Comprehensive Nursing Study Guide: Psychiatric Pharmacology, Theories, and Crisis Intervention
Pharmacological Interventions and Reversal Agents
Morphine (Opioid Agonist): * Primary adverse reaction of concern is respiratory depression. * Common side effects include nausea and constipation. * Antagonist/Reversal Agent: Naloxone is used to reverse morphine in the event of an overdose or adverse reaction.
Benzodiazepines (e.g., Lorazepam, Ativan): * Clinical indications include acute anxiety and seizure management. * A major risk associated with these agents is respiratory depression. * Antagonist/Reversal Agent: Flumazenil is the specific reversal agent for benzodiazepines.
Selective Serotonin Reuptake Inhibitors (SSRIs): * Serotonin Syndrome: A critical risk when SSRIs are mixed with Monoamine Oxidase Inhibitors (MAOIs). * Timeframe for Efficacy: These medications typically take to become fully effective. * Side Effects and Education: Patients may experience nausea. It is encouraged to take these medications early in the morning. * Suicidal Ideation Risk: There is an increased risk for suicidal ideation, especially during the initial phases of treatment. Healthcare providers must monitor for subtle hints or verbalizations, such as "I wish I wouldn't wake up."
Tricyclic Antidepressants (e.g., Amitriptyline): * Major Side Effect: Cardiac arrhythmias. * Lethality: These medications can be lethal in an overdose. Consequently, they should not be administered to clients experiencing active or passive thoughts of suicide due to the risk of a fatal overdose.
Clinical Indications and Dual Usage: * Trazodone: Often prescribed specifically for sleep rather than solely for depression. * Neuropathic Pain: Antidepressants are frequently used to treat neuropathic pain conditions. * Dual Diagnosis Treatment: A patient may be prescribed a single antidepressant to treat both depression and neuropathic pain simultaneously.
Psychological Structures and Defense Mechanisms
The Functions of the Ego: * The ego serves as an adaptive mechanism helping individuals function in society and the world. * It acts as a protective shield and helps individuals cope with difficult emotions. * Example of Suppression: An individual with a terminal condition might suppress their anxiety or sadness to participate in a child's wedding.
Denial as a Defense Mechanism: * Involves the refusal to accept reality or facts (e.g., "I can't have this disease. There's no way it's me."). * Personal Narrative Example: The speaker's father, upon being diagnosed with ALS (Amyotrophic Lateral Sclerosis), attributed all his physical symptoms to a spider bite. This served as a defense mechanism to help him deal with the traumatic prognosis. * Reference Table for a complete list of defense mechanisms.
The Superego: * Operates largely on a subconscious or unconscious level involving moral territory. * It dictates doing the "right thing," such as stopping at a red light instinctively.
Therapeutic Concepts: Transference and Countertransference
Countertransference: * Definition: Occurs when the nurse treats a client in a specific way based on the nurse's past personal experiences, thoughts, or biases. * Positive Bias Example: A nurse treats "Miss Smith" with extra care (e.g., giving her cookies no one else gets) because she resembles the nurse's mother. * Negative Bias Example: A nurse may be overly harsh or judgmental toward a patient with diabetes because they remind the nurse of their own child who refuses to take their medication. * Impact: Can lead to judgmental behavior or over-nurturing, which interferes with objective care.
Transference: * Definition: Occurs when the client displaces their feelings, thoughts, or expectations onto the caregiver. * Negative Example: A client becomes frustrated during an interview, feeling interrogated, and tells the nurse, "You remind me of my ex-husband." * Positive Example: A client stating "I love my therapist" is a demonstration of transference.
Major Developmental and Nursing Theories
Erikson’s Psychosocial Development (Table 3.3): * Focuses on emotional and social development across the entire lifespan. * Example: Middle adulthood involves reflecting on one's future, contribution to society, and avoiding the feeling of being "stuck."
Jean Piaget’s Cognitive Development Theory: * Explains how thinking and understanding occur in children. * Importance in Nursing: Used to assess developmental milestones and tailor patient education/expectations to the child's specific developmental stage.
Harry Sullivan: * Supports therapeutic communication and the building of nurse-patient relationships. * Focuses on how to build trust and communicate effectively to support clients through their relationships.
Hildegard Peplau: * Central focus is on the therapeutic nurse-patient relationship.
Maslow’s Hierarchy of Needs: * Prioritizes needs starting from the bottom of the pyramid. The bottom layers are the highest priority. * Physiological Needs (Base Level): Food, water, shelter, blood pressure, and vital sign stability. These must be addressed first. * Self-Actualization (Top Level): While important, it is the lowest priority in acute patient management. * Psychiatric Unit Priorities: In acute settings, the priority is addressing physiological needs (hydration, nutrition) and ensuring the safety of the patient and others.
Carl Rogers: * Emphasizes empathy, caring, and a nonjudgmental attitude. * Rationale: If a client feels judged, they may feel shame and retract, which halts their progress.
Behavioral Theories and Conditioning
Core Concepts: Behavior is learned through experience and can be modified through rewards or consequences.
Positive Reinforcement/Incentivizing: * Educational Example: Teachers using candy, extra recess, praise, or silver and gold stars to maintain order. * Healthcare Example (Operant Conditioning): Insurance companies offering a to incentivize clients to complete their annual physicals. This targets individuals who otherwise would not prioritize the appointment due to time constraints.
Crisis Intervention Strategies
Primary Objective: To return the client to their previous level of function (their "baseline"). * Note: A patient's baseline may include underlying psychiatric components (e.g., chronic hallucinations in schizophrenia) that are not life-threatening.
Types of Crises: * Maturational: Occurs during life transitions, such as leaving home or beginning to pay bills. * Situational: Unexpected events, such as the sudden death of a loved one in a car crash. * Adventitious (Social): Large-scale disasters like the COVID-19 pandemic or the St. Louis tornadoes which affected low-income communities lacking insurance for rebuilding.
Intervention Strategies: * Focus on problem-solving with the client. Nurses should not solve problems for the client but rather provide tools to foster autonomy and self-drive. * Maintain empathy and support. * Energy Matching: For some clients, a kind/soft approach works; for those with firm/aggressive personalities, the nurse may need to be "respectfully assertive."
Treatment Modalities and Settings
Individual Therapy: One-on-one sessions. The speaker notes that finding a therapist is like "going on a date"—personalities and viewpoints must gel for it to be effective.
Group Therapy: Highly effective for normalizing feelings through lived experience. Examples include Alcoholics Anonymous (AA) and GriefShare for processing loss.
Psychosocial Interventions: Focus on social and "soft" skills necessary for maintaining relationships and employment.
Inpatient Care: Focuses on safety and symptom management in the "least restrictive environment."
Intensive Outpatient Program (IOP): Provides daily therapy while allowing the client to live at home.
Residential Care/Skilled Nursing: For clients with severe, persistent illness requiring ongoing management in a facility that serves as their home.
Assertive Community Treatment (ACT): * A 24/7 interdisciplinary model (nurses, social workers, case managers) for patients with severe mental illness. * The team meets the client "where they are," including shelters or on the street.
Nursing Self-Awareness and Advocacy
Self-Awareness: The conscious awareness of one's own beliefs and values to prevent personal feelings from interfering with patient care. * Example: A nurse on an OB (Obstetrics) unit who had previously lost a baby must remain self-aware to ensure her own grief doesn't impact her care for new parents. * Professionalism: Nurses must leave personal chaos (e.g., family arguments on cell phones) at the door.
The Goal of Psychiatric Rehabilitation: * Self-empowerment and community empowerment. * Improving quality of life, self-efficacy, and resilience.
Locus of Control: * Internal Locus of Control: The belief that one's own actions cause life events. A positive internal locus (e.g., "If I take my meds and change my diet, I will be healthier") improves outcomes. * High External Locus/Helplessness: Over-dependence on outside factors can create conflict.
Special and Vulnerable Populations: * Includes children/adolescents (impacted by parental crises, abuse, or neglect), older adults, veterans (PTSD), the unsheltered/homeless, and those using illicit substances. * Strategies: Empowering clients with strategies to access care, identifying unique barriers, and advocating for equitable access. * Interdisciplinary Team: Includes pharmacists (medication management), psychiatrists, and nurses.
Questions & Discussion
Question: What are the functions of the ego? * Response: Protection and serving as an adaptive mechanism to help people function and cope with hard feelings.
Question: Can someone give an example of denial? * Response: Not believing a diagnosis (e.g., the speaker's father attributing ALS to a spider bite).
Question: What is countertransference? * Response: When the nurse treats a client a certain way because of a previous experience with someone else, involving personal bias.
Question: What is transference? * Response: When the client displaces feelings (like sibling rivalry or ex-spouse issues) onto the nurse.
Question: Why is Piaget's theory important in nursing? * Response: For assessing milestones and tailoring teaching or expectations based on the child's developmental stage.
Question: Why is it important not to show judgment (Rogers' theory)? * Response: Because it prevents the client from feeling shame, retracting, or stopping progress.
Question: In an acute psychiatric setting, what are priority needs? * Response: Physiological needs (hydration, nutrition, illness stabilization) and safety for everyone.
Question: Why is a dual diagnosis (substance abuse + mental health) challenging? * Response: Overlap in symptoms, potential contraindications in treatment, and substances causing symptoms like psychosis.
Assessment Question: A nurse is performing a psychosocial assessment on an adolescent client. Which of the following should indicate to the nurse a potential risk for suicide? * Answer: C (The transcript notes that giving away favorite personal belongings is a high-risk sign).