Engage week 2
Building Therapeutic Relationships
Therapeutic Role Functions:
Social Role: Client advocate.
Occupational Role: Educator, facilitator, manager.
Therapeutic Role: Conducting holistic assessment, coordination of care, providing encouragement, integration of modalities, and reinforcement of progress.
Phases of the Therapeutic Relationship:
Phase 1: Pre-Interaction:
Recognize the needs of the client.
Perform a self-evaluation of personal beliefs, attitudes, and potential biases/behaviors.
Phase 2: Orientation:
Collect baseline client data.
Assess the client's knowledge base regarding their condition.
Work collaboratively with the client to establish mutual goals.
Phase 3: Working:
Establish mutual trust and comfort between nurse and client.
Work actively together toward achieving the established therapeutic goals.
Phase 4: Termination:
Acknowledge that original therapeutic goals have been met.
Formulate new goals and establish a comprehensive plan for continuity of community-based care.
Building Client Trust, Rapport, and Therapeutic Alliance:
Qualities that Engender Trust: Honesty, transparency, respect, fidelity, and empathetic understanding.
Barriers to Trust: Perceived differences in gender, education, language/literacy, racial or cultural ways of being, and socioeconomic status.
Maintaining Professional Boundaries:
Boundary blurring interferes directly with treatment goals; strict professional and therapeutic boundaries must be maintained.
Transference: Occurs when the client displaces feelings, expectations, or emotional responses onto the nurse.
Countertransference: Occurs when the nurse displaces unresolved personal feelings or reactions onto the client. Both phenomena compromise care and can result in the nurse being removed from the treatment team.
Nonverbal Communication Strategies:
Maintain congruence between verbal and nonverbal communication.
SOLER Framework:
S: Sit squarely to the client (make slight positional adjustments if sitting directly opposite feels confrontational to the client).
O: Maintain an open posture.
L: Lean slightly forward toward the client.
E: Maintain appropriate eye contact.
R: Maintain a relaxed demeanor.
Client Nonverbal Cues Requiring Verbal Clarification:
Affect: Frowning, grimacing, smacking lips, pursing lips, lip-licking, biting.
Appearance: Disheveled appearance, inappropriate clothing choices for the climate or setting, or disrobing.
Autonomic: Perspiring, flushed face, dilated pupils.
Body: Body rocking, altered posture, abnormal gait, hand clenching, psychomotor agitation.
Eyes: Squinting, minimal blinking.
Verbal Communication Strategies:
Open-Ended Questions: Utilized to encourage elaboration and keep the conversation flowing.
Affirmations: Convey support and encouragement (must be genuine; avoid if insincere).
Reflections: Restate the core message of what the client said to confirm understanding. Pitch inflection must go down at the end to ensure it functions as a statement rather than a question. Can be simple or complex.
Summaries: Restate key concepts discussed during the interaction to transition topics or close the interview.
Cultural Considerations & Transcultural Nursing Theory Concepts:
Essential nurse attributes: Recognize culture as ever-changing, maintain continuous skills, close personal knowledge gaps, examine personal values and beliefs, engage in lifelong learning, and actively interact with diverse cultures.
Transcultural Nursing Principles:
Maintenance (Cultural Preservation): Supporting and helping the client retain core cultural beliefs and values (e.g., eye contact preferences, gender-based care needs).
Negotiation (Cultural Accommodation): Helping the client adapt or negotiate when cultural beliefs conflict with essential health outcomes (e.g., beliefs regarding evil spirits causing illness).
Restructuring (Cultural Repatterning): Supporting the client in attempting to change or reorder cultural practices to achieve healthy outcomes (e.g., modifying dietary/eating habits).
Domains of Cultural Assessment:
Biologic variations.
Orientation to time.
Social organization.
Environmental control.
Communication (interpersonal space, speech pace, eye contact).
Health beliefs and practices.
Interviewing Techniques:
Determine clear interview goals prior to initiating the interaction.
Consider specific mental health challenges when deciding whether to utilize Socratic questioning or direct questions.
Active Listening Steps: Look interested, involve by responding, stay on task, test understanding, evaluate the message, and neutralize personal feelings.
Cultural Formulation Interview (CFI) Domains:
Cultural definition of the problem.
Cultural perceptions of cause, context, and support.
Cultural factors that affect self-coping and past help-seeking.
Cultural factors that affect current help-seeking.
Motivational Interviewing (MI):
Core Processes:
Engage: Establish rapport and a working alliance (spend the majority of time in this phase).
Focus: Clarify specific areas or behaviors the client wants to work on.
Evoke: Elicit the client's own motivations, importance levels, and confidence regarding change (utilize Likert scales).
Plan: Establish realistic, measurable goals for behavior change.
Applications: Used to promote behavioral changes in health promotion, medication adherence, therapeutic regime compliance, and illness management.
SMART Goal Alignment: Goals must be Specific, Measurable, Achievable, Realistic, and Time-bound.
Promoting Diversity, Equity, and Inclusion (DEI): Bias-Free Language:
Appropriate Specificity: Focus on relevant characteristics. Include demographic details during hand-off reports or treatment team meetings only when they directly impact care.
Acknowledge Differences: Avoid overgeneralization by recognizing relevant individual differences that affect care (supported by completing the CFI).
Label Sensitivity & Humanity: Refer to clients as persons rather than identifying them by their disorder or symptoms (person-first language).
Avoid False Hierarchies: Be mindful of using the term "normal."
Using Technology in Mental Health Nursing:
Modalities: Electronic health records (EHR), patient education videos, online surveys/assessments, electronic referrals, and telehealth services.
Telehealth Data: Nearly of mental health clients access healthcare services via telehealth modalities.
Definition: Telehealth encompasses any care delivery method that is not face-to-face, including mobile devices, telephone calls, email, and videoconferencing.
Legal and Ethical Considerations in Mental Health Nursing
Frameworks & Governance:
Psychiatric-mental health nursing practice is governed by the Scope of Practice for Psychiatric-Mental Health Nursing, the ANA Code of Ethics for Nurses, ANA Scope and Standards of Practice, and state/federal regulations.
Milieu Therapy:
Definition: A structured, therapeutic healing environment designed to modify and control the environment to promote healing and develop life and social skills.
Principles: Trauma-informed care, physical/emotional/psychological safety, open expression of feelings, support when practicing new behaviors, building trust, and restoring self-efficacy and self-control.
Nurse Responsibilities: Provide education, orient client and family, establish a welcoming trauma-informed environment, select and advocate for therapeutic activities, deliver culturally sensitive care, and ensure ongoing safety.
Components of the Therapeutic Milieu:
Physical Environment: Floor plans, furniture, decor, lighting, noise control, home-like welcoming setting, balance of privacy and community spaces. Must focus on safety considering client cognition and physical needs, fostering the least restrictive environment, and providing opportunities for varying observation levels.
Psychosocial Environment: Focuses on interpersonal relationships, quality of life, recovery orientation, client ownership of recovery, providing a refuge from self-destructiveness, and transparent rules/rights. Focus principles include physical and emotional safety, empathy, mutual trust, balancing autonomy, openness, predictability, consistency, communication, and equitable care delivered with dignity.
Ethics and Bioethical Principles:
Ethics: A system of moral principles governing conduct, rooted in cultural norms, personal values, and professional values (guided by the Mental Healthcare Act of 2017).
Autonomy: Respecting the client's right to self-determination, linked to decision-making competency or capacity.
Beneficence: Taking positive actions to benefit or promote the well-being of others.
Nonmaleficence: The duty to do no harm or inflict minimum harm.
Fidelity: Faithfulness, loyalty, and honoring commitments.
Veracity: The obligation to tell the absolute truth.
Justice: Ensuring fairness and equality in the distribution of healthcare resources.
Confidentiality & Informed Consent: Protecting client privacy and securing voluntary agreement for care.
Additional Concerns: Avoiding boundary violations and evaluating the burden of treatment.
Mental Health Laws and Federal Legislation:
Focuses on ensuring parity in mental health services across federal and state levels.
Key Federal Legislation:
Mental Health Parity and Addiction Equity Act.
21st Century Cures Act.
Comprehensive Addiction and Recovery Act (CARA).
Children's Health Act of 2000.
Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) Act.
Patient Record Confidentiality Regulations.
Types of Psychiatric Admissions:
Voluntary Admission: Occurs at the request of the client who recognizes their need for mental health treatment.
Involuntary Admission: Mandated admission occurring when a client is a danger to self, a danger to others, unable to meet basic self-care needs, or has a severe mental illness preventing recognition of the need for care.
Emergency Admission: Temporary, urgent admission when a client presents an imminent danger to self or others, conducted primarily to evaluate mental illness.
Client Rights to Privacy and Exceptions:
Governed by the Client's Bill of Rights and HIPAA regulations (rights must be publicly posted in an understandable language).
Exceptions to Confidentiality:
Imminent danger to self.
Duty to Warn third parties of imminent harm.
Evidence or client reports of abuse (e.g., child, elder, or vulnerable adult abuse).
Consent Standards:
Informed Consent Requirements: Must include a complete description of the treatment, expected benefits, inherent risks, potential consequences of refusing treatment, and available alternative treatments.
Incompetence: If a client is legally deemed mentally incompetent, an alternate legal decision-maker must provide consent.
Implied Consent: Applies in emergency situations where a client is unconscious or unable to give consent, a legal representative is unavailable, and the client's actions or emergency state demonstrate implied willingness for life-saving treatment.
Capacity vs. Competence:
Capacity: A medical term determined by a qualified medical provider regarding whether a client's cognitive processes are intact enough to give informed consent.
Competence: A legal term determined by a judge regarding whether a client has global impairment preventing them from making legal or care decisions.
Psychiatric Advance Directives (PAD):
A legal tool protecting client autonomy and self-direction if capacity or competence is lost.
Includes designation of a Health Care Power of Attorney (surrogate decision-maker) and specific directives for mental health treatment, medication choices, and preferred care providers.
Legal Liability and Torts:
Nurses are legally and ethically accountable for client safety, protection, and quality of care.
Unintentional Torts:
Negligence: Failure to provide standard care resulting in harm.
Malpractice: Professional negligence failing to meet standards of care.
Intentional Torts:
Assault: An intentional act that creates a reasonable apprehension of immediate harmful or offensive contact.
Battery: Intentional, unconsented physical contact.
False Imprisonment: Unlawful restraint or restriction of a client's freedom of movement.
Documentation Standards:
Serves as evidence in lawsuits and malpractice claims.
Must provide a detailed, accurate, objective, and nonjudgmental record of client behavior, care rendered, and response to care.
Restraints and Seclusion Protocols:
Clients have a legal right to be free from inappropriate physical or chemical restraints and seclusion, and a right to be treated with dignity in the least restrictive environment.
Operational Requirements:
Requires a licensed provider order/prescription (obtained immediately during emergent situations).
Documentation must state specific client behaviors leading up to restraint, de-escalation techniques attempted, type of restraint used, client response, and criteria for discontinuation.
Continuous or ongoing monitoring documented every .
Nursing Care During Restraints/Seclusion: Support and reassurance, ongoing assessment of skin integrity and circulation, basic needs care (hydration, food, elimination), range of motion (ROM) exercises, administration of required medications, and continuous evaluation for release readiness.
De-Escalation and Debriefing:
De-Escalation: Use clear, calm verbal communication, nonthreatening body language, respectful approach, clear limit-setting, and environmental adjustments (lower lighting, reduced noise, calm activity).
Debriefing: Conducted with staff and client following a behavioral emergency to review events, identify triggers, evaluate actions taken, discuss feelings, and implement strategies to prevent future restraint or seclusion use.
Interprofessional Team Roles:
Includes Psychiatrists, Psychologists, Social Workers, Occupational Therapists, Counselors/Therapists, and Psychiatric Pharmacists working alongside Intraprofessional nursing staff.
Workplace Protections and Safety Measures:
Types of Workplace Violence: Physical violence, harassment, intimidation, and threatening/disruptive behavior.
Inpatient Unit Safety Measures: Banned or restricted personal items, systematic inspection of belongings, physical unit security features, clear behavioral rules, and consequences for violent actions.
Nurse Burnout: Manifests as emotional exhaustion, hopelessness, reduced accomplishment, and feeling unengaged due to high workloads. Managed through self-assessments and organizational interventions.
Incivility vs. Bullying:
Incivility: Often inadvertent violations of social norms.
Bullying: Purposeful, repeated, and continuous aggressive behavior. Requires institutional policies for awareness and resolution.
Psychopharmacology
Neurobiology and Synaptic Function:
Brain function is influenced by neurobiological, genetic, and environmental factors.
Neurons communicate across the synaptic gap via chemical neurotransmitters.
Neurotransmitter action is terminated via reuptake mechanisms or enzymatic deactivation (e.g., via Monoamine Oxidase).
Neuroplasticity: The brain's capacity to adapt through chemical changes, structural changes, and functional changes.
Key Neurotransmitters:
Dopamine.
Serotonin.
Norepinephrine.
Histamine.
Gamma-Aminobutyric Acid (GABA).
Glutamate.
Acetylcholine.
Etiological Factors in Mental Illness:
Genetics evaluated through family, adoptive, and twin studies.
Psychiatric pharmacogenomic testing.
Stress responses evaluated via psychoimmunology.
Infections and compromised neuroplasticity.
Major Psychotropic Drug Classes:
Anxiolytics (Antianxiety):
Exemplars: Benzodiazepines, Buspirone.
Antidepressants:
Drug Classes: Monoamine Oxidase Inhibitors (MAOIs), Tricyclic Antidepressants (TCAs), Selective Serotonin Reuptake Inhibitors (SSRIs), Serotonin Norepinephrine Reuptake Inhibitors (SNRIs).
Tyramine Dietary Restrictions (MAOIs): Clients taking MAOIs must strictly avoid foods high in tyramine to prevent hypertensive crisis, including aged/strong cheese, cured or processed meats, rich sauces, and dried or overripe fruit.
Antipsychotics (Neuroleptics):
First-Generation Antipsychotics (FGA / Conventional / Typical).
Second-Generation Antipsychotics (SGA / Atypical).
Third-Generation Antipsychotics (TGA).
Mood Stabilizers:
Lithium.
Anticonvulsants (modulate the kindling process).
SGA Depot Injections (e.g., Aripiprazole depot).
Sedative-Hypnotics:
Benzodiazepines, Nonbenzodiazepine hypnotics, Melatonin receptor agonists.
Stimulants.
Herbal Remedies (OTC):
St. John's Wort, Ginseng, Chamomile, Echinacea.
Lithium Monitoring and Toxicity Levels:
Requires baseline and ongoing liver function tests and kidney function tests.
Serum level monitoring: Drawn weekly or every 2 weeks upon initiation until therapeutic stability is reached.
Serum Thresholds:
Subtherapeutic: Therapeutic response uncommon at serum concentration levels less than .
Early Toxicity: Manifestations appear at serum lithium levels greater than .
Advanced Toxicity: Occurs at serum levels of .
Severe Toxicity: Occurs at serum levels greater than .
Adverse Drug Syndromes and Conditions:
Serotonin Syndrome: Driven by high serotonin influx. Manifestations include restlessness, sweating, dilated pupils, tachycardia, blood pressure instability, muscle rigidity, and loss of muscle coordination.
Activation Syndrome: Manifests as irritability, anxiety, impulsivity, aggressiveness, agitation, and a heightened risk for increased suicidal thoughts.
Antidepressant Discontinuation Syndrome (ADDS): Occurs following abrupt withdrawal; causes insomnia, anxiety, depression, and flu-like symptoms.
Agranulocytosis: Dangerous drop in white blood cells. Manifests with flu-like symptoms including sore throat, fatigue, fever, and muscle aches.
Neuroleptic Malignant Syndrome (NMS): Life-threatening condition. Manifests with high fever, encephalopathy, vital sign instability, elevated creatine kinase (), and severe muscle rigidity.
Extrapyramidal Symptoms (EPS): Manifests as acute dystonia, akathisia, pseudoparkinsonism, and tardive dyskinesia.
Substance Detoxification Protocols:
Alcohol Withdrawal: Long-term alcohol use depresses the CNS. Chronic adaptation leads to tolerance; abrupt cessation causes life-threatening CNS excitation.
Opiate Withdrawal: Physiological adaptation causes receptor down-regulation or up-regulation. Withdrawal manifestations require managed opiate replacement therapy and toxicity management.
Nursing Process and Clinical Judgment in Mental Health
Framework Integration:
The Nursing Process integrates directly with the Clinical Judgment Action Model (Cognitive Operations) and the Tanner Clinical Judgment Model to guide clinical decision-making.
Model Comparative Mapping:
Tanner Clinical Judgment Model: Noticing Interpreting Responding Reflecting.
Nursing Process: Assessment Analysis Outcome/Planning Implementation Evaluation.
Clinical Judgment Action Model: Recognize Cues Analyze Cues & Prioritize Hypotheses Generate Solutions Take Actions Evaluate Outcomes.
American Psychiatric Nurses Association (APNA) Standards:
Aligned with standard phases: Assessment, Diagnosis, Outcome Identification, Planning, Implementation, Evaluation.
Assessment Phase (Recognizing Cues):
Psychosocial & MSE Assessment: Gather data regarding presenting symptoms, Mental Status Exam (MSE), suicide and aggression risk, medical history, current treatments, strengths, coping abilities, available resources, and past goal successes.
Physiologic & Demographic Assessment: Assess ability to participate, co-occurring medical conditions, demographic data, History of Present Illness (HPI), cultural/spiritual beliefs, and current health status.
Focused Physical Assessment:
Dental Health: Condition of teeth and gums.
Vision/Eye Health: Visual acuity, glaucoma screening, visual disturbances.
Sexual/Reproductive Health: Sexually transmitted infections (STIs), history of abuse.
Substance Use Assessment:
Tobacco: Specific quantities smoked over time.
Alcohol/Drugs: Degree, frequency, and pattern of substance use.
Cognitive Assessment Screening Tools:
Mini-Mental State Examination (MMSE): Takes approximately to administer; assesses language, memory, attention, orientation, and visuospatial proficiency.
Mini-Cog: Takes less than to administer; assesses language, memory, visuospatial proficiency, and executive function (excludes attention and orientation).
Montreal Cognitive Assessment (MoCA): Takes approximately to complete; assesses attention, language, memory, orientation, and executive functioning.
Addenbrooke's Cognitive Examination Revised (ACE-R): Takes approximately to complete; assesses executive functioning, orientation, language, visuospatial proficiency, and memory.
Assessment Environment & Execution: Conduct in a quiet, private setting using a "funnel" (layering) interview technique.
Family Assessment: Evaluates family functioning (managing life, resolving disagreements, boundaries). Utilizes the Family Assessment Device (FAD) to assess problem-solving, communication, behavior control, affect-involvement, responsiveness, and internal family roles.
Spiritual Assessment: Conducted upon admission using spiritual frameworks (e.g., FICA framework covering Faith, Importance/participation level, Faith Community membership, and Special needs like dietary rules, provider gender preference, or prayer rites).
Situational Assessment: Performed upon entering the room. Observe behavior, wear appropriate clothing, locate and preserve unblocked exit paths, ensure quick security access, and maintain communication with the team.
Community Assessment: Evaluates population needs and resources using surveys, questionnaires, and Community-Based Participatory Research (CBPR).
Analysis Phase (Analyzing Cues & Prioritizing Hypotheses):
Recognize patterns, link clinical cues, cluster data, narrow diagnostic possibilities, and identify concerning data.
Use the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as the primary tool to delineate symptoms, define criteria, and provide standardized communication among providers.
Prioritizing Problems: Evaluate risks of action versus inaction. Immediate safety threats (risk of suicide, self-harm, or harm to others) take absolute priority over all other nursing diagnoses.
Planning Phase (Generating Solutions):
Collaborate with the client, family, and interprofessional team to establish desired outcomes and evidence-based interventions.
Goals & Outcomes: Formulated by the client and facilitated by the nurse. Focus on measurable behavioral outcomes (e.g., "The client will report having fewer than three panic attacks in the next 14 days").
Discharge Planning: Initiates upon initial diagnosis/admission; requires robust interdisciplinary communication to connect clients to resources such as Assertive Community Treatment (ACT) programs.
Implementation Phase (Taking Action):
Public/Community Health Model (Focused on WHEN intervention occurs):
Primary Prevention: Prevents disease onset (e.g., giving vitamins to prevent dementia).
Secondary Prevention: Early screening and detection (e.g., screening for alcohol use/abuse).
Tertiary Prevention: Treatment to prevent further decline or disability.
Institute of Medicine (IOM) Model (Focused on WHO receives intervention):
Universal: Targeting the general public/everyone (e.g., school-wide mental health classes).
Selective: Targeting biological, social, or environmental subsets at risk (e.g., support groups for exposed individuals).
Indicated: Targeting high-risk individuals showing early signs or markers of illness.
Client & Family Education: Must cover the nature of the disorder, medication adherence/side effects, relapse warning signs, and the critical importance of follow-up care.
Evaluation Phase (Evaluating Outcomes):
Continuously evaluate goal achievement against set timelines.
Maintain ongoing communication with the client, family, and interprofessional team.
Document status, review effectiveness of interventions, revise care plans as conditions change, report findings, and ensure interventions do not cause undue suffering.