Foundations of Psychiatric–Mental Health Nursing Notes

Mental Health

  • Definition: Difficult to define, no single universal definition. It is a dynamic and ever-changing state influenced by individual (personal), interpersonal (relationship), and social/cultural (environmental) factors.

  • Indicators: Positive attitude toward self, growth, development, reality perception, fulfilling relationships, self-esteem, and resilience. Successful adaptation to stressors, as evidenced by thoughts, feelings, and behaviors that are age-appropriate and congruent with local & cultural norms.

Mental Illness

  • Definition: A clinically significant behavioral or psychological syndrome with alterations in thinking, mood, and/or behavior that causes distress or inability to function. It cuts across personal, physical, interpersonal, and societal levels.

  • Includes disorders that affect mood, behavior, and thinking, often causing significant distress and/or impaired functioning.

  • Contributing Factors:

    • Individual: Biologic makeup, intolerable or unrealistic worries or fears.

    • Interpersonal: Ineffective communication, inadequate social support.

    • Social/Cultural: Unwarranted negative view of the world, discrimination (stigma, racism, classism, etc.).

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR)

  • Taxonomy published by the American Psychiatric Association.

  • Purposes:

    • Standardize nomenclature and language.

    • Identify defining characteristics or symptoms.

    • Assist in identifying underlying causes.

  • Classification:

    • Allows practitioners to identify all factors relating to a patient's condition:

      • Major psychiatric disorders

      • Medical conditions

      • Psychosocial and environmental problems

Historical Perspectives

  • Community mental health movement led to deinstitutionalization.

  • Legislation for disability income.

  • Changes in commitment laws.

Mental Illness and the 21st Century

  • Current State:

    • 51.5 million adults in the United States have a mental illness, but only 23 million received treatment within the past year (National Institutes of Mental Health, 2021).

    • Nearly 11 million children and adolescents are diagnosed with a mental disorder.

    • The economic burden of mental illness exceeds the economic burden caused by all types of cancer.

    • Leading cause of disability in the United States and Canada for those aged 15 to 44.

    • An increasing number of both adults and children/adolescents are being treated for mental illness, yet only 1 in 4 adults and 1 in 5 children are treated.

    • Treatment is still lagging in homeless populations (42% with mental illness and substance abuse) and those with substance abuse problems.

  • Issues and Concerns:

    • “Revolving-door” effect due to deinstitutionalization and lack of community resources.

    • Patients are often “boarded” in EDs while awaiting inpatient beds.

    • Shorter hospital stays, decompensation, re-hospitalization, and dual diagnoses (mental illness and substance abuse).

    • Homelessness: about one-third have serious mental illness associated with substance abuse.

    • Lack of adequate community resources.

Future Objectives (Healthy People 2030)

  • Reduce the suicide rate.

  • Increase the proportion of children and adolescents who get treatment.

  • Reduce the proportion of persons who experience major depressive episodes.

  • Increase the proportion of adults with mental health disorders who receive treatment.

  • Increase the number of homeless adults with mental health problems who receive mental health services.

Community-Based Care

  • Lack of appropriate number of community mental health centers to provide services.

  • Development of community support programs.

  • Availability and quality of services are highly variable.

  • Inaccurate anticipation of the extent of people’s needs.

  • Despite flaws, positive aspects make them preferable for treatment.

Cultural Considerations

  • Culturally diverse population.

  • Cultural differences influence mental health and the treatment of mental illness.

  • Changes in family structure.

Psychiatric Nursing Practice

  • H. Peplau: Therapeutic nurse-client relationship; interpersonal dimension (foundation for current practice).

  • J. Mellow: Focus on client’s psychosocial needs and strengths.

  • American Nurses Association Standards of Care:

    • Collects client health data (physical and MH focus).

    • Diagnosis-NANDA.

    • Outcome Identification.

    • Planning with the client.

    • Implementation.

    • Psychiatric-Mental Health Nursing Phenomena of Concern (see Box 1.2).

Psychiatric Nursing Practice - Basic-Level Functions

  • Counseling

  • Milieu therapy

  • Self-care activities

  • Psychobiologic interventions

  • Health teaching

  • Case management

  • Health promotion, maintenance

Psychiatric Nursing Practice - Advanced-Level Functions

  • Psychotherapy

  • Prescriptive authority for drugs

  • Consultation, liaison

  • Evaluation

  • Program development, management

  • Clinical supervision

Psychotherapeutic Management and the Continuum of Care

  • Clarifies the role of the psychiatric nurse.

  • Nurse-Patient Relationship: therapeutic use of self.

  • Psychopharmacology.

  • Milieu Management.

  • Nursing in the context of moving toward recovery and reintegration.

  • Involving consumers and family.

  • Holistic thinking (stabilizing, housing, medical care, and finances).

  • Drop in inpatient stay-managed care, $ and move to outpatient treatment, community services.

  • Goal: Stabilize, develop working relationship, case manage, discharge.

Preparing for NCLEX and MH Nursing

  • Abuse/Neglect, behavioral interventions, chemical and other dependencies.

  • Crisis intervention skills, Coping Mechanisms, Mental Health concepts.

  • Stress Management, Sensory/Perceptual Alteration, Support Systems.

  • Therapeutic Communication, Therapeutic Environment.

  • Psychotropic medications, Culturally Sensitive care, and meeting spiritual needs.

  • 6-12% of test items on 2019-2023 RN.

  • www.ncsbn.org - NCLEX examinations- Test Plans.

Neurobiologic Theories and Psychopharmacology

  • Neurotransmitters: Chemical substances that facilitate neurotransmission.

  • Important in the right proportions to relay messages.

  • Play a role in psychiatric illness and psychotropic medications, including their actions and side effects.

Neurotransmitters

  • Excitatory:

    • Dopamine: complex movements, motivation, cognition, regulation of emotional response.

    • Norepinephrine: attention, learning, memory, sleep, wakefulness, mood regulation.

  • Inhibitory:

    • Serotonin: food intake, sleep, wakefulness, temperature regulation, pain control, sexual behaviors, regulation of emotions.

    • Gamma-aminobutyric acid (GABA): major inhibitory neurotransmitter; modulation of other neurotransmitters.

  • Excitatory or Inhibitory:

    • Acetylcholine: sleep-and-wakefulness cycle; signals muscles to become alert.

Brain Imaging

  • Computerized tomography (CT)

  • Magnetic resonance imaging (MRI)

  • Positron emission tomography (PET)

  • Single photon emission computed tomography (SPECT)

  • Limitations:

    • Use of radioactive substances.

    • Expense of equipment.

    • Client’s inability to tolerate technique.

    • Changes non-detectable with current techniques.

  • Nurse’s Role:

    • Informed consent

    • Describe procedure and what to expect

    • Remove any metal objects

    • Keep NPO, empty bladder before, keep still

    • Always follow facility policy for preparation

Neurobiologic Causes

  • Genetics and heredity: play a role along with non-genetic factors.

  • Twin, adoption, and family studies are used.

  • Psychoimmunology: a compromised immune system could contribute, especially in genetically at-risk populations.

  • Infections: theories include viruses that alter human genes, viruses during fetal development.

Nurse’s Role in Research and Education

  • Ensure all clients and families are well informed.

  • Help distinguish between facts and hypotheses.

  • Explain if or how new research may affect a client’s treatment or prognosis.

  • Provide information and answer questions.

Psychopharmacology

  • Psychopharmacology and medication management are important in the treatment of many mental illnesses.

  • #1 cause of relapse is medication noncompliance

Psychopharmacology - Additional Information

  • Off-label use: a drug may be effective for treating a disease different from the one involved in original testing.

  • Black box warning: indicates serious or life-threatening side effects.

Principles of Psychopharmacology

  • Effect on target symptom.

  • Adequate dosage for sufficient time.

  • Lowest dose needed for maintenance (lower doses for the elderly).

  • Follow-up care.

  • Tapering rather than abrupt cessation to avoid rebound or withdrawal.

  • Simplify the regimen for increased compliance.

Antipsychotic Drugs

  • Conventional: chlorpromazine, fluphenazine, thioridazine, haloperidol, loxapine.

  • Second generation: clozapine, risperidone, olanzapine.

  • Third generation: dopamine system stabilizers; aripiprazole.

Antipsychotic Drugs - Use and Mechanism

  • Use: treatment of psychotic symptoms

  • Mechanism of action: block dopamine receptors

Antipsychotic Drugs: Side Effects

  • Extrapyramidal syndrome (EPS):

    • Acute dystonia: Torticollis, oculogyric crisis - Treatment: anticholinergic drugs or diphenhydramine (see Table 2.4)

    • Pseudo-parkinsonism: stooped posture, mask-like faces, shuffling gait - Treatment: anticholinergic or amantadine (dopamine agonist)

    • Akathisia: restlessness, anxiety, agitation - Treatment: Beta blocker, anticholinergic, benzodiazepine

  • Neuroleptic malignant syndrome (NMS)

  • Tardive dyskinesia (irreversible involuntary movements)

  • Anticholinergic effects (dry mouth, constipation, urinary hesitancy or retention)

  • Other side effects

    • Weight gain (second-generation agents, except ziprasidone)

    • Metabolic syndrome

    • Cardiovascular adverse effects

      • Lengthening of QT interval (thioridazine, droperidol, mesoridazine)

    • Agranulocytosis (clozapine)

Antipsychotic Drugs: Client Teaching

  • Adherence to regimen

  • Side effects, management

    • Thirst/dry mouth (sugar-free candy, liquids)

    • Constipation (dietary fiber, exercise)

    • Sleepiness/drowsiness (safety measures)

  • Actions for missed dose (dose if within 4 hours of usual time)

  • CBC, ANC with clozapine