Quiz 1:
Chapter 1- Basic Mental Health Nursing Concepts
American Nurses Association + American Psychiatric Nurses Association + International Society of Psychiatric-Mental Health Nurses → make up provision of mental health care
Nurses should use:
Nursing process
Holistic approach (biological, social, psycho, spiritual)
Observe, interview, physical exam, collaboration
Physical Assessment: each encounter is an ongoing assessment
Use touch to communicate as caring
dont touch if not desired
Ask questions about:
Sleeping dificulties?
Incontinence?
Falls/Injuries?
Depression?
Dizzy?
Loss of energy?
Include significant others
Obtain med h/x
Ask for feedback from pt
Psychosocial History:
Check for pt’s own meaning of health
beliefs
What they do to pass the time
Assess substance use/ substance use disorder h/x
Assess stress level + coping
coping stratergies & support systems
Assist pt in finding support persons/resources
Assess culture → intergrate into care plan
Is the pt’s diet cultural specific?
Does the pt have specific beliefs regarding health care?
How is the pt’s d/x looked at in their culture?
Spirituality: pt’s internal values, sense of morality & how pt views purpose of life
not always connected to religion
assist in locating spiritual leader
Religion: pt’s beliefs according to organized set of patters of worship/rituals
assist in locating religious leader
Mental Status Examination (MSE):
LOC:
Alert: responsive and able to respond via opening their eyes and has a normal tone of voice and speech
answer all questions spontaneously and appropriately
Lethargic: open eyes and responds but is drowsy and falls asleep easily
Stuporous: req. vigorous/painful stimuli to elicit a brief response
may not be able to respond verball
Comatose: pt is unconscious and does not respond to painful stimuli
Decorticate rigidity: Flexion & Internal rotation of upper-extremity joints & legs
Decerebrate rigitiy: Neck and Elbow extension, wrist and finger flexion
Physical Appearance:
checks for hygiene, grooming, nutrition status, clothes, older than stated age
Expected: well-kempt, clean, dressed appropriate
Behavior
voluntary & involuntary body movements
Eye contact
Mood:
emotions that pt feels
Affect:
obj expression of mood
flat affect/lack of expression
Cognitive and Intellectual Abilities:
Assess AOX3
Assess memory
Immediate: ask pt repeat series of numbers/objects
Recent: ask pt to recall recent events or the purpose of their admission/appointment
Visitors seen from today
Remote: ask pt fact from past
Birth date
Mother’s maiden name
Assess lv of knowledge (current ilness/hospitalization)
Assess ability to calculate (count backward from 100-7)
Assess abstract thinking
How are cars and trains similar?
Must be culturally sensitive
Objective assessment of pt’s perception of their illness
Assess judgement to hypothetical question (logical response)
What would you do if there was a fire in this room?
Assess rate, volume of speech, and quality of language
Expected: meaningful, articulated, and appropriate responses
Write a sentence for language
Pain Assessment:
VAS
Wong-Baker FACES
Faces Pain Scale-Revisted
Mc Gill Pain Questionnaire (MPQ)
PAINAD scale
Children and Adolescents Assessment: temperament, SDOH, culture/religious issues, developmental lv; both can experience some mental health problems as adults
Care giver can also provide information
Mentally Healthy jits can:
trust others
view world as safe
interpret their environment
master tasks
use good coping skills
Factors that delay mental health disorder d/x:
Lack of ability to describe what is happening
Many variations of “normal” behaviors present
Check for
Mood
Anxiety
development
Behaior
ED
Risk for self-harm/suicide
HEADSSS format:
Home: relationship w/parents?
Education/Employment: pt employed? school performance?
Activities: Participate in sports? how do they interact with peers?
Drug use: Alcohol, Tobacco, illicit drugs?
Sexuality: Engage in it? Many partners?
Suicide/Depression: Pt at risk? pt has depression s/s?
Safety: Pt exposed to abuse in house/neighborhood?
Older Adults Assessment: Functional ability (ADLs), economic/social status, environmental status (stairways in home)
Geriatric Depression scale, Michigan Alcoholism Screening Test, MMSE
Conduct assessment by:
Private, quiet, adequate lighting
Introduce yourself → ask for name and pronouns
Sit level to pt
SDOMH: ways they live/work and how it shapes their health
Identified by WHO
Looks at disparities in health care, treatment, accessibility
Similar to SDOH but more liniated w/mental health care approach
Trauma Informed Care: must understand importance of screening for interpersonal violence & trauma → better understand pt’s behavior + relationships
trauma can affect ppl + groups
know signs of trauma
organized responses to trauma
Resisting re-traumatization
Mental Health Diagnosis:
DSM-5-TR: used to d/x mental health disorders in pts; includes:
expected a/x findings for disorders
Helps with planning, implementing, & evaluating care
NANDA: basis for appropriate nursing interventions
Serious Mental Illness (SMI):
severe/persisten
Difficultiy w/ADLs
Lifelong with patterns of remissions and exacerbations
Role and Life changes:
Role Transition: loss of employment, divorce, retired, grandparent, widowed, death of parent, becoming caregiver or receiving care
Predicted → retiring
Unpredicted → receiving care due to sudden illness
Check for ability to cope via:
Health status & functional abilities
Living arrangemetns and employability
Personality/Attitude
Client, caregiver, family a/x
Lv of info (community programs)
Medication use & services
Positive adaptation signs:
States positive coping behaviors
Knows maladaptive coping behaviors
Participates in community resources
Lists stress reduction techniques
Maintains housing + employment
Therapeutic Strategies List:
Counseling:
using therapeutic comms skills
Assisting with problem solving
Crisis intervention
Stress management
Milleu Therapy:
Orient pt to physical setting
Identify rules & boundaries
Ensure safe environment
Assist pt in participating with activities
Screenings:
Trauma h/x
Suicide/nonsuicide self-injury r/x
Substance use
Coping skills
Support systems
Self-care activities promotion
Offer assitance if needed
Allow time for pt to complete self-care
Set incentive to promote pt self-care
Psychobiological Interventions:
Meds
educate pt/family about meds
Monitor for AEs & effectiveness
Cognitive & Behavioral Therapies:
Modeling
Operant conditioning
Systematic Desensitization
Chapter 2- Legal and Ethical Issues
Legal rights for Mental Health patients:
Right to
Informed consent
Refuse t/x
Written plan of care (discharge, follow-up, participation & review in care plan)
Communicate with family, attorney or other HCPs
Interpreter
Care with respect, dignity, non-discriminatory
Freedom from restraints, seclusion, physical/mental abuse/neglect
Psychiatric ADs
Care w/least restrictive measures possible
Legal issues are looked over in court with a tort:
Wrongful act/injury commited by a person against someone or their property
decides liability and criminal penalities
Varies by state
Mental Health Parity and Addiction Equity Act of 2008: insurance coverage required for ALL mental illness and must be reviewed like any other medical t/x
Ethical Issues: Nurses are always faced with bioethical issues (ethical dilemmas regarding pt care)
Ethical dilemma: conflict between 2+ courses of action
Pharmacogenetic testing: predicts side effects and efficacy w/psychotropic meds
Genetic testing not legalized by FDA yet
Nurses must use these ethical principles:
Beneficence: Doing good; charity
RN helps pt feel safe
Autonomy: pt makes own decision; pt must accept consquences
Considering alternatives
Justice: fair and equal t/x
Fidelity: loyalty and faithfulness to pt
Pt asks nurse to be present → RN stays present when asked
Veracity: Honesty when dealing with pt
Dont lie
Confidentiality: Protected by HIPAA
Must understand federal + state laws
Only share with ppl related to pt’s t/x plan
Ask for pt consent
Dead Man’s Statute: protects info about deceased pt’s
Must snitch if pt reports abuse or self-harm or harm to others
Informal Admission: Does not pose a threat to self or others
Free to leave at any time
Least restricive type of admission
Voluntary Admission: Pt or guardian choose to bring them =
pt is competent and can refuse meds + t/x
Pt is evaluated and decided if they can leave or go through a involuntary admission
Temporary Emergency Admission: admitted when unable to make decisions
HCP initiates admission and mnetal HCP evaluates it
Length does not exceed 15 days
Involuntary Admission: Against their will; based on their need for t/x, risk to harm or unabe to self-care
Criteria:
s/s of mental illness
poses danger
severe disability and cannot perform ADLs
needs t/x but cannot receive it which can relate to a mental illness?
Often 2 physicians and family, guardian, PCP, or Mental HCP needed for admission
Limited to 60 days until review of admission is needed
Pt’s are still competent and can refuse t/x and meds
People who are imcompetent by court are appointed a guardian which can sign informed consent.
Long-term Involuntary Admission: Type of admission similar to temporary but imposed by court
Usually 60-180 days
some have no release date
Pt’s rights regarding Seclusion and Restraint:
Restraints are either physical or chemical (neuroleptic)
Timeout can be asked by a patient for them to leave a environment that is too overstimulating
Must prescribe the least restrictive and for the least time as possible
Less restrictive measures:
Verbal
“calm down”
ask for cooperation
active listening
Diversion/Redirection
Calm & Quiet environment
PRN meds
Never use seclusion or restraints if its for:
Convinience of staff
Punishment
Physical or mentally unstable
Pts who cannot tolerate seclusion rooms due to the limited stimuli
When ordering a seclusion/restraint
Prescribe in writing
Time for them
18+ → 4 hrs
9-17 → 2hrs
<8 → 1hr
Rewrite prescription every 24 hrs if needed more
Continuous in person/remote supervision needed
Check facility protocols
Document every 15-30 mins:
Precipitaitng events leading to measures given
Alternative actions given before
time of t/x
pt’s current behavior, nutrients given, needs given, vitals monitored
Med administered
Time releases from restraints
If emergency, restrain/seclude first → prescribe 15-30 mins later
Always obtain a prescription before re applying/doing
Intentional Torts: more likely in mental health seetings
False Imprisonment: confining physically, verbally, or chemicaly when not needed
It is not this if its to protect ppl from pt’s harmful behaviors
Assault: making a threat to a pt
Battery: touching offensivel to cause harm
Injected against their will
Invasion of privacy
Unintentional Torts: result of nurse failing to meet their duties
Negligence: Failure to provide care
RN had duty to protect → breached duty → caused injury when it coulded been avoided → dmgs occured
Malpractice: Professional negligence
Breach of duty: not meeting standards of care
Cause in fact & Proximate cause:
Did injury occur of action of nurse, or lack of action?
Did RN foresee injury as a cause of their negligence?
Damages: loss of $, property, or causes pain/suffering
Duty: knowing one’s knowledge needed for practice
E.g.: psychiatry
Chapter 3- Effective Communication
Intrapersonal Communication: self-talk
for self-assessment of values/belief before caring for a pt who can be triggered
Interpersonal Communication: One-on-one w/another person
Obtaining psychosocial h/x from pt or active listening
Small-group Communication: between 2+ people in a small group
Discuss pt’s changed behavior w/HCP team or during group therapy
Public Communication: large group
Education
Verbal Communication:
Vocabulary: Words used to communicate
Limited → difficult to understand
Jargon → v understanding
Denotative/Connotative meaning:
Multiple meaning words can be interpreted differently
Clarity/Brevity: shortest + simplest is the best
Long and complex makes it difficult
Timing/Relevance: know when to communicate allows them to be more attentive
Like when a pt has pain or is distracted
Pacing: rate of speech
rapid speech → looks like the RN does not have time for the pt
Intonation: tone of voice
Acceptance, judgment, dislike
NonVerbal Communication
Affect:
Frowning, lack of expression, grimacing, pursed lips, raise/lowered eyebrows, biting/licking/smacking lips, nose scrunching
Appearance:
Sudden disrobing, incongruent clothes, vvv grooming
Autonomic response:
visible brow/palm perspiration, dilated pupils, flushing, pale, ^ RR
Behaviour:
Gait, posture, hand clenching, rocking, psychomotor agitation
Eye Movement:
Suspicious, squinting, minimal blinking
Thereapeutic Communication purpose: client centered and it is purposeful, planned, and goal-oriented
Attend to pt’s thoughts, feelings, concerns, needs
Empathy, concern for pt
Obtain info and give feedback to pt
Intervene to promote relationships and functional behavior
Evaluate pt’s progress
Therapeutic Communication Essential Components:
Time:
Plan for adequate comm talk
Major depressive disorder or schizo pts require more time to respond
Active Listening:
Conveys interest
Eye contact (varies w/culture)
Body language
Vocal Quality ^^^ raport and aids in emphasizing
Verbal tracking is for feedback (restating/summarizing)
Caring Attitude:
concern and facilitates emotional connection w/pt + family
Honesty:
Open, directed & truthful
Trust:
Reliabilty w/out doubt/question
Empathy:
objective awareness of feelings, emotion and behaviors of others
Stepping in their shoes
Nonjudgmental
Mental Health Nursin Process
Assessment:
Verbal + Nonverbal communication
Cultural consideration
Check for verbal + nonverbal congruency
anxiety, anger, depression
Check developmental lv and adapt
Children:
simple and straightfoward
Be aware of nonverbal msg
Be at child’s eye level
Incorporate play
Understand and adapt child’s development
Adolescents:
How they perceive health
How their mental health d/x affects their relationships
Older Adults:
Pt for amplification
Minimize distractions
Allow time to respond
Ask for caregiver input for most effective communication
Planning:
Minimize distraction
Privacy
Mutually agree with patient for outcome
set priorities
Plant for adequate time for interventions
Implementation:
Establish a nurse-client relationship
Diversity, Equity, Inclusion
Bias-free language:
Focus on relevant characteristics
Know that different that do not exist
Acknowledge pronouns
Do not use the word “normal”
Effective Communication Skills:
Silence: allows time for reflection
Active Listening: hear → observe → understand → communicate → provide feedback
Questions
Open-ended: Facilitates spontaneous responses
Closed-ended: Used sparingly; repeated can block comms
Projective: “what if” to explore understanding
Presupposition: Explore pt’s life goals or motivation via a hypothetical question where the pt does not have a mental health disorder
Clarifying Techniques:
Restating
Reflecting: directs focus back to pt to examine their feelings
Paraphrasing: restate pt’s feelings & thoughts to confirm what has been communicated
Explore: allow RN to gather more infor mention by pt
Offer broad-opening statements: helps pt determine when convo starts and ends
Show Acceptance and Recognition
Focusing: helps pt concentrate
Give info: used to aid pt in decision making
Presenting Reality: dispels false beliefs, hallucinations, or delusions
Summarizing: emphasizes on important points and reviews them
Offering self: willingness to spend time w/pt
Touch: when appropriate; provides comfort
Seating: allow pt to walk around room if unable to stay seated
Motivational Interviewing: assist in pt developing motivation to resolve insecurities/ambivalence
Barriers:
Asking irrelevant personal question
Personal opinions
Advice
False reassurance
Minimizing feelings
Changing the topic
“Why” questions
Offering value judgements
too many questions
Rapid questioning
Giving approval/disapproval
Chapter 4- Stress and Defense Mechanism
Defense Mechanisms: Manages conflict in anxiety
Reversible and can be adaptive or maladaptive
Maladaptive: Interfere w/functioning, relationships, and orientation to reality
Best for pt to use variety of mechanisms, not just one.
Altruism and Sublimation: ALWAYS Healthy
Actions as RN when pt is exhibiting defense mechanisms:
maintain trust → well-being focus → assist towads healthy coping
Altruism: Dealing with anxiety by reaching out to others
Adaptive Use: RN lost her family to fire becomes firefighter
Maladaptive Use: N/A
Sublimation: Dealing with unacceptable feelings by unconsciously substituting acceptable forms of expression.
Adaptive Use: RN angry at supervisor → sublimates those feelings by working out hard at the gym
Maladaptive Use: N/A
Suppression: Voluntarily denying unpleasant thoughts & feelings
Adaptive Use: Student puts off thinking about a fight they had with a friend to lock in for the Psych Exam
Maladaptive Use: A person who lost their job says that they will worry about the bills next week
Repression: Unconsciously putting unacceptable ideas, thoughts, and emotions out of awareness
Adaptive Use: Someone is preparing for a speech and forgets about the time where he got laughed at in the middle of a speech
Maladaptive Use: A person who has a fear of taxes forgets to do their taxes.
Regression: Sudden use of childlike/primitive behavior that do not correlate with one’s developmental level
Adaptive Use: Young child temporarily wets the bed when they learn that their dog died.
Maladaptive Use: A person who has a disagreement begins throwing things in the house.
Displacement: Shifting feelings related to a person, situation, or object to another less threatening object, person, or situation.
Adaptive Use: A person angrily punches a punching bag after having an argument
Maladaptive Use: A person who is angry at losing their job destroys their child’s favorite toy
Reaction Formation: Unnaceptable feelings/behaviors are controlled or kept out of awareness by overcompesating or demonstrating. Demonstration the opposite behavior of what is felt.
Adaptive Use: A person who is trying to quit smoking repeatedly tells kids about the dangers of nicotine.
Maladaptive Use: A personwho resents having to care for an aging parent becomes overprotective and restricts their freedom
Undoing: Performing an act to make up for something done bad; common in children
Adaptive Use: A kid does their chores by themselves after arguing with their parents.
Maladaptive Use: Someone buys their partner flowers after abusing them.
Rationalization: Creating reasonable and acceptable explanations for unacceptable behaviors.
Adaptive Use: A guy says, “They must have a boyfriend already” after being rejected.
Maladaptive Use: A young adult says that they had to drive home from a party after drinking alcohol because they had to feed their dog.
Dissociation: disruption in consciousness or perception that causes compartmentalization of uncomfortable aspects of oneself.
Adaptive Use: Parent blocks child noise in order to focus while driving.
Maladaptive Use: A person forgets who they are after being sexually assaulted.
Denial: Pretending the truth is not reality to manage anxiety-causing thoughts.
Adaptive Use: A persons initially says, “No that can’t be true” after being told they have cancer.
Maladaptive Use: A parent whose child was killed a month ago tells everyone that their kid is coming over for christmas.
Compensation: Emphasizes strengths to make up for weaknessess.
Adaptive Use: A kid who physically cannot participate in sports excells at spelling bees.
Maladaptive Use: A person who is shy learns computer skills to avoid socializing.
Identification: Conscious/Unconscious assumption of characteristics of others.
Adaptive Use: A child who has a chronic illness pretends to be a nurse for their dolls.
Maladaptive Use: A child who observes their parent be abusive towards the other parent becomes a bully.
Intellectualization: separation of emotions/logical facts when coping with a situation.
Adaptive Use: A officer blocks out the emotional side of the crime to lock in.
Maladaptive Use: A person who learns they have a terminal illness focuses on creating a will rather than acknowledging their grief
Conversion: responding to stress through unconscious development of physical s/s
Adaptive Use: n/a
Maladaptive Use: Someone becomes deaf after hearing that their mother died.
Splitting: Demonstrating inabiltity to reconcile negative and positive attribute of self/others into a cohesive image.
Adaptive Use: n/a
Maladaptive Use: A pt tells the nurse that they are the only one that cares about them but in the following day, the patient hates her.
Projection: Attributing one’s unacceptable thoughts and feeling into one who does not have them.
Adaptive Use: n/a
Maladaptive Use: Married client who cheated says that their partners are having affairds.
Anxiety Types:
Normal: Motivates people to take action
Violent situation goes on in a unit → RN rapidly defuses the situation
Acute (Immediate State): From an imminent loss/change that threatens one security
Sudden death of a lover one
Chronic (Sustained Trait): develops over time (stemming from childhood)
Displays other s/s
Fatigue, Frequent Headaches.
Toxic Stress Response: Biological and neurological changes from sustained toxic stress
GI discomfort, body ahces, SOB
language + problem solving vvv
ACE
Anxiety Levels:
Mild:
Everyday living
^ perception of reality
Identifiable cause
Mild discomfort, restless, irritable, impatient, apprehension
Mild tension-relieving behaviors: fidgeting, lip-chewing
Moderate:
v perfection and info procession → selective inattention
Ability to think hampered; learning and problem-solving still occur
difficulty concentrating, tired, pacing, pitch change, voice tremors, shaky, ^ HR ^RR
Benefits from direction of others
Severe:
vvv Perceptual field
X learning and problem solving
Behaviors are automatic and functioning is effective
Confused, impemding doom, Hyperventilating, tachycardic, withdrawal, loud/rapid speech, aimless activity
Hard to receive direction from others
Panic:
Markedly disturbed behavior
Lost of touch with reality
Extreme fright and horror
Hyperactivity, flight, immobile
X speak, dilated pupils, severe shaky & withdrawal, cannot sleep, delusions, hallucinations
Mild-Moderate Anxiety Interventions:
Active listening → encourage pt to express feelings, develop trust, and identify source
Provide calm presence → aids in pt focus and problem solving
Evaluate past coping mechanisms → offer options for problem solving
Encourage participations in activities (exercise) → helps release pent-up tension, ^ endorphin release and mental well-being
Severe-Panic Anxiety Interventions:
Provide environment meeting physical and safety needs; remain with the patient and stay calm → minimizes r/x as they may be unaware of basic needs
Fluids, food, sleep
Provide a quiet environment w/v stimulation → Helps X intensification of anxiety
Use medication + restraints when least restrictive measures have failed → prevent harm to self, others, or RN
Encourage gross motor activites (walking/exercise) → helps release pent-up tension, ^ endorphin release and mental well-being
Set limits with firm, short and simple statements; repetition may be necessary; speak in a slow-low-pitched voicde → v r/x to pt & ^ understanding
Direct pt to acknowledge reality and focus on present environment → assists in v anxiety level
Chapter 5- Creating and Maintaining a Therapeutic and Safe Environment
Milieu Therapy: Creats a therapeutic, safe, and supportive environment.
Management: total environment, physical, psychosocial to provide lowest amount of stress, ensure pt safety, manage behavioral crisis
Promotes pt’s beliefs toward recovery and improved functiong
Milieu environment is used to help pt’s cope adaptively, interact more effectively, and strengthen relationship skills
RN is responsible for structuring and implementing mileu aspects into the facility
E.g. regular facility community meetings
Therapeutic Milieu Characteristics:
Physical Setting:
Unit should be clean and orderly
Comfortable furniture → promotes interaction
Solitary spaces → reading and thinking
Comfortable spaces → meals
Quiet areas → sleeping
Color scheme + design designed for age group
Materials: attractive, easy to clean, and safe
“Traffic-flow”?
HCP responsibilites:
Promote self-care and individual growth
Treat as individuals
Allow most autonomy
Apply rules of fair t/x
Modeling
Collaboration w/other HCPs
Boundaries
Maintain professional
Promote self-worth feelings
Practice open communications
Emotional Climate:
Pts should feel safe from harm (either from others or self)
Pts should feel accepted
Therapeutic Relationship Benefits:
^ t/x success
Collaboration: improves RN’s ability to examine their own feelings, set boundaries, and learn from relationships
Factors that positively affect therapeutic relationships:
RN:
Consistent approach to all interaction
Adjustment of pace to pt’s needs
Active listening
Positive initial impressions
Comfort level
Self-awareness
Availability
Therapeutic use of self
Patient:
Trusting Attitude
Willingness to talk
Active Participation
Orientation | Working | Termination |
RN:
| RN:
| RN:
|
Pt:
| Pt:
| Pt:
|
Transference: when pt views member of HCP as having characteristics from another person
Pt expects exclusive services from RN (extra time during sessions)
Pt gets jealous, hostile, or affectionate for the nurse
Pt compares nurse to an Authority figure
Parent
Attempt to reorient pt towards goals
Countertransference: when HCPs displace characteristics of others onto pt
RN overly identifies, competes, argues with pt
RN is overly/underly involved w/pt
Community Meetings: ^ emotional climate of therapeutic milleu via:
Interaction & comm between pt & staff
Pt’s decision making skills
Feeling of self-worth
Discussion of common unit objectives
Discussion of issues of concerns
Meets can be structure so it is client-led
Individual Therapy: scheduled sessions w/ MHP to address depression, trauma, etc.
Group Therapy: scheduled sessions of group of pt’s w/similar mental health issues
Psychoeducational groups: Based on pt’s level of functioning and personal needs
AE of medication
Coping skills and stratergies
Recreational Therapy: Leisure time and socializing with others to ^ mental health
Unstructured, flexible time: Opportunities for RN to observe pt as they interact with the environment.
Chapter 6- Diverse Practice Setting
Settings for Mental Health Care
Acute Care: intensive t/x and supervision for pt’s w/severe mental illness
To stabilize s/s and promote rapid return
RN management that is family centered (private/general hospital)
State-run: for homeless pts; full-time acute care for forensic pts (those in correctional facilities)
Case Management programs: aid pt in transitioning to community after discharge
Community: Primary Mental Health Care
Clinics, schools, day-cares, partial hospitalization, substance t/x facilies, forensic settings, psychosocial rehab programs, telephone crisis counseling centers, home health care
RN help stabilize & ^ mental functioning
Teach, support, and make referrals to promote positive social activities
Primary, 2ndary, tertiary prevention for mental illness
Educational groups, medication dispensing programs, individual counseling, family therapy
Mobile Crisis teams: provide on-site psychiatric care
Intensive outpatient programs: for pt community reintegration
Telehealth:
Many use this as a primary form of receiving t/x
Forensic Nursing: biophysical edu + forensic science
RN uses collection of evidence, analysis, prevention, and t/x of trauma or/death of perpetrators and victims of violence, abuse, and traumatic accidents.
Rehabilitation: focuses on cognitive and behavioral changes related to substance use, non-suicidal self-injury, ED, anxiety disorders
Pts may need help w/ADL
Medication regimen, eating, daily hygiene
weeks → months
Client Care Nursing Roles:
Management of unit (pt activities and therapeutic milieu)
Safe administration and monitoring of meds
Implementation of individual pt treatment plans (education)
Documentation of the nursing process
Managing crises
Case manager: helps pt coordinate t/x, meds, appointments, and transportation
Primary Prevention: Promotes health & emphasizes efforts in preventing mental health issues before they happen
Community education program on stress reduction
Secondary Prevention: early detection of mental illness
Screening uncs for depresison
Tertiary Prevention: Rehav & prevention of further problems who had previous d/x
Prevents further detoriation
Support group leading from substance use disorder programs
Community-based Mental Health Programs:
Partial Hospitalization Programs: Intense short-term t/x for pt’s who can go home every night and have a support system
Detoxification programs: medical supervision, stress management, substance use counseling, relapse prevention
Assertive Community Treatment (ACT): Nontraditional case management for pts w/severe mental illness and are noncompliant to traditional t/x
v recurrences of rehospitalization
Crisis management
assists in independent living
Community Mental Health Centers: Edu programs, medication dispensing programs, individual & familty counseling programs
Psychosocial Rehab programs: structured range for pts
Residential services, day programs for uncs
Home based services: Must be homebound, have a psychiatric d/x, needs the skills of a Mental Health RN and a plan of care already set
Chapter 7- Psychoanalysis, Psychotherapy, Behavioral Therapies
Classical Psychoanalysis: Assesing unconscious thoughts & feelsing → resolving conflicts by talking w/a psychoanalyst
Very lengthy
Sigmund Freud
Past relationships and internal early childhood conflicts
Therapeutic Tools
Free association: spontaneous, uncensored verbalization of whatever comes to mind
Dream Analysis and interpretation: Urges impulses of unconscoius mind that happen in dreams
Psychotherapy: more verbal therapist-client interaction
Psychodynamic Psychotherapy: focuses more on pt’s present state
t/x tends to last longer than others
Interpersonal Psychotherapy: many mental health disorders are influece by interpersonal interactions & social context
Cognitive Therapy: Individual thoughts are used to solve problems
Thoughts come before feelings
For depression, anxiety, and ED
Behavioral Therapy: Changing behavior is key to treats issues (anxiety + depression)
Behavior is learned and has consequences; does not look at the underlying cause
Abnormal behavior → attempt to avoid painful feelsing
Teachs pt’s how to v anxiety or avoidant behavior via relaxation techniques & modeling
Sucessful with:
Phobias
Substance use disorders
Eye movement Desensitization Reprocessing (EMDR): reconnecting with traumatizing memories and emotions in a millieu environment
Uses adaptive defense mechanisms
Effective w/anxiety and trauma related disorders
Cognitive-Behavioral Therapy: uses both approaches to manage anxiety & self-injurous behavior.
Focuses on gradual behavioral changes & acceptance/validation to them
Cognitive Therapy Techniques:
Cognitive Reframing: identifying negative thoughts that produce anxiety, examine the cause, and develop supportive ideas that replace negative self-talk
pt w/depressive disorder says → “I am a bad person” → cognitive reframing → make them realize that they may have done some bad choices, but they are not “bad”
Priority Restructuring: Aids in what requires priorities
Journal Keeping: Write down stressful thoughts
Assertiveness Training: Teachs pt to express feelings and solve problems in a nonaggressive manner
Monitoring Thoughts: Aids pt in becoming more aware of their negative thinking.
Mindfulness
Behavioral Therapy Techniques:
Modeling: Serving as a role model → pt → ^ behavior
Improves interpersonal skills
Goal for pt to imitate + behavior
Operant conditioning: receiving + rewards for + behavior
receiving tokens
Systematic Desensitization: gradual exposure to anxiety-causing stimuli → implementing relaxation techniques → able to tolerate more and more stimuli
For phobias
Aversion Therapy: receiving punishment for bad behavior
Bitter tast or mild electric shock for bad behaviors
Constant monitoring needed
Meditation, Guided imagery, diaphragmatic breathing, muscle relaxation, biofeedback
Other Techniques:
Flooding: exposing pt to ^^^ of undesirable stimuli to turn of anxiety response
Response Prevention: Preventing pt from performing compulsive behavior
To v anxiety
Thought Stopping: when negative thoughts arise → shout, “STOP” → think positevily
Soon it would be silently
Trauma-Focused CBT: Psychoeducation about trauma responses & coping mechanisms
Gradual exposure to trauma
Validation Therapy: respecting and validating their feelings that is real to them
For neurocognitive disorders
Virtual Reality Exposure Therapy: VR → v depression, anxiety, phobia, post-traumatic stress, and attachment issues
Chapter 8- Group and Family Therapy
Democratic Leadeship: supports group interactions → solve problems
Offering opportunities to grow and feel like they belong
Laissez-Faire Leadership: Leader does not control direction
Autocratic Leadership: leader is in complete control of direction & structure
Group Therapy:
Group Process: verbal & nonverball communication
how work progresses
how members interact
Group Norm: Way the group behaves → provides structure over time
E.g.
member raises hand
Member sit in the same place each session
Hidden Agenda: some members/leader have goals different from group goals
Ages
Children: form of plays
Adolescents: strong peer relationships
Older Adults: Helps w/socialization & sharing memories
Settings:
Acute: focus on relief
Unit Activities impact leading
Leader must provide higher level sturcture
Outpatient: consistent, focus on grouth, leader can determine group’s directions
Virtual: no non-verbal cues communication, losing control of group setting, lack of presence
Homogeneous Group: members share characteristic
Diagnosis/Gender
Heteregoneous Group: all clients on unit; mixture of both genders w/diff d/x
Subgroup: small number of ppl w/in larger group whose function is completely separate
Open/Closed groups: new members can come in or not
Purpose of Therapy Sessions:
Open & clear comms
Cohesiveness for session
Direction to goal
Maximize positive interactions
Respect
Available community resources
Types:
Individual: needs & problems
Make more + interaction
Make productive life decisions
Develop strong-sense of self
Family:
How to deal w/mental illness in family
Improve understanding
^ Interaction
Group:
Members shar common exp
Positive behavior changes as a group
Feeback from others
Group Therapy Concerns:
Privacy
Not all member receives the same attention
Personal opinions may be discouraged from group norms
Disruptive members
Planning Phase: Identify group characteristics
inclusions, group name, seating, schedule
Know group composition: socially withdrawn ppl
Overcrowded room: discomfort + anxiety
Large room but small ppl: X intimacy
Circular Seating
Orientation Phase: define purpose & goals
Set tone, respect, trust, confidentiality
Members get to know one another
Discussion about termination
Working Phase: Problem-solving skills → improve behavioral changes
Power & control issues may be present
Therapeutic communication
Members can take informal roles (+ or -)
Cohesiveness
v role of leader present
Termination: End
Members discuss termination issues
Summarize work & contributions
Members can take on roles
Feedback
Maintenance Role: help maitain purpose & process of group
Task Roles: Recorder
Individual roles: X teamwork; promotes their own agenda
dominator
Recognition seeker
Family Therapy:
Nuclear: normal
Single-parent
Adoptive
Blended: married + step
Cohabiting: parent + random
Extended: parent + unc/grandma
Dysfunctional Family Functioning:
Blaming: blame others to shift focus away from themselves
Manipulating: lying to support own agenda
Placating: Member takes responsibilities for all problems
Distracting: member put irrelevant info during attempts to problem solve
Generalizing: “Always” “Never”
Dysfunctional Family Management:
Chaotic
Child makes decisions at times
Dysfunctional Family Boundaries:
Enmeshed: Thoughts, roles, feelings, blended so roles are not clear
Rigid: isolation, minimal communication
Other issues w/Dysfunctional Families:
Scapegoating: member w/little power blammed for everything
Triagulation: third party drawn into relationship that is unstable
Multigenerational issues: 3+ generations
patterns of:
Substance use
Grief patterns
Triangulation
Divorce
Chapter 9- Stress Management
Protective Factors that ^ resilience:
Physical Health
Strong sense of self
Religious beliefs
Optimism
Hobbies
Interpersonal relationship
Strong social support
Humor
Individual response:
Fight: facing stressor/situation
Faint: limiting exposure to stress; syncope
Flight: running away
Freeze
Fawn: attempt to please or give in to stressor
Acute Stress (Flight/Fight)
Apprehension
Unhappy/sorrow
v Appetitie
^ RR, HR, CO, BP
Increased metabolism + glucose use
v Immune system
Prolongued Stress: Chronic stress/panic attacks
Depression, chronic pain, sleep issues
^/v weight
^ MI, Stroke, infection r/x
v diabetes control, HTN, fatigue, irritable, v ability to concentration
Prolongued cortisol exposure → v immune system → ^ infection r/x
Cognitive Techniques for Stress:
Cognitive Reframing: pt looks at irrational thoughts in a more realistic light → turn into a more positive way
Talk to themselves more +
Behavioral Techniques for Stress:
Meditation: train the mind & help a greater calm
Helps connect pt w/inner self & promote healing
Guided imagery: Pt guided through series of images to promote relaxation
Breathing exercises
Progressive Muscle Relaxation
Yoga, walking, biking → endorphins release
Chapter 10- Brain Stimulation Therapies
Electroconvulsive Therapy: Electricity → brieft seizure activity when anesthetized → theory that it ^ serotonin, dopamine, norepinephrine
Major depressive disorder:
Pt is undersponsive to pharmacology t/x
other t/x r/x outweigh Risk of ETC
Suicidal/Homicidal
Psychotic s/s
Schizo spectrum
Catatonic s/s
Schizoaffective disorder: schizo + mania
Acute Manic Episodes:
Bipolar w/rapid cycling (4+ mania episodes/year)
Lithium & antipsychotics dont work
ECT Contradictions
CV: MI, HTN, Heart Failure, Arrhythmias
ECT ^ stress on heart
Cerebrovascular: stroke, brain tumor, subdural hemotoma,
ECT ^ ICP & Blood flow to brain
ECT is useless in these conditions:
Substance use
Personality disorder
Dysphoric disorder
ECT Procedure:
2-3 times/week (6-12 treatments for depression)
Informed consent needed
Pre-ECT work up:
Chest x-ray, blood work, ECG, X BZDs
Meds:
30 mins before, Atopine sulfate or glycopyrrolate IM → v secretions of aspirations and prevent bradycardia
Short-acting anesthetic given (monitor pt throughout procedure)
Succinylcholine (muscle relaxant given) → paralyzes the muscles → v r/x of injury but need to be ventilated (100% O2)
Reassure and educate family
IV during procedure
Electrodes applied in scalp for EEG monitoring
BP, ECG, O2 sat monitoring
15 mins after procedure → client becomes alert
ECT is a montly/weekly thing to prevent relapse
ECT Complications:
Short-term memory loss, confusion, disorientation
For several hours
Retrograde amnesia
for several weeks
Make sure to orient pt, safe environment, and aid w/personal hygiene
Repetitive transcranial magnetic stimulation (RTMS)
Uses magnetic pulsations to stimulate cerebral cortex
For major depressive disoder when not responsive to pharmacological t/x
Sim to ECT but DOES NOT induce seizure activty
Considerations:
4-6 weeks (daily: 30-40mins)
Outpatient procedure
pt is alert; may feel tapping/knocking sensation, scalp skin contraction, tightening of jaw muscles
RTMS + psychotherapy → effective for depression t/x
Complications:
Mild discomfort/tingling, lightheadness
Low frequency for seizure h/x
Avoided in pts w/:
Cochlear implants
Brain stimulators
Medication pumps: has metal which can interfere w/t/x
Vagus Nerve Stimulation: electrical stimulation via vagus nerve → brain via surgically implanted under skin
^s neurotransmitters & aids w/ antidepressant meds
Depression resistant to pharmacological t/x
Also for anxiety, obesity, pain
Considerations:
Outpatient surgical proceudre; takes weeks to achieve effects
Pulsations every 5 mins for 30 secs
Can turn off it by placing magnet over site
Complications:
Voice changes
Neck, throat pain, coughing
Dyspnea → turn off when exercising
Deep Brain Stimulation: surgically implanted electrodes → ^ neurotransmitters
PD, for pt’s who all other measures failed
Considerations:
pulsations every 5 mins for 30 secs; takes several weeks to achieve
Can turn off with magnet
Contradictions:
R/x for infection
Hypomania: elevated mood
Headaches, seizures, stroke, confusion
Chapter 21- Care of Clients Who are Dying and/or Grieving
Bereavement: Grief & mourning
bereavement exclusion: s/s of depression w/in 2 months
Types of Lossess:
Necessary: part of cycle of life; anticipated
Actual: any loss of a person or item
Perceived: loss that is not obvious to pt
Maturational: losses normally expected due to developmental processes of life
Situational: unanticipated loss from external event
Kubler-Ross:
Denial: difficulty believing terminal d/x or loss
Anger: directed towards self, others, objects
Bargaining: Negotiating for more time or a cure
Depression: saddened by unable to change situation
Acceptance: accepts what is happening
Concept of Death across lifespan:
Infant/Toddler
Crying & irritability
Looking for dead person
Regression
Preschoolers
Does not understand
Repetivitve questions
Regression
School Age:
Understanding of death
Play used
Mood lability
Adolescents:
Conceptualizes & understands death
Abnormal sudden behaviors
^ in r/x taking behviors
Depression; self-harm
Factors influencing grief, coping, loss
Interpersonal relationships
Type of loss
Culture & Race
Spiritual & Religious
Prior experience of loss
Socioeconomic status
Complicated Grieving:
Risk:
dependent on deceased
Unexcpected death at young age
Inadequate coping
v Social support
Depression, substance use disorder
Protective:
Spiritual/Religion
Personal well-being
Financial control
No losses
Normal Grief:
Uncomplicated
Anger, resentment, withdrawal, hopelessness, guilt
changes to acceptance after 6 months
Chest pain, palpitations, headaches, N, sleep changes, fatigue
Anticipatory Grief:
Letting go of an object/person before loss
Terminal illness
Prologued Grief Disorder:
Identity confusion & separation distress
Cardiac disease, depression, anxiety, substance use, immune deficiency, v QOL
Intense yearning
^ r/x for suicide
Complicated
Delayed/Inhibited grief:
Do not demonstrate expected behaviors
Influenced by culture
Denial stage of grief
A minor loss in the future can trigger grief response
Disorted/Exaggerated Grief response:
Exaggerated s/s
Unable to ADLs
remains in the anger stage
May develop clinical depression
Chronic/Prolongued Grief:
Hard to identify due to the amount of time
Stays in denial stage
May result in inability to perform ADLs
Disenfranchised grief:
Experienced loss that cant be shared
Facilitated Mourning:
Time for grieivng
Identify grieving behaviors
Name the emotion that pt is feeling
“It feels like you are angry”
Avoid cliches:
“ they are in a better place now”
Psychosocial Care:
Provide care to pt & family
Encourage to use coping skills used in the past
Dont talk behing someone unconsicous
Chapter 22- Mental Health Issues of Children and Adolescents
Mental health and neurodevelopmental disorders in children/adolescents are often under-recognized, delaying treatment.
Comorbidity is common (more than one disorder at the same time).
Behavior becomes a mental health concern when it impairs home, school, or peer functioning.
DISORDERS SEEN IN CHILDHOOD & ADOLESCENCE
Depressive disorders (MDD, persistent depressive disorder)
Anxiety disorders (separation anxiety, panic disorder)
Trauma- & stressor-related disorders (PTSD)
Substance use disorders
Feeding & eating disorders (anorexia, bulimia, binge-eating)
Disruptive / impulse control disorders
Oppositional defiant disorder (ODD)
Disruptive mood dysregulation disorder (DMDD)
Conduct disorder
Intermittent explosive disorder (IED)
Neurodevelopmental disorders
ADHD
Autism spectrum disorder (ASD)
Intellectual developmental disorder
Specific learning disorder
Bipolar & schizophrenia spectrum disorders
Self-harm & suicide
⚠ Suicide = leading cause of death ages 10–24
WHY DIAGNOSIS IS DIFFICULT
Limited language, emotional, and cognitive skills
Wide range of developmentally “normal” behaviors
Hard to differentiate behavioral vs emotional pathology
CHARACTERISTICS OF GOOD MENTAL HEALTH
Accurate perception of reality
Positive self-concept
Age-appropriate coping with stress
Mastery of developmental tasks
Creative self-expression
Ability to form healthy relationships
ETIOLOGY & RISK FACTORS
Biologic
Genetic links: schizophrenia, bipolar, ADHD, ASD, IDD
Neurotransmitter changes (NE, serotonin, dopamine)
Psychosocial / Environmental
Parental mental illness or substance use
Abuse or neglect
Low SES, overcrowding, foster care
Family conflict, criminality
Cultural
Poor assimilation
Lack of role models/support
Protective Factor
Resiliency: coping skills, nurturing relationships, problem-solving
DEPRESSIVE DISORDERS
Risk Factors
Family history
Abuse/neglect
Bullying (victim OR aggressor)
Chronic illness
Learning disabilities
Homelessness
High-risk behaviors
Expected Findings
Sadness, crying
Irritability, aggression
Temper tantrums
Appetite & sleep changes
Low energy
Social withdrawal (solitary play)
Poor school performance
Hopelessness
Suicidal ideation or attempts
🧠 NCLEX TIP: Kids often show irritability and aggression, not just sadness.
ANXIETY & TRAUMA-RELATED DISORDERS
General Findings
Anxiety interferes with normal development
Impaired functioning at home, school, or socially
Separation Anxiety Disorder
Excessive distress when separated from caregivers
Can lead to school refusal
Often follows a stressor (death, illness, move)
Can progress to panic or phobias
Post-Traumatic Stress Disorder (PTSD)
Triggered by experiencing or witnessing trauma
Symptoms: anxiety, depression, phobias, somatic complaints
Externalized behaviors: irritability, aggression
Sleep disturbance, belief life will be short
Young children: trauma-focused play or decreased play
DISRUPTIVE, IMPULSE CONTROL & CONDUCT DISORDERS
Shared Features
Problems across home, school, social settings
Often comorbid with ADHD, anxiety, depression
Worse with:
Sustained attention (classroom)
Unstructured settings (playground)
Oppositional Defiant Disorder (ODD)
Negativity, defiance, hostility
Argumentative, limit testing
Refuses responsibility
Behavior mostly toward authority figures
Child does not see behavior as problematic
May progress to conduct disorder
Disruptive Mood Dysregulation Disorder (DMDD)
Severe temper outbursts ≥ 3×/week
Outbursts are developmentally inappropriate
Occur in ≥ 2 settings
Persistent angry/irritable mood between outbursts
Onset: ages 6–18
Not bipolar disorder
Intermittent Explosive Disorder (IED)
Sudden aggressive outbursts (verbal/physical)
Disproportionate to situation
Followed by shame and regret
More common in males
Can contribute to chronic illness (HTN, DM)
Conduct Disorder
Persistent violation of rights of others
Categories:
Aggression to people/animals
Destruction of property
Deceit/theft
Serious rule violations
Childhood-onset (<10): more males
Adolescent-onset (>10): equal gender ratio
Key Manifestations
Lack of remorse
Bullying, intimidation
Weapon use
Cruelty to animals
Lying, theft, truancy
Running away
Suicidal ideation possible
NEURODEVELOPMENTAL DISORDERS
General
Affect 1 in 6 children
May improve with age but persist into adulthood
High overlap → diagnostic challenges
ADHD
Inattention
Hyperactivity
Impulsivity
Present before age 12
Occurs in more than one setting
Types
Predominantly inattentive
Predominantly hyperactive-impulsive
Combined type
⚠ Increased risk for injury due to impulsivity
Autism Spectrum Disorder (ASD)
Impaired social interaction & communication
Repetitive behaviors, rigid routines
Poor eye contact
Delayed language/cognition
Associated physical issues: GI, sleep, seizures
Wide range of functioning (low → high)
Intellectual Developmental Disorder
Deficits in reasoning, learning, adaptive functioning
Requires ongoing support
Severity: mild → profound
Specific Learning Disorder
Persistent difficulty in reading, writing, or math
Requires IEP (Individualized Education Program)
Communication Disorders
Speech/language impairment
Stuttering
Difficulty with social communication
PATIENT-CENTERED NURSING CARE
Assessment
Prenatal & birth history
Developmental milestones
Sleep, eating, elimination
School performance & peer relationships
Abuse history
Family mental health history
Substance use
Suicide risk & access to weapons
NURSING INTERVENTIONS
General
Promote coping & self-esteem
Encourage protective behaviors (seatbelts, helmets)
Suicide & depression screening
Education on substance use
Referral to therapy & community resources
Anxiety Disorders
Accept regression
Protect during panic
Promote success & self-esteem
Trauma-Related Disorders
Process trauma
Encourage group therapy
Disruptive Disorders & ADHD
Calm, firm, consistent approach
Clear limits
Reward systems
Family involvement
Structured physical activity
Positive reinforcement
Autism Spectrum Disorder
Early intervention (OT, PT, speech)
Structured environment
Predictable routines
Short, clear communication
Reward desired behaviors
Prepare for transitions
INTERPROFESSIONAL CARE
Family therapy
Cognitive-behavioral therapy (CBT)
Grief & trauma interventions (GTI)
Play, music, group therapy
PHARMACOLOGIC OVERVIEW (HIGH-YIELD)
ADHD
CNS stimulants (methylphenidate)
Atomoxetine
Alpha-2 agonists (guanfacine, clonidine)
Behavioral & Mood Disorders
Atypical antipsychotics
SSRIs
TCAs
Mood stabilizers (IED)
⚠ Medications are most effective when combined with behavioral therapy
Chapter 23- Suicide
Core Concepts
Suicide: intentional act of killing oneself.
Clients can be ambivalent (part of them wants help) → interventions can work.
Suicidal thinking often comes from hopelessness, helplessness, inner pain.
Survivors of suicide loss often need long-term therapy/support.
Suicide Myths (Know these = exam traps)
“People who talk about suicide never do it.” ❌
“Suicidal clients only want to hurt themselves, not others.” ❌
“Nothing can help someone who really wants to die.” ❌
“Asking about suicide puts the idea in their head.” ❌
“Ignoring threats / challenging them reduces it.” ❌
“They only want attention.” ❌
✅ Reality: Always take it seriously and ask directly.
Risk Factors (High Yield)
Pattern: females attempt more, but males (adolescent/middle/older) complete more.
Higher-risk groups
Older adults
Active military / veterans
LGBTQ+ individuals
Comorbid mental illness: depression, substance use, schizophrenia, bipolar, personality disorders
Older adult-specific risks
Untreated depression
Financial/employment loss
Isolation/powerlessness
Prior attempts (older adults more likely to succeed)
Declining health/function
Substance use
Loss of loved ones
Biological
Family history of suicide
Serious/chronic medical disorders (ex: cancer, CV disease, stroke, CKD, dementia, epilepsy, head injury, MS, etc.)
Psychosocial
Hopelessness
Intense rage/anger/guilt
Poor relationships (home/school/work)
Adolescent developmental stressors
Trauma/abuse history
Cultural
American Indian/Alaskan Native groups: highest suicide rate
Environmental
Access to lethal means (firearms)
Poor access to mental health care
Unemployment
Protective Factors
Responsibility to partner/children
Pregnancy
Religious/cultural beliefs
Life satisfaction
Social support
Coping/problem-solving skills
Access to medical care
Expected Findings / Warning Signs
Key nursing principle
Ask directly about suicide → it does not cause suicide.
Use SAFE-T framework to assess risk.
Overt vs Covert clues
Overt (direct): “There’s no reason to go on living.”
Covert (indirect): “Everything is looking pretty grim.”
What you MUST assess (Priority)
The plan = the danger
Do they have a plan?
How lethal is it?
Can they describe it exactly?
Do they have access to the means?
Mood shift red flag: sudden “peaceful/happy” after depression can mean decision to attempt.
Physical cues
Lacerations, scratches, scars (prior self-harm/attempts)
Serious warning signs
Extreme mood swings
Collecting pills/buying gun
Guilt/shame
Increasing substance use
Agitation/anxiety
Sleep/eating changes
Rage/revenge talk
Priority Question (NCLEX Classic)
If client states “I plan to commit suicide,” priority assessment is:
✅ Lethality of method + availability of means
Nursing Care: 3 Levels of Prevention
Primary (Prevent before crisis)
Community education, screening programs, prevention teaching
Secondary (Acute crisis)
Suicide precautions, constant observation, environmental safety
Tertiary (After a death)
Support survivors/family, grief resources, long-term support
Suicide Precautions (Milieu Safety Checklist)
Constant supervision
1:1 continuous observation (24/7), client always in sight
High risk during staff rotation/change of shift
Documentation
q15 min (or facility protocol): location, mood, statements, behavior
Search + remove hazards
Remove: glass, cords, belts/shoelaces, razors, nail files, tweezers, matches, plastic bags, perfume/shampoo, etc.
Meals
Plastic utensils only; count utensils in/out
Room/environment
No private room; door open
Check windows, pipes, shower rods/nozzles (ligature risks)
Hands visible
Keep hands visible even during sleep
Meds
Ensure client swallows meds (no hoarding)
Identify if meds are lethal in overdose → collaborate for safer alternatives
Restrict visitors bringing harmful items
Safety plan
Collaborate with client to develop a safety plan
Therapeutic Communication (Testable)
Ask directly + follow up even after denial:
Example flow:
“Are you thinking of suicide?”
If “No” → “Are you thinking about hurting yourself?”
Other key actions:
Build trust
Limit time alone
Involve significant others (as appropriate)
Treat comorbid conditions (ex: substance use disorder)
Treatments / Procedures
ECT: effective in decreasing suicidal ideation in severe depression or psychosis.
Medications Used to Reduce Suicide Risk (What to Teach)
SSRIs (citalopram, fluoxetine, sertraline)
Lower lethal toxicity vs many older antidepressants
Takes 1–3 weeks initial effect; up to ~2 months max effect
Don’t stop abruptly
Watch for nausea, headache, insomnia/anxiety/agitation
Sexual dysfunction possible
Monitor closely for worsening depression/suicidal intent
Benzodiazepines (diazepam, lorazepam)
CNS depression (sedation, ataxia, ↓ cognition)
Avoid alcohol/other CNS depressants
Avoid hazardous activities
Don’t stop abruptly → taper with provider guidance
Caffeine can interfere with desired effects
Lithium (mood stabilizer)
Maintain fluids 2–3 L/day
Maintain adequate sodium
Take with food to reduce GI upset
Requires lab monitoring
Second-generation antipsychotics (risperidone, olanzapine)
Preferred vs first-gen due to fewer adverse effects
Weight gain/metabolic effects → diet/exercise teaching
Report sedation, dizziness, sleep disruption, agitation
Chapter 11- Anxiety Disorders & Psychopharmological Therapies
Anxiety Disorders: Recognized and defined by the DS-5-TR
Separation Anxiety Disorder: excessive fear/anxiety when separated from person
Disrupts ability to perform ADLs
Headaches, N/V, sleep issues
Specific Phobias: irrational fear of a certain object/situation
Some may intake Alcohol to relieve s/s
Examples:
monophobia: fear of being alone
zoophobia: fear of animals
Acrophobia: fear of heights
Agoraphobia: extreme fear of certain place where pt feels vulnerable; out of proportion
Disrupts employment & ADL ability
Social Anxiety Disorder: excessive fear of social situation
may lead to actual/factitious s/s to avoid social situation
Panic Disorder: recurrent panic attacks (last minutes or longer); 4+ s/s occur:
Palpitations
SOB
Chocking
Chest pain
N
Depersonalization
Fear of dying or insanity
Chills/Hot flashes
Worried about next attack
Generalized Anxiety Disorder (GAD): excessive worry > 6 months
Restless
Muscle tense
Avioding events
Increased time & effort required to prepare for stressful situations
Procreastination
Sleep disturbance
Obssesive Compulsive Disorder: intrusive thoughts of unrealistic obsession → control w/compulsive behaviors
repetitive cleaning of an object or hands
impairs social & work life
Hoarding Disorder: difficulty throwing away possessions
Unsafe living environment
Body Dysmorphic disorder
Anxiety Disorders Risk Factors
Females (Anxiety, OCD)
Males (Hoarding)
Check for physical cuases first to rule out fake anxiety s/s
Hyperthyroidism, PE
AE of meds can mimic anxiety
ACE
Poor lifestyle
Substance-induced anxiety
Benzodiazepine Sedative Hypnotic Anxiolytics: ^ X effects of GABA in CNS → relief of anxiety
OG: Alprazolam
GAD + Panic disorder (short-term)
Seizures, Insomnia, Muscle spasm, withdrawal, induction of anesthetia, amnesic pre-surgery
Administer meds w/meals or snacks to X GI upset
Complications:
CNS depression → sedation, lightheaded, ataxia
Avoid driving and using heavy stuff
Evoid alcohol or other CNS depressants
Diazepam: next day sedation
Anterograde Amnesia:
W/hold meds if it occurs
Acute toxicity: give flumanezil
Oral: drowsy, lethargy, confused
Gastric lavage + charcoal
IV: resp depression, severe hypotension, cardiac arrest
Diazepam & Lorazepam
Paradoxical Response:
Insomnia, excited, euphoria, anxiety, rage
Notify provider
Withdrawal effects:
Anxiety, insomnia, diaphoresis, tremor, delirium, seizures, lightheaded
Taper the dose over several weeks to prevent
Contraindictation:
Transmitted through milk
Schedule IV
Sleep apnea, resp depression, glaucoma, liver disease (substance use disorder)
Assess for Fall risks in unc
Interactions:
Avoid alcohol, barbiturates, & opiods as they can v CNS
X hazardous activities
Atypical Anxiolytic/Nonbarbiturate Anxiolytics: GAD
OG: Buspirone → for anxiety and is long-term
Binds to serotonin & dopamine receptors; less abuse potential
No AE of v CNS
Takes 1-4 weeks for full effects; not suitable as a PRN; give same time each day
Complications:
Dizzy, N, Headache, lightheaded, agitated
Dotes NOT cause sedation
Contradictions:
Teratogenic
Liver/kidney issues
MAOI usage → can cause hypertensive crisis
Interactions:
Erythromycin, ketoconazole, St. John’s wort, grape fruit
All ^ effects of buspirone (bad)
Education:
Take w/meals
Tolerance is not an issue
SSRIs: X serotonin reuptake → ^ serotonin in junctions → panic disorders & trauma-related issues
OG: Paroxetine: causes CNS stimulation → insomnia
For GAD
Panic Disorders
OCD
Social Anxiety disorder
PTSD
Depression
Adjustment disorders
long-half life → 4 weeks to work
Monitor plasma lv and take it w/food and in the morning to prevent sleep issues
Complications:
Early AE: N, sweating, termor, fatigue, drowsy
Effects should subside, avoid ETOH
Later AE: sexual dysfunction, ^ weight, headache
report problems: change dose, holiday, or change med
5-6 weeks in
Weight loss early in therapy → weight gain
GI bleeding
Hyponatremia: common in uncs taking diuretics
Check baseline and monitor
Serotonin Syndrome: 2-72 hrs after t/x → lethal
Confusion, agitated, hostile
Delirium, Hallucinations
Seizures → status epilectus
Tachycardic → cardiovescular shock
Labile BP
Sweat, fever, N/V, diarrhea, abd pain
Coma → apnea
Bruxism: grinding of teeth when sleeping
Switch med or provide with buspirone (low-dose)
Use mouth guard
Withdrawal: N, sensory issues, anxiety, tremors, malaise
Tape meds to avoid this
dont stop meds abruptly
Contradictions:
Pregnancy
MAOI or TCAs
Alcohol
Liver/renal issues, GI bleeding, seizures
Bipolar disorder: ^ r/x for mania w/SSRI
Interactions:
TCAs, MAOIs, St John’s wort → serotonin syndrome
Avoid MAOIs 14 days before therapy
Fluexetine stopped 5 weeks before starting MAOI
Warfarin: displaces it and ^ warfarin levels
Check for Prothrombin & INR levels
Check for bleeding
Lithium & TCA → ^ SSRI med lvs
NSAIDs & anticoagulants → further X platelet aggregation → ^ bleeding r/x
Serotonin Norepinephrine Reuptake Inhibitors: Xs s & nore → major depression, panic disorders, GAD
OG: Venlafaxine
Duloxetine
4 weeks for effect
Complications:
Headache, N, agitated, anxiety, dry mouth, sleep issues
Hyponatremia: Uncs w/diuretics
Anorexia
HTN
Sexual dysfunction
Contraindications:
Pregnancy
MAOI
Hepatic disease or alcohol users → X duloxetine
Interactions:
MAOIs & St John wort → serotonin syndrome
X MAOI 14 days before SNRI
ETOH, opiods, antihistamines, sedative/hypnotics → CNS depression
NSAIDS + Anticoagulatns → ^^^ r/x for bleeding
Module 8- Psychopharmacology
Dopamine (Excitatory)
Functions:
Emotional responses
Complex movements
Cognition
Pleasure and reward
Origin:
Derived from tyrosine
Operates primarily in the brainstem
Clinical significance:
Dysregulation linked to schizophrenia
Antipsychotic medications regulate dopamine transmission
Stress can alter dopamine neurotransmission
Serotonin (Inhibitory)
Functions:
Mood regulation
Sexual behavior
Sleep
Temperature regulation
Pain management
Unique features:
>14 receptor sites
Highly complex system
Disorders associated with imbalance:
Anxiety
Depression
Psychotic disorders
Medication mechanism:
Blocks serotonin reuptake
Improves mood by enhancing postsynaptic neurotransmission
Norepinephrine (Excitatory)
Functions:
Learning
Mood
Memory
Attention
Sleep
Most common neurotransmitter in the nervous system
Derived from epinephrine
Low levels associated with:
Anxiety
Social withdrawal
Depression
Memory loss
Trauma-related disorders:
Increased norepinephrine levels
Medications:
Block reuptake (similar to serotonin)
Histamine
Role:
Neuromodulator
Regulates release of:
Histamine
Glutamate
Serotonin
GABA
CNS effects:
Alertness
Wakefulness
Other body functions:
Gastric secretion
Allergic response
Cardiac stimulation
Clinical relevance:
Many psych meds are histamine antagonists
Common side effects:
Sedation
Weight gain
Gamma Amino Butyric Acid (GABA) – Inhibitory
An amino acid neurotransmitter
Functions:
Neuromodulation
Neuronal development
Improves sleep
Reduces anxiety and depression
Medications:
Benzodiazepines
Enhance GABA binding to receptors
Result in:
Anxiety reduction
Sedation
Glutamate (Excitatory)
Brain’s primary (+)
Amino acid neurotransmitter
Functions:
Motor regulation
Affective regulation
Cognitive regulation
Interacts with dopamine
Clinical significance:
High levels linked to psychosis
Released in large amounts after:
Head injury
Stroke
Excess glutamate:
Neurotoxic
Causes permanent neuronal damage over time
Acetylcholine (Excitatory & Inhibitory)
Found throughout the body
High concentration in skeletal muscle
Functions:
Muscle movement
Sleep–wake cycle
Neurocognitive disorders:
↓ Acetylcholine-secreting neurons in Alzheimer’s disease
Medications:
Increase acetylcholine concentration
Improve neurotransmission in Alzheimer’s clients