Psychiatric Nursing Review Flashcards

Psychotherapeutic Management

• A model of care that clarifies psychiatric nursing's nature and distinguishes it from other disciplines.
• Application of psychotherapeutic management interventions, emphasizing that "One Size Does Not Fit All".

Three Interventions

• Therapeutic nurse-patient relationship
• Psychopharmacology
• Milieu management

Therapeutic Relationship

• Therapy provided by nurses with graduate degrees.
• Involves communication, respect, understanding of mental mechanisms, adaptation styles, and coping strategies.
• Mastering therapeutic intervention skills is essential.

Psychopharmacology

• Requires knowledge of psychiatric medications and application of the nursing process.
• Nurses assess how medications assist patients, identify drug-related problems, determine when to provide PRN medications, and educate patients about their medications.

Therapeutic Milieu

Key elements:

• Safety
• Structure
• Norms
• Limit setting
• Balance
• Environmental modifications

Psychopathology

• Considered the key to psychotherapeutic management.
• Lays the groundwork for understanding psychopharmacology.
• Provides a theoretical structure for milieu management.

Continuum of Care

• Mental health assessment determines the appropriate level of care needed.
• Assessment includes:
  • Risk assessment
  • Danger to self or others
  • Gravely disabled
  • Acutely psychotic
  • Suicidal or homicidal tendencies

Hospital-Based Care

• Length of stay is around 3 to 5 days.
• Emphasis includes crisis intervention and ensuring safety.
• Staffing should be cost-effective while providing safe care.
• Patients are acutely symptomatic.
• Discharge planning begins upon admission.
• Care is provided for individuals experiencing toxic reactions to medications or substances.
• Safe detoxification services are available.
• Care is available for those with medical illnesses presenting behavioral symptoms or complicating psychiatric conditions.

Long-Term Care: Residential Services

• Long-term, state-run facilities
• Extended-care facilities, nursing homes
• Group homes and halfway houses
• Supervised apartment living
• Foster care homes
• Shelters for homeless or individuals needing safety due to domestic violence

Traditional Outpatient Services

• Offered in clinics or private practices with appointment schedules based on individual needs.
• Staff may include psychiatrists, psychologists, nurse practitioners, nurses, social workers, licensed mental health counselors, and case managers.
• Patients may receive services from multiple practitioners based on their needs.

Day Treatment Program

• Offers minimal supervision with structured, ongoing treatment.
• Care provided for 4 to 8 hours daily, 1 to 5 days a week.
• Programs available for adults, children, or adolescents.
• Some programs specialize in specific populations, such as substance abuse care.

Self-Help Groups

• Meetings conducted by nonprofessionals, often individuals who have experienced mental illness.
• Groups can be addiction-based, survivor-based, disorder-based, loss-based, medical-based, or prevention-based.

Primary Care

• Patients with mental illness often seek care from primary care practitioners.
  • Reasons include less stigma compared to mental health services, lack of awareness of where to obtain care, and difficulty accessing care.
• Primary practitioners sometimes prescribe psychotropic medications.

Legal Issues

Sources of Laws

• Common law: Derived from judicial decisions
• Statutory law: Created by federal and state legislatures
• Administrative law: Developed by administrative agencies, such as state boards of nursing

Major Court Decisions: Common Law

Right to Refuse Treatment

• Rogers v. Okin: Nonviolent patients cannot be forced to take medications against their will.
• Patients or their guardians must give informed consent before drug treatment can begin.
• Nurses cannot force patients to take medications "for their own good."

Duty to Warn

• Tarasoff v. Regents of University of California: Mental health professionals have a duty to warn of threats of harm to others.
• Currently a national standard of practice.
• Important to know the law in your geographic area; some jurisdictions still hold that any disclosure of confidential information is a violation of patient rights.

Torts (Civil Law)

Negligence

• Failure to do or not do what a reasonable person would do under the circumstances.
• Elements:
  • Reasonable care (standard of care)
  • Duty to care
  • Breach of duty
  • Injury caused by a breach of duty

Malpractice

• Professional negligence; claims usually arise from nurse's failure to prevent harm and maintain standard of care.
• The employer is responsible for the acts of the employee within the scope and authority of employment.

Treatment and Patient Rights

Assault

• Deliberate threat and the ability to do physical harm to another.
  • Example: Verbally threatening to force medication on a patient against their will.

Battery

• Intentional touching of another person in a socially impermissible manner.
  • Example: Force used in unlawful detention of a patient.

False Imprisonment

• Unlawful restraint of a person’s personal liberty.
  • Restraint or confinement.

Commitment Issues

• Voluntary Patients
• Involuntary Patients: dangerous to self or others
  • Emergency care: evaluation and emergency treatment
  • Short-term observation and treatment: a treatable disorder that will improve with treatment
  • Long-term commitment: need prolonged care, but refuse to seek help; determined by a hearing officer

Probable Cause

• A statement that indicates a person is a danger to self or others or is gravely disabled.
• The Fourth Amendment of the US Constitution requires the probable cause statement.
• If probable cause exists, the person is detained for observation and treatment.
• Patients must be released when no legal basis exists for continued confinement.

Commitment of Incapacitated Individuals

• Incapacitated persons:
  • Gravely disabled, unable to provide food, clothing, and shelter for self due to mental illness, and viewed as incompetent.
  • Loses rights to marry, vote, drive a car, or enter into contracts.
• Conservators and guardians are legally obligated to act in the patient’s best interest.

Freedom From Restraints or Seclusion

• Staff must receive special training and demonstrate competency.
• Use alternative interventions before restraint or seclusion.
• A physician’s order is required within 1 hour of restraint; physician assistants and advanced practice nurses can also write this order.
• Use the least restrictive method.
• Document the events leading to the intervention and justification.
• Orders must contain type of restraint/seclusion, rationale, and time limitations.
• PRN orders are not permitted.
• Use for the shortest period of time.
• Patients must know what behaviors are expected for release.
• Reevaluate the patient every 2 hours for continued need.
• Constantly observe the patient, documenting safety and comfort interventions every 15 minutes.
• Debrief patients after restrictive interventions.
• Patients may request notification of a family member.
• Death of a patient in restraints must be reported to the FDA.

Refuse Consent to Treatment

• Does the patient have the legal capacity to give informed consent to refuse medication?
• The court decides whether a person is not competent, and medications can be imposed on the patient.
• Never hide medications in food or liquid when a patient refuses; it is forcing a patient against his or her will.

Patient’s Rights

• Suspension of rights: Therapeutic use requires clear documentation presenting the rationale.
• Provide advance directives: Choose type of medical treatment in case of a life-threatening condition.

Mental Illness and the Justice System

• Thirty-seven percent of people in state and federal prisons have been diagnosed with a mental illness.
• The justice system was not designed to treat mental illness.
• Large numbers of inmates pretend to have mental disorders to receive medications and be in a more comfortable or safer environment.
• Individuals needing medications may fear taking them because some medications can render inmates less able to defend themselves.
• Risk of therapeutic medications being abused, sold, or taken by other inmates.

Cultural Issues

Basic Concepts

• Internal and external behaviors and thought patterns that are learned and shared.
  • Values
  • Beliefs
  • Norms of a person, group, or community
• Helps individuals function in life and assists with understanding and interpreting life’s occurrences.

Cultural Competence

• Proficiency in cultural competence includes:
  • Awareness
  • Knowledge of cultural impact on the person/community
  • Skills to promote effective care
  • Incorporates cultural competence in interactions with peers, students, patients, families, and communities.
• Key to the patient’s recovery process.

Barriers to Culturally Competent Care

• Miscommunication between the nurse and the patient.
• Lack of knowledge and sensitivity regarding cultural beliefs and practices.
• Patients unaware of the nurse’s cultural perspectives, therefore misinterpreting health care recommendations from the nurse.
• Failure to assess the patient’s cultural perspective.

Cultural Etiology of Illness and Disease

• Definition of health
• Perception of illness and how it occurs
• Cultural worldview
• Natural causes of illness: everyone and everything in the world are interrelated; a disruption of the connection causes illness
• Unnatural causes: outside forces cause illness
• Scientific: specific concrete explanations of the illness

Primary Worldviews

• Analytic
• Relational
• Community
• Ecological
• Individuals may have a mix of primary worldviews.
• When with family or significant others or during stress, the primary worldview is predominate.

Four Worldviews

• Analytic: values detail to time, individuality, and possessions; learning is through written, hands-on, and visual resources.
• Relational: spirituality and the significance of relationships and interactions between and among individuals; learning is through verbal communication.
• Community: Community needs and concerns are more important than the individual’s needs. Learning style is quiet, respectful communication, meditation, and reading.
• Ecological: Interconnectedness exists between human beings and the earth, and individuals have a responsibility to take care of the earth. Learning style is quiet observation and contemplation.

Alternative Therapies

• Acupuncture
• Acupressure
• Nutritional therapy
• Skin scraping
• Moxibustion
• Cupping

Ethnopharmacology

• Pharmacogenetic, pharmacodynamic, and pharmacokinetic influences are based on different ethnic, racial, and cultural groups.
• Variation in metabolism can cause differences in response to medications, based on genetically based pharmacokinetic variations when metabolizing the medications.

Nurse’s Role in Cultural Assessment

• Basic elements:
  • Communication
  • Orientation
  • Nutrition
  • Family relationships
  • Health beliefs
  • Education
  • Spiritual or religious views
  • Biological or physiological elements
• Cultural preservation: the nurse’s ability to acknowledge, value, and accept the cultural beliefs of the patient
• Cultural negotiation: the nurse’s ability to work within the patient’s cultural belief system
• Cultural repatterning: the nurse’s ability to incorporate cultural preservation and negotiation to identify patient needs, develop outcomes, and evaluate outcome plans

Spirituality Issues

Aspects of Spirituality

• Forgiveness
• Grief
• Peace
• Trust
• Transcendence
• Discovery
• Fear
• Meaning
• Alienation
• Purpose
• Hope
• Love
• Relationship
• Gratitude

Toward An Understanding of Spirituality

• Spirit—not strictly physical; gives life depth and meaning to existence
• Making sense of life
• Hope, plans, and fears
• Values
• Individuals relating to each other with issues of meaning and belonging

Interpretations of spirituality

• Theistic: Connected to a transcendent source (God, a higher power or a universal spirit) often expressed within a religious community.
• Humanistic: Distinguishes spirituality from a religious perspective; emphasizes the human spirit and relationship to other human spirits not dependent on the notion of a higher power.

Theistic View

• Spirituality in relation to a transcendent spirit
• Exemplified in the creation story of the three largest monotheistic religions
• Human lives inspired by a supreme being
• Gratitude for basic existence

Humanistic View

• People attempt to bring meaning in their lives apart from a religious community or understanding of God.
• Emphasis is on the human spirit, individually and collectively.
• Theistic and humanistic are not mutually exclusive.

Clinical Understanding

• Positive correlation between mental health and spiritual well-being
• “Sick religiosity”: negative experiences with someone or a religious institution that may have been painful or dehumanizing
• “Healthy spirituality”: positive experience
• Importance of hope for will to live

Importance of Spiritual Care

• Spiritual refers to cultural, religious, or existential concerns.
• DSM-5: religious or spiritual problem
• NANDA: several nursing diagnoses dedicated to spiritual care
  • Moral distress
  • Hope
  • Hopelessness
  • Religiosity
  • Spiritual distress

Health Care Applications

• Take a spiritual history.
• Support and show respect for the patient’s beliefs.
• Pray with the patient if the nurse is comfortable doing so and the patient wants and requests this intervention.
• Provide spiritual care by being kind, gentle, sensitive, and compassionate.
• Refer to pastoral care.

Using Clergy Resources

• Refer a patient with spiritual concerns to a clinically trained spiritual care professional, usually a chaplain.
• A board-certified chaplain should service on the multidisciplinary team.

Models for Working With Psychiatric Patients

Recovery Model

• Improving the patient’s competencies, not simply alleviating symptoms
• Not a medical model
• Does not involve a cure; movement toward a meaningful way of life
• Patient striving to improve his or her own health and wellness
• Striving to achieve the full potential of life
• Person-driven and self-directed
• Collaborating with consumers instead of telling them what to do
• Encouraging consumers to try new things
• Consumers taking responsibility for their own care
• Recovery being nonlinear; setbacks not considered as failure
• Creating atmosphere of hope
• Person is not identified by his or her illness.
• Person is not “bipolar.”
• Consumers develop meaningful roles in their communities, not with the mental health system.
• Support systems include family members, peers, and community members.
• Peer support is essential.
• Relevance to nursing practice
  • Assessment focus on the consumer’s perception of mental health and desire to make the changes for recovery
  • Consumer incorporated in every level of planning, training, delivery, policy, and evaluation of mental health care services
  • “Nothing about us without us!”

Attachment Theory

• Humans have a natural tendency to develop intimate emotional bonds throughout life
• Humans are motivated by a need for relationships
• Found to be associated with the development of personality and mental disorders
• Development of psychiatric disorders can occur as a result of childhood trauma

Psychoanalytic Theory

• Sigmund Freud
• Emphasized unconscious process of psychodynamic factors for motivation and behavior.
• Self psychology: every human being longs to be appreciated.
• Object relations theory: individuals relate to others based on expectations formed by early experiences.
• If early parental relationships are secure and loving, the child grows up secure in relationships.
• Disruptions in early parent-child relationships lead to future relationship problems by distorting their perceptions of others.

Defense Mechanisms

• When anxiety becomes too painful, defense mechanisms are used to protect the ego and diminish the anxiety.
• Excessive use of defense mechanisms prevents the person from problem-solving.
• Defense mechanisms are unconscious; some are within voluntary control.
• Transference: Unconscious distortion in the relationship; a patient displaces distrustful feelings for her father to her male psychiatrist and refuses treatment.
• Projection: Unconsciously or consciously attributing one’s own repressed thoughts to someone; individual often projects to the second person, who reacts to the projection, then the reactivity elicits a response from the first person.
• Denial: unconscious refusal to admit an unacceptable idea or behavior
• Repression: unconscious and involuntary forgetting of painful ideas, events, and conflicts
• Suppression: conscious exclusion from awareness of anxiety-producing feelings, ideas, and situations
• Rationalization: conscious or unconscious attempts to justify one’s feelings or behaviors
• Intellectualization: conscious or unconscious logical explanations without an affective component
• Dissociation: unconscious separation of painful feeling and emotions from an unacceptable situation, object, or idea
• Identification: conscious or unconscious attempt to model oneself after a respected person
• Introjection: unconsciously incorporating values and attitudes of others as if they were your own
• Compensation: consciously covering up for a weakness by overemphasizing or making up a desirable trait
• Sublimation: consciously or unconsciously channeling instinctual drives into acceptable activities
• Reaction formation: conscious behavior that is the exact opposite of an unconscious feeling
• Undoing: consciously doing something to counteract or make up for a transgression
• Displacement: unconsciously discharging pent-up feelings to a less threatening object
• Conversion: unconscious expression of intrapsychic conflict symbolically through physical symptoms
• Regression: unconscious return to an earlier more comfortable developmental level

Relevance to Nursing Practice

• Brief, therapeutic encounters a nurse must recognize and understand:
  • Maladaptive defense mechanisms
  • Share observations regarding the defense mechanisms
  • Assist patient to increase awareness about use of defense mechanisms
  • Increase use of adaptive behaviors

Developmental Model

• Erikson built on Freud’s psychoanalytic model.
• Every person passes through eight interrelated stages over the life cycle.
• Failure to complete a stage results in reduced ability to cope psychologically.
• Trust versus mistrust (0 to 18 months): developing realistic trust of self and others
• Autonomy versus shame (18 months to 3 years): developing self-control and willpower
• Initiative versus guilt (3 to 5 years): developing an adequate conscience
• Industry versus inferiority (6 to 12 years): sense of competence
• Identity versus role diffusion (12 to 20 years): confident sense of self
• Intimacy versus isolation (18 to 30 years): ability to give and receive love
• Generative lifestyle versus stagnation or self-absorption (30 to 65 years): productive, constructive, creative activity
• Integrity versus despair (65 to death): feelings of self-acceptance
• Patients with psychiatric disorders demonstrate partial mastery of developmental stages.
• Nurse conducts an assessment of the patient’s level of functioning.
• Assessment identifies the degree of mastery of each stage up to the patient’s age.
• Assessment reveals issues to be addressed while working with the patient.

Interpersonal Model

• Nurse’s role is to focus on current interpersonal relationships and experiences.
• Develop mature and satisfactory relationships relatively free from anxiety.
• Nurse-patient relationship is a vehicle to analyze the patient’s interpersonal process and test new relationship skills.
• Focus on interpersonal issues and distortions due to past experiences.

Cognitive-Behavioral Model

• Beck’s cognitive therapy and Ellis’s rational-emotive therapy models focus on thinking and behavior rather than on expressing feelings
• Cognitive approach—ability to think, analyze, judge, decide, and do
• Irrational and illogical beliefs responsible for causing emotional problems
• Recurrence of irrational thoughts produces emotional disturbances that keep dysfunctional behaviors operant.
• Purpose of rational-emotive therapy is to stop blaming self and accept self, and attack problems from a cognitive, emotive, and behavioral standpoint.
• Cognitive therapy and rational-emotive therapy both focus on thinking and behaving rather than on expressing feelings.
• Rational-emotive therapy teaches individuals to stop blaming themselves and to accept themselves as they are, attacking problems from a cognitive, emotive, and behavioral standpoint by using the A-B-C theory of personality
• Behavioral therapy (BT) builds on cognitive therapy with principles of classical and operant conditioning: reinforcement, skills training, response prevention, exposure (in vivo or imaginal), and systematic desensitization
• Cognitive-behavioral therapy (CBT) is effective in directly changing behaviors as well as changing faulty thinking and is the most evidenced-based therapy
• Nurse’s role: collaborative effort to achieve goals for improving self-esteem, coping, relationships, and lifestyles
• Humor is used to confront ineffective thinking.
• Focus of therapy is on the present.
• Patients learn to take responsibility for irrational thoughts, feelings, and behavior to replace these with more productive thoughts.
• Relevance to nursing practice: assist the patient to learn from mistakes; patients who project blame can be shown that they are responsible for their behaviors; patients who focus on shoulds, oughts, and musts can be taught to act according to their personal wants and beliefs

Learning to Communicate Professionally

Nurse-Patient Communication

• Two-way process between two or more individuals
• Focused on the patient’s needs and problems
• Implements nursing process to achieve quality patient care
• Builds trust, develops therapeutic relationship, and provides support, comfort, growth, change, and patient education
• Categories of Communication
  • Speech and behavior
    • Body language and tone of speech must match.
    • Verbal and nonverbal communication must match.
    • Behaviors that show one message and verbal speech that shows another message will be confusing to the patient.

Dynamics of Therapeutic Communication

• Words and nonverbal behaviors that relate to the patient’s health needs are exchanged between the patient and the nurse.
• Communication is influenced by:
  • Individual’s personal experiences, gender, culture, values, and beliefs
  • Purpose of interaction
  • Physical and emotional context of the interaction (Watch out for patronizing, condescending, or stigmatizing behavior.)
• Themes in Patient Communications
  • Content theme examines underlying messages about patient’s perceptions of self and problems.
  • Mood theme relates to affect and feelings conveyed while discussing the issues and concerns.
  • Interaction theme examines relationship to others.
  • Incongruent mood theme is when the affect does not match the content theme.
• Environmental Considerations
  • Privacy
  • Furniture
  • Temperature
  • Noise level
  • Proxemics: the way people perceive and use environmental, social, and personal space during interactions
  • Boundaries
• Physical Considerations
  • Sensory limitations, such as hearing loss
  • Developmental disabilities presenting problems of comprehending and remembering
  • Speech impediments
  • Pain interfering with ability to think clearly and concentrate
• Kinesic Considerations
  • Culturally based
  • Body language
    • Facial expression
    • Eye movement
    • Gestures
    • Mannerisms
    • Eye contact
  • Might be incongruent with words
  • Validate meaning

Therapeutic Communication

• Therapeutic
  • Patient-centered
  • Planned
  • Directed by professional
  • Meets patient’s needs
  • Guides the patient to explore personal issues and painful feelings
  • Listener objective
  • Information shared with health team

Therapeutic Use of Self

• Verbal and nonverbal communication
• Silence and therapeutic listening
• Components
  • Being actively alert
  • Using eye contact
  • Attending posture
  • Concentrating
  • Being patient
  • Displaying openness
• Offering empathy/support
• Asking questions
• Assimilating information
• Organizing, synthesizing, and interpreting information
• Validating and clarifying information
• Responding verbally and nonverbally
• Summarizing
• Giving feedback
• Sensitivity: recognize important cues and prioritize the cues
• Objectivity: remain open to many aspects of the patient and their problems
• Self awareness
• Empathy
• Patients must feel respected, valued, and accepted
• Genuineness
  • Congruence
  • Authenticity
  • Honesty
  • Nonevaluative
  • Sets limits
• Touch: use with caution
  • Might violate personal space
  • Might be misinterpreted

Techniques

• Offering self: showing interest and concern
• Active listening: paying close attention to verbal and nonverbal communication, patterns of thinking, feelings, and behavior
• Silence: allowing the patient to think and say more
• Empathy
• Questioning: using open-ended questions
• General leads
• Restating
• Verbalizing the implied
• Clarification
• Making observations
• Presenting reality
• Encouraging description of perceptions
• Voicing doubt
• Placing an event in time or sequence
• Encouraging comparisons
• Identifying themes
• Summarizing
• Focusing
• Interpreting
• Encouraging evaluation
• Suggesting collaboration
• Encouraging goal setting
• Giving information
• Encouraging consideration of options
• Encouraging decisions
• Encouraging the formulation of a plan
• Rehearsing
• Role-playing
• Supportive confrontation
• Limit setting
• Feedback
• Encouraging evaluation
• Reinforcement
• Repeating steps of nursing process as needed

Interference in Therapeutic Communication

• Nurse’s:
  • Fears
  • Feelings
  • Lack of knowledge
  • Insecurity
  • Inappropriate responses

Ineffective Responses

• Not fully listening, not paying attention
• Looking too busy, ignoring the patient
• Seeming uncomfortable with silence, fidgeting
• Being opinionated, arguing with the patient
• Avoiding sensitive topics, changing the topic
• Being superficial or using clichés
• Having a closed posture, avoiding eye contact
• Making false promises or reassurances
• Giving advice or talking too much
• Laughing or smiling inappropriately
• Showing disapproval or being judgmental
• Belittling feeling or minimizing problems
• Being defensive or avoiding the patient
• Making flippant or sarcastic remarks
• Lying or being insincere
• Texting while sitting with patient