Part 5

Addressing Patient Concerns in Group Settings

  • Individual Sessions: Offer individual sessions to patients uncomfortable sharing in group settings to facilitate their group involvement and promote interpersonal learning.

Enhancing Therapeutic Communication

  • Active Listening:

    • Practice remaining silent and attentively listening when a patient is speaking, avoiding interruptions, to encourage them to continue expressing themselves fully.

  • Open-Ended Questions: Utilize open-ended questions to promote therapeutic communication, encouraging patients to elaborate and explore their feelings and experiences more deeply.

    • Example:
      • Instead of asking "Are you feeling sad about the loss of your spouse?", ask "How are you feeling about the loss of your spouse? How has this affected you?"

Strategic Use of Closed-Ended Questions

  • Specific Circumstances: While open-ended questions are generally preferred, closed-ended (yes/no) questions may be necessary in certain situations:
    • Children: When interviewing a child who cannot construct a chronological narrative, use yes/no questions before involving parents.
    • Emergency Situations: In emergency departments, use closed-ended questions to obtain time-sensitive information efficiently when a patient is circumstantial or tangential.
    • Intellectual Disabilities: Patients with intellectual or developmental disabilities may find it easier to process closed-ended questions.

Genetic Conditions and Intellectual Disability

  • Risk Factor: Genetic conditions are a significant risk factor for intellectual disability.
    • Example: Fragile X syndrome.

Mindfulness Meditation

  • Key Elements: A core aspect of mindfulness meditation encompasses:
    • Breath awareness
    • Awareness of body sensations
    • Awareness of thoughts
    • Awareness of sounds

Enmeshment

  • Definition: Describes a relationship with unclear personal boundaries between two or more people.
  • Context: Can occur during countertransference, where a therapist becomes too emotionally connected to a patient, blurring professional boundaries.

Parentification

  • Definition: A child is forced to take on adult emotional, financial, or other responsibilities without appropriate support.
  • Effects: Harms the child's development and can lead to various mental health problems and negative outcomes later in life.
  • Root Cause: Lack of healthy boundaries within the family system.

Family Scapegoat

  • Role Assignment: In dysfunctional families, one member (often a child) is assigned the role of scapegoat, becoming the target of blame, criticism, and negative attention.
  • Signs:
    • Defiant or withdrawn behavior.
    • Academic struggles.
    • Constant blame and criticism.
    • Role reversal (taking on parental responsibilities).
    • Isolation and alienation.

Emptiness Syndrome

  • Definition: The grief experienced by parents when their children leave home (empty nest syndrome).
  • Symptoms: Feelings of loss, sadness, anxiety, grief, irritability, and fear.
  • Impact: Affects both men and women.

Empathy vs. Compassion

  • Empathy: Understanding and feeling what another person is experiencing by putting yourself in their shoes; recognizing and sharing someone else's emotions.

    • Expressing empathy is the initial reaction.
      • Example: A patient says, "I've been abused." The first reaction is to respond with empathy like, "I'm sorry that happened to you."

  • Compassion: Arises after empathy, involving the desire to help or alleviate the person's suffering.

    • Example: Helping the patient access resources to deal with their trauma.

  • Distinction: Empathy is feeling with someone; compassion is acting on those feelings to support or assist them.

Cognitive Therapy

  • Originator: Aaron Beck.

  • Focus: Changing irrational thoughts, beliefs, negative thoughts, false conceptions, and negative cognitive distortions.

  • Goal: Replacing these with positive thoughts through techniques like cognitive rehearsal.

    • Cognitive Rehearsal: Therapist and patient collaborate to explore strategies for specific problems, practicing them in advance to better handle real-life situations.

Behavioral Therapy

  • Focus: Changing maladaptive behaviors through active behavioral techniques.
  • Techniques:
    • Exposure, relaxation skills training, problem-solving, role-playing, and modeling.
  • Application: Supporting medication adherence by creating structured schedules, reminders, and addressing behaviors that lead to non-compliance.

Cognitive Behavioral Therapy (CBT)

  • Definition: A combination of cognitive and behavioral therapies.
  • Focus: Changing unhelpful or unhealthy thoughts and behaviors.
  • Tools:
    • Journaling to track thoughts (e.g., thoughts of self-harm) for cognitive restructuring or reframing.
      • Cognitive Restructuring/Reframing: Exploring causes of negative thoughts and pairing them with positive ones.

Interpersonal Therapy

  • Focus: Interpersonal issues that cause distress (e.g., relationship problems).

  • Goal: Help individuals identify and modify interpersonal problems to manage relationship issues.

    • Example: Marital conflict.

Psychodynamic Therapy

  • Focus: Unconscious processes manifested in the client's present behavior.
  • Goals: Client self-awareness and understanding the influence of the past on present behavior.
  • Similarity to Psychoanalysis: Similar, but psychodynamic therapy looks at all past experiences, while psychoanalysis focuses specifically on childhood experiences.

Psychoanalytic Therapy

  • Focus: How childhood experiences affect current behavior.

Humanistic Therapy

  • Originator: Carl Rogers.
  • Alias: Person-centered therapy.
  • Core Belief: Assumes people strive for self-directed growth and self-actualization; each person has the potential to find meaning.

Existential Therapy

  • Focus: Accepting freedom and making responsible choices.
  • Ideal Candidates: Suited for those facing existential issues such as terminal illness or contemplating suicide.
  • Approach for Suicidal Patients: Understand their subjective experience and encourage reflection on their life and purpose through self-confrontation.
  • Goals: Live authentically, focusing on the present and personal responsibility.

Logotherapy

  • Developer: Victor Frankl.
  • Focus: Helping individuals find meaning in life, especially in the face of suffering or existential challenges.
  • Emphasis: Search for purpose, freedom of will, and the ability to choose one's response to life circumstances.

Trauma-Focused CBT

  • Focus: Addressing the mental health needs of children, adolescents, and families suffering from the impacts of early trauma.
  • Sensitivity: Particularly sensitive to unique problems resulting from sexual abuse, physical abuse, violence, or grief.

Multisystemic Therapy (MST)

  • Target Population: Youth aged 12-17 with serious antisocial and problematic behavior, including criminal offenses.

  • Goals: Empowering parents with resources and skills and reducing barriers to needed resources.

  • Approach: Home-based service delivery to reduce barriers to accessing services.

    • Identifying and utilizing natural support systems (extended family, neighbors, friends, church members).
    • Removing barriers such as parental substance abuse, high stress, and poor relationships between partners.

Strategic Therapy

  • Focus: Problem-focused and symptom-focused.

  • Techniques:

    • Paradoxical Directive/Intervention: Used when family members are resistant to change or noncompliant (use with caution).

      • Involves reverse psychology, such as telling a patient to yell at their wife with the intention of them not doing so.

    • Straightforward Directive: Used with compliant family members.

    • Reframing the system.

  • Enhancements

    • Enhance a patient’s self-awareness
    • Encourage patients to adhere to medication
    • Address patient’s fear of failure

Solution-Focused Family Therapy

  • Focus: Reworking solutions that have worked previously for the present situation.
  • Techniques:
    • Miracle questions, exception-finding questions, and scaling questions

Family Systems Therapy

  • Originator: Murray Bowen.
  • Goals:
    • Increase the family's awareness of their function.
    • Increase levels of self-differentiation (being able to possess and identify one's own thoughts and feelings separately from others).
    • Decrease triangles in the family (dyads forming triangles to decrease stress).
  • Triangles:
    • When one person has a problem with another, instead of addressing it with them directly, they involve a third family member.
    • Lower adaptation levels in families lead to more triangles.
  • Keywords: Triangles, triangulation, self-differentiation.
    *Note: genograms is important but not really considered a therapy

Structural Family Therapy

  • Goal: To help the family establish clearly defined boundaries and hierarchies.
  • Techniques:
    • Genograms
    • Enactment: Family members are asked to spontaneously play out relationship patterns during a therapy session.
      • Allows the therapist to observe interactions firsthand and helps clients express different ways of interacting.
      • The goal is to help map, track, and modify the family structure.

Promoting Resilience in Children

  • Self-esteem building exercises.
  • Exercise can also:
    • Improve relationships.
    • Reduce social anxiety.

Reducing Stress and Pain

  • Massage can:
    • Reduce stress by decreasing cortisol levels.
    • Reduce pain by improving blood circulation.

Conjoint Appointments

  • If a conjoint appointment is scheduled (e.g., for a couple), both individuals must be present.
  • If only one person shows up, reschedule the appointment.

Normal Development in Children

  • Phallic Stage (3-6 years): Normal for children in this age range to play with their genitalia as part of self-exploration.
  • Boys (9-16 years): Normal to develop swelling and tenderness under the nipples, which usually disappears within six months.

Rheumatoid Arthritis

  • Erythrocyte Sedimentation Rate (ESR): Often increased in patients with rheumatoid arthritis.

Infant Cries

  • Shrug Cry/High-Pitched Cry: Can indicate increased intracranial pressure in infants.

Infant Reflexes

  • Rooting Reflex:
    • Present at birth.
    • When the corner of the baby's mouth is stroked, the baby turns their head and opens their mouth in that direction.
    • Disappears between 4-6 months.
  • Landau Reflex:
    • Emerges at 3 months after birth.
    • When held in a prone position, the baby extends their head and legs.
    • Disappears by 12-24 months.
  • Grasp (Palmar) Reflex:
    • Present at birth.
    • When an object is placed in the baby's palm, they grasp it.
    • Normal up to 5-6 months.
  • Moro (Startle) Reflex:
    • Present at birth.
    • Occurs in response to a sudden change in position or loud noise, causing the baby to throw their arms outward.
    • Normal up to 5-6 months.
  • Babinski (Plantar) Reflex:
    • Present at birth.
    • When the sole of the baby's foot is stroked, the toes fan outward.
    • Normal up to 2 years.

Elderly Female Patients

  • If an elderly postmenopausal female is complaining of low or decreased sex drive, that decreased sex drive can be due to decreased:
    • Testosterone
    • Progesterone
    • Estrogen
  • Reduced blood flow in the pelvic region.
  • Osteogen and progesterone therapy:
    • Can help manage depression in menopausal women.
  • High Body Fat:
    • Linked to depression
    • Educate patient on low fat diets.

Alcohol Metabolism

  • Alcohol Dehydrogenase: Women have lower levels of this enzyme compared to men, making them more susceptible to alcohol-related liver damage and intoxication.

Macrocytic Anemia

  • Testing: Check folic acid and, more importantly, vitamin B12 levels, as B12 deficiency can lead to neurological symptoms.
  • MTHFR Gene Mutation: Primarily affects folic acid metabolism; choose folic acid over B12.
  • Microcytic Anemia: Iron Deficiency

Iron Deficiency Anemia

  • Major Cause:
    • Major cause of macrocytic anemia is iron deficiency
  • Prevalence in Vegetarians: Vegetarians have higher rates of iron deficiency anemia.
  • Effects of Low Iron Levels:
    • Low levels of iron less oxygen gets into their cells, keeping them from functioning properly and often leading to fatigue, weakness, and even anxiety.

Acupuncture

  • Can help with pain and depression.
  • Can help them find a reputable practitioner.

Habeas Corpus

  • Legal concept protecting individuals (especially those with mental illnesses) against unlawful hospitalization, allowing them to leave against medical advice (AMA) if unjustly hospitalized.

Evidence-Based Practice

  • Make evidence based decisions.
  • If you are replacing an old treatment method with a new treatment method, you want to make that decision based on evidence
  • When replacing old treatments with new ones, decisions should be evidence-based, requiring access to current journal articles.

Assisting Patients with Memory Recall

  • To help patients recall a timeline of symptoms for diagnosis, ask specific questions to anchor their memory or questions that link to memorable events.

Teaching and Assessment

  • Before teaching a patient about something (e.g. lithium), first assess what the patient knows and believes about it to identify misconceptions and tailor your education accordingly.

PICO Question

  • When investigating a topic in nursing or health care, you want to start off by developing a PICO question.
  • PICO: Population/Problem/Patient, Intervention/Issue of Interest, Comparison, Outcome, Time

Levels of Evidence

  • Level 1: Evidence from systematic reviews or meta-analyses of all relevant randomized controlled trials (RCTs).
  • Level 2: Evidence obtained from at least one well-designed RCT.

Policy Implementation

  • Nationwide implementation:
    • To implement a policy affecting nurse practitioners nationwide use an online forum or survey to address concerns efficiently.
  • Workplace implementation:
    • To overcome resistance to a new policy at work when colleagues say against, emphasize how it improves patient care quality.

Quality Improvement in Outpatient Clinic

  • To ensure a continuous improvement of quality, you need to develop an instrument using a rating scale to determine baseline scores and regular intervals during treatment.

Diabetic Ketoacidosis (DKA)

  • A common complication of type 1 diabetes.
  • Signs and Symptoms:
    • Kussmaul respirations (rapid and deep).
    • Fruity-scented breath.
    • Excessive thirst and urination.
    • Fatigue.
    • Confusion.

Enuresis

  • Desmopressin can be used for enurancis because it reduces urine production
  • Management of Enuresis:
    • An alarm clock setting for overnight voiding or moisture alarms.

Patient Privacy

  • Looking up patient information on social media is violating their trust.

FDA Black Box Warnings

  • Iif the FDA releases a black box warning, it doesn't mean that the patient needs to stop taking their medication immediately, research the risks and benefits.

Prescribing Medications

  • When prescribing a certain medication for off label use, documentation is very important.
  • Key component of your documentation is full disclosure meaning, you want to document:
    • The benefits of taking that medication.
    • The risk.
    • Evidence that supports off label use in your documentation.

Risk Factors for Sleep Apnea

  • Excess weight, obesity, diabetes, smoking, high blood pressure, narrowed airways.

Tolerance

  • The decreased effect with continued use of the same dose of a medication over time.

Reflective Practice

  • The use of debriefing strategies after an event has occurred with the goal to improve practice.

Legal Issues in Telemedicine

  • Confidentiality issues, medical errors, jurisdictional authority over licensure, and scope of practice issues.

Substance Use Disorder Treatment

  • To determine when a patient can switch to a less intensive outpatient program, evaluate if patient is taking responsibility for their actions and they develop coping skills.

Med Errors and Policy Creation

  • If an hospital has a lot of med errors in order to decrease those errors, your initial action should be to assess the common types of MED errors.
  • To implement a new policy, assess learning needs of staff.

Assessment Scales Ranges

  • The ones that I've highlighted in blue, please remember every single range because sometimes, especially the MMFC, it's very high. MMSE (Mini Mental State Exam)

    • Assume patient was scored a 20 if there is a score a of 20 it means moderate or middle stage Alzheimer's disease.

  • Then the ones highlighted in yellow only remember the moderate ranges, you can still get a question right.

  • If your examiner gives you any score above the the moderate, it is severe. Treatment will not change if it is moderate or severe

  • PHQ-9: Moderate range is 10-14

  • GAD-7 (Generalized Anxiety Disorder): Moderate range is 10-14

  • COWS (Clinical Opiate Withdrawal Scale)

    • Used for opioid withdrawal.

  • Used to determine when to administer medication for opioid withdrawal or detoxification.

    • Patient as a mild score, give them clonidine.
    • Their score reaches 13 and above = start scheduled medications like buprenorphine or Suboxone.

  • Suboxone is made up of buprenorphine and naloxone.
    * Safer compared to methadone (methadone can cause increase cardiac issues)
    *Methadone - *This is unsafe when you have other options available*

  • CIWA (Clinical Institute Withdrawal Assessment for Alcohol)

    • If your patient was scoring an eight and above, you give PRNs. Maybe they're withdrawing from alcohol and they're presenting nausea, diarrhea, vomiting, you can give PRNs to help with those.
    • Once their score hits 15 and above, you can start them on scheduled medications and PRNs.

  • Scheduled Medications -> Diazepam, Lorazepam, Olivarib
    * You can give Diazepam.
    * The reason to prescribe valium is because it has a longer half life, so it helps treat withdrawal symptoms beta.
    * If your examiner includes that the family has hepatitis, you want to give with a shorter half life. Otherwise, you give valium.

  • you're not going to initiate it from an out patient setting

  • If you have a patient who's pregnant and if you from medications, who is withdrawn from opioids or alcohol, your priority action is to do is to send her to residential treatment center so that she can undergo detoxification within the help of the OB doctor and an addiction specialist.

Diagnosing Anxiety and Depression

  • Once their score hits mild to moderate, they need Medication and therapy*

  • Anxiety and Depression: Mild or moderate = therapy only; Moderate to severe = medications and/or therapy.

    • If there is score hit to severe range = also assess suicidal ideation on the depression scale.

Important Review Material that you will be questioned on:

  • What is used for?
  • components
  • Cow scale: Know what it is used for.
  • alcohol and opioid.