predictor), access to firearms, substance use, and social isolation.

  • Assessment Order: Ask directly about ideation $\rightarrow$ plan $\rightarrow$ means $\rightarrow$ timeline/lethality.

  • Mandatory Precautions: $1:1$ observation, removal of all sharps/cords/ligature points, and collaborative safety planning.

• Crisis Phases and Types

  • Maturational: Expected life transitions.

  • Situational: Unexpected external events (e.g., job loss).

  • Adventitious: Disasters or mass violence.

  • Intervention Goal: Returning the individual to their pre-crisis level of functioning within $4-6\,\text{weeks}$.

Anxiety and Trauma-Related Disorders

• Anxiety Levels

  • Mild: Enhances focus and awareness.

  • Moderate: Narrowed perceptual field; focus on the immediate task.

  • Severe: Significantly reduced perceptual field; focus on scattered details.

  • Panic: Loss of rational thought; physical pacing or immobilization.

• Clinical Presentation

  • OCD: Obsessions (thoughts) and compulsions (actions). Do not stop rituals abruptly; use Exposure and Response Prevention (ERP).

  • PTSD: Symptoms (flashbacks, hyperarousal) persisting for >1\,\text{month} after trauma.

  • Acute Stress Disorder: Similar to PTSD but lasts between $3\,\text{days}$ and $1\,\text{month}$.

Personality Disorders

• Cluster A (Odd/Eccentric): Paranoid, Schizoid, Schizotypal.

• Cluster B (Dramatic/Erratic):

  • Borderline: Instability, fear of abandonment, self-harm, and "splitting" (viewing staff as all good or all bad). Requires consistent firm limits and DBT.

  • Antisocial: Disregard for others' rights, lack of remorse, and manipulation. History of conduct disorder before age $15$.

• Cluster C (Anxious/Fearful): Avoidant, Dependent, Obsessive-Compulsive Personality Disorder.

Schizophrenia Spectrum and Psychotic Disorders

• Symptom Categories

  • Positive Symptoms: Added behaviors like hallucinations (auditory most common) and delusions (persecutory, grandiose).

  • Negative Symptoms (The $5\,\text{As}$): Flat affect, Alogia (poverty of speech), Avolition (lack of motivation), Anhedonia (lack of pleasure), and Asociality.

• Nursing Priorities: Safety during command hallucinations, reality testing without confrontation, and medication adherence to prevent relapse.

Eating Disorders and Medical Complications

• Anorexia Nervosa: Restriction leading to low weight, bradycardia, lanugo, and electrolyte imbalances. Focus on physical stabilization.

• Bulimia Nervosa: Bingeing and purging. Look for Russell's sign (knuckle calluses) and parotid gland swelling.

• Refeeding Syndrome: Life-threatening drop in phosphorus, potassium, and magnesium when nutrition is reintroduced too quickly.

Anger, Aggression, and Patterns of Abuse

• De-escalation: Maintain personal space, use a calm tone, identify exit routes, and offer choices before resorting to chemical or physical restraints.

• Abuse and Reporting: Mandatory reporting of suspected child, elder, or dependent adult abuse.

• Intimate Partner Violence (IPV): Follows the Cycle of Violence (Tension $\rightarrow$ Battering $\rightarrow$ Honeymoon). Assess in private and provide resources without pressuring the patient to leave.

Neurodevelopmental and Impulse-Control Disorders

• ADHD: Characteristics of inattention, hyperactivity, and impulsivity appearing before age $12$ in multiple settings.

• Conduct Disorder: Persistent violation of the rights of others (aggression, theft). Precursor to Antisocial Personality Disorder.

Substance-Related and Addictive Disorders

• Alcohol Withdrawal: Can be fatal. Manifests as tremors and tachycardia, progressing to Delirium Tremens ($48-96\,\text{hours}$ post-drink). Managed with benzodiazepines ($\text{CIWA-Ar}$ protocol) and thiamine.

• Opioid Withdrawal: Misery-inducing (flu-like symptoms) but not typically fatal.

• Opioid Overdose: Pinpoint pupils and respiratory depression; reversed by Naloxone.

Neurocognitive Disorders: Comparison of the Three Ds

• Delirium: Sudden onset, fluctuating course, impaired consciousness, and usually reversible. Often caused by medical issues like UTIs.

• Dementia: Gradual onset, progressive, clear consciousness, and irreversible.

• Depression (Pseudodementia): Reversible with mood treatment; consciousness is clear.

Comprehensive Review and Prioritization Strategies

• Maslow Application: Prioritize physiological needs and safety (e.g., nutrition and suicide prevention) before higher-level psychosocial work.

• Standardized Recovery Model: Shifts from paternalistic treatment to a patient-directed, hope-based approach focusing on strengths.

• Grief Stages (Kbler-Ross): Denial, Anger, Bargaining, Depression, and Acceptance.

• Emergency Interventions: Airway and physiological instability (e.g., NMS, Lithium toxicity, or overdose) always take precedence over behavioral issues.