Psych Exam 1 review Notes

Chapter 1: Prioritizing Psychiatric Nursing Decisions

• Immediate Safety Needs

  • CRITICAL FIRST FOCUS!!!

  • Ensure physical safety of patient, staff, and others.

    • Address potential aggression, violence, or self-harm immediately.

    • It's essential to ensure the patient and the nurse are in a safe position (you can't care for someone's breathing if they are about to hit you!)

• Immediate Physiological Needs

  • Second in importance following immediate safety.

  • Focus on ABCs (Airway, Breathing, Circulation) to prevent death or severe deterioration.

• Sustained Physiological Needs

  • Third priority after immediate physiological needs.

  • Assess and manage:

    • Nutrition and hydration: Address malnutrition or dehydration.

    • Skin integrity: Treat frostbite, pressure ulcers, etc.

    • Sleep/rest deficits: Promote recovery with adequate rest.

• Psychosocial + Psychiatric Needs

  • Lowest priority in the nursing pyramid.

  • Address after physical needs:

    • Medication adherence: Address missed doses.

    • Chronic symptom management: Stabilize long-term psychiatric conditions.

    • Psychosocial support: Provide therapy and coping strategies.

Page 2: Principles of a Therapeutic Relationship

• Characteristics of Therapeutic Relationship:

  1. Therapeutic, not social

  2. Client-focused

  3. Goal-directed

  4. Objective, not subjective

  5. Time-limited

• In-Depth Principles:

  • 90-10 relationship:

    • 90% focus on the patient, 10% provider empathy.

  • Avoid expectations of social contract.

  • Nurses can be friendly but not friends - maintaining ethical standards.

• Peer Specialist:

  • Works beyond therapeutic with a 50-50 relationship.

  • Promotes recovery through narrative understanding.

• Client Focused:

  • Always refocus on patient’s issues, as they may divert to avoid discussing painful topics.

• Goal Directed:

  • Establish goals collaboratively.

  • The patient leads their recovery.

• Objective vs Subjective:

  • Objective: Free from bias

  • Subjective: Personal feelings and opinions expressed.

Page 3: Time-Limited Relationships

• Parameters Established:

  1. Meeting days

  2. Number of sessions

  • Different approaches for inpatient vs outpatient settings.

• Importance of Boundaries:

  • Maintain limits to avoid feelings of abandonment.

  • Regression is expected during closure, which can be planned for.

• Stages of a Therapeutic Relationship:

  1. Pre-Orientation Phase

  2. Orientation Phase

  3. Working Phase

  4. Termination Phase

• In-Depth Stages:

  • Pre Orientation Phase: Gathering patient info and self-reflection.

  • Orientation Phase: Building trust and establishing contracts.

  • Working Phase: Client takes responsibility for behavior change.

  • Termination Phase: Prepare for ending the relationship clearly as improvements are made.

Chapter 2: Mental Status Examination (MSE)

• The nurse-client interview is the primary tool for evaluating mental health.

• Steps of MSE:

  1. Appearance

  2. Attitude (cooperative, hostile, apologetic, etc.)

  3. Behavior and activity

  4. Speech

  5. Mood and Affect

• Mood and Affect:

  • Mood: Patient's self-reported feelings.

  • Affect: Observable emotional expressions.

  • Incongruity: Mismatch between reported mood and observable affect.

Page 5: Thought Processes

• Thought Process: How thoughts are organized and expressed.

  • Speed of thought (normal, blocking, racing)

  • Organization (mild to severe issues with coherence).

Page 6: Thought Content and Perception

• Thought Content: Themes, ideas, presence of delusions or obsessions.

  • Examples illustrate how to differentiate thought process vs content.

• Perceptual Disturbances:

  • Hallucinations: Auditory, visual, olfactory, tactile, gustatory.

  • Illusions: Misinterpreting real stimuli.

Page 8: Depersonalization and Derealization

• Depersonalization: Feeling detached from oneself.

• Derealization: Perception that the external world is unreal.

• Judgment: Ability to evaluate situations rationally and understand consequences.

  • Examples illustrate poor judgment in assessments.

• Insight: Understanding one's condition and relationships.

Chapter 3: Ethics in Healthcare

• Ethics: Internalized morality differentiating right from wrong, particularly in healthcare.

• Law: Enforceable rules that may conflict with ethical standards.

• Common Ethical Issues:

  • Hospitalization against will, medication administration, reporting misconduct.

• Key Ethical Principles:

  • Autonomy: Right to self-determination.

  • Beneficence: Act in the best interests of others.

  • Nonmaleficence: Do no harm.

  • Justice: Fair treatment.

  • Veracity: Truthfulness to patients.

  • Fidelity: Loyalty and commitment to professional duties.

Page 9: Autonomy and Competence

• Competence vs Capacity:

  • Competence is fluid and not static; determined by ability to make healthcare decisions.

  • Capacity is a legal term determined by courts.

• Paternalism: Making decisions for those unable to decide for themselves.

Chapter 4: Theories and Therapies

• Key Theories: Nursing’s role as an advocate to identify cultural needs.

• Psychoanalytic Theory: Generally modified for contemporary understanding.

• Recovery Model: Shift from medical model to holistic approaches focusing on personal recovery.

• Cognitive Behavioral Therapy (CBT):

  • Developed by Aaron Beck; focuses on altering perceptions to influence mood.

  • Cognitive triad: negative views of self, the world, and the future.

• Dialectical Behavioral Therapy:

  • Developed for emotional distress; features mindfulness, distress tolerance, and emotional regulation.

Chapter 5: Depression

• Major Depressive Episode: Must have 5 symptoms present for at least 2 weeks.

• Symptoms Include:

  • Depressed mood, loss of interest, weight changes, sleep disturbances, fatigue, feelings of worthlessness, recurrent suicidal thoughts.

• Persistent Depressive Disorder (Dysthymia):

  • Chronic, less severe depressive symptoms lasting longer than major depression.

Page 17: Antidepressant Medications

• SSRIs: Common first-line treatment with varied side effects.

• SNRIs: Another option but requires monitoring for blood pressure.

• TCAs: Less common due to severe side effects; lethal overdose risk.

• MAOIs: Have dietary restrictions to avoid hypertensive crises.

• Antidepressants Black Box Warning: Increased suicidality in children/adolescents.

Page 19: Bipolar Disorder

• Bipolar Type I: One manic and one depressive episode.

• Bipolar Type II: Hypomanic and depressive episodes; no manic episodes.

• Medications for Bipolar: Mood stabilizers, anti-epileptics, and atypical antipsychotics.

Page 21: Lithium

• Important considerations: Narrow therapeutic range, and signs of toxicity.

• Monitoring: Renal and thyroid functions are critical.

Page 25: Anxiety Disorders

• Generalized Anxiety Disorder (GAD): Excessive anxiety lasting 6 months or more.

• Panic Disorder: Recurrent panic attacks lead to maladaptive changes in behavior.

• Phobias: Intense, irrational fears leading to significant distress and avoidance behaviors.

• Treatment Approaches: Combination of therapy and medications; behavioral therapies are effective in helping with coping skills.

Page 30: OCD (Obsessive-Compulsive Disorder)

• Core Symptoms: Obsessions (thoughts) and compulsions (behaviors).

• Treatment: Education, therapy (CBT with exposure/response prevention), and pharmacology (SSRIs, tricyclics).

• Self-Awareness: Awareness of how perfectionism can be counterproductive in mental health.