Psychiatric-Mental Health Nursing Exam Notes

Psychiatric-Mental Health Nursing Exam Notes Ch 7-10

Chapter 07: The Nursing Process and Standards of Care

• Prescriptive Privileges: Advanced practice nurses (master’s-prepared nurse practitioners) with special courses can prescribe psychotropic medication.

• Basic Level Nurses: Perform mental health assessments, establish therapeutic relationships, and provide individualized care planning.

• Priority Nursing Diagnosis for Suicidal Client:

  • Risk for suicide takes priority over other diagnoses (imbalanced nutrition, hopelessness, low self-esteem) when the client has suicidal ideation and a plan.

• Suicide Precautions:

  • Implementing suicide precautions is the priority intervention for a client with suicidal ideation and a plan.

  • Other interventions (nutrition, self-esteem, medication) are important but not priorities.

• Evaluating Outcomes:

  • Outcomes must be fully achieved to be marked as demonstrated.

  • Example: Sleeping a total of 6 hours daily, but not in one uninterrupted session, means the outcome of sleeping 5 hours nightly is "never demonstrated."

• Revising Plan of Care:

  • If a desired outcome is not met, examine interventions and consider revising the target date.

  • Do not remove the nursing diagnosis if the outcome remains reasonable.

• Implementation Phase:

  • Involves nursing prescriptions to achieve outcomes.

  • Example: "Encourage client to attend one psychoeducational group daily."

  • Should be specific

• Assessment and Bias:

  • Assess clients based on data collected from all sources.

  • Evaluate biased assessments objectively.

• Medical vs. Psychiatric Symptoms:

  • Elevated BUN (blood urea nitrogen) and creatinine can indicate renal problems that mimic psychiatric disorders.

  • Assess the client for a history of renal problems.

• Prioritizing Interventions:

  • Client safety is always the priority.

  • Address suicide risk before self-esteem, anxiety, or sleep.

• Outcome Criteria:

  • Should be measurable and related to social involvement.

  • Example: "Client will select and participate in one group activity per day."

• Implementation Phase Actions:

  • Using available resources

  • Performing interventions

  • Finding alternatives when necessary

  • Coordinating care

• Priority Focus for Plan of Care:

  • Auditory hallucinations that create a risk for violence.

• Problem-Oriented Charting:

  • Uses the acronym SOAPIE to organize data:

    • S: Subjective data

    • O: Objective data

    • A: Assessment

    • P: Plan

    • I: Intervention

    • E: Evaluation

• Assessment from Secondary Sources:

  • When the client cannot provide information, use secondary sources (e.g., family members).

• Assessing Cognition:

  • Involves determining a client’s judgment and decision making.

  • Example: Asking what the client would do if they had a fever and vomiting for 3 days.

    • Intact cognition implies a response such as calling a doctor.

• Confidentiality with Adolescents:

  • Most information is confidential.

  • Exceptions: threats of suicide, homicide, use of illegal drugs, or abuse.

• Assessing Recent Memory:

  • Example: Asking what the client had for breakfast that morning.

• Assessing Older Adults:

  • Vague answers, leaning forward, and frowning may indicate difficulty hearing.

• Assessing Coping Strategies:

  • Ask what the client does when upset or stressed, and about their faith.

• Milieu Management:

  • Providing a therapeutic environment where the client feels comfortable and safe.

  • Includes explaining unit rules and daily schedules.

• Nursing Process Steps:

  • After nursing diagnoses, determine goals and outcome criteria.

• Selecting Nursing Diagnoses:

  • Based on etiological factors and assessment findings.

  • Example: Social isolation related to shyness and poorly developed social skills.

• QSEN:

  • Quality and Safety Education for Nurses.

  • Focus: client safety and quality.

  • Goal: prepare nurses with the knowledge, skills, and attitudes to increase quality, care, and safety.

• Impaired Verbal Communication:

  • Defining characteristics: muteness, lack of eye contact, inattentiveness.

• Language Barriers:

  • Assess the client for language barriers.

  • Determine whether a translator is needed.

  • Family members are not always reliable translators.

• Documentation Standards:

  • Narrative notes should describe client appearance, behavior, and conversation.

  • Mention less-restrictive measures attempted before administering medication.

  • Document client response to medication.

• Documenting Assessments:

  • Include both content and process of the interview, including descriptions of the client’s behavior.

• Standardized Rating Scales for Substance Use:

  • Examples: Addiction Severity Index (ASI), Brief Drug Abuse Screen Test (B-DAST), and Recovery Attitude and Treatment Evaluator (RAATE).

• Nursing Diagnoses:

  • Reflect unmet client needs, supporting data, and probable causes.

• Assessing Suspicious Clients:

  • Listen attentively and accept the client’s statements nonjudgmentally.

  • Reassure safety.

Chapter 08: Therapeutic Relationships

• Countertransference:

  • Nurse's unconscious emotional responses to the patient.

  • Based on the nurse’s own needs, conflicts, or views.

  • Example: Feeling sadness and reflecting, "This patient is like one of my grandparents … so helpless."

• Empathy:

  • Seeing an event from the patient’s perspective and understanding their feelings.

  • Communicating this understanding to the patient through statements like, "You must have been very upset when you tried to hurt yourself."

• Countertransference Indicators:

  • Strong positive or negative reactions toward a patient.

  • Over-identification with the patient indicate possible countertransference.

• Confidentiality:

  • Patients have the right to know with whom the nurse will share information.

  • Acknowledge that information will be shared with other staff.

• Session Duration:

  • Adhere to the schedule when specific duration for sessions has been set.

• Successful Termination:

  • Discuss changes during the relationship and evaluates outcomes.

• Orientation Stage Outcomes:

  • Rapport and trust with the nurse.

• Working Phase:

  • The nurse assists the patient in making connections among dysfunctional behaviors, thinking, and emotions.

• Addressing Termination:

  • Address termination during the orientation phase

  • Inform the patient of the number of sessions.

• Contract:

  • Specifies participation and responsibilities of each party.

  • Emphasizes that the nurse works with the patient rather than doing something for the patient.

• Gifts:

  • Acknowledge the patient’s gesture of appreciation, but the gift should not be accepted.

  • Example: Instead of accepting a necklace, say: "I’m glad I could help you, but I can’t accept the gift. My reward is seeing you with a renewed sense of hope."

• Working Phase Indicators:

  • Readiness to make a behavioral change.

  • Example: "I want to find a way to deal with my anger without becoming violent."

• Nurse-Patient Relationship vs. Social Relationships:

  • The focus shifts to the patient, problems are discussed, but solutions are implemented by the patient.

• Genuineness:

  • Communicating them when appropriate using congruent communication strategies

• Managing Anger:

  • Discuss the anger with a clinician during a supervisory session.

• Positive Regard:

  • Can be shown by staying with a tearful patient.

• Nonjudgmental Responses:

  • Encourages to patient to explore feelings and values

  • Example: When a patient says, “I’ve done a lot of cheating and manipulating in my relationships.” respond with “How do you feel about that?”

• Differing Values:

  • Nurses must be aware of their own values and be sensitive to the values of others.

• First Interview Issues:

  • Relationship parameters, the contract, confidentiality, and termination.

• Countertransference Example:

  • When a nurse relates feelings about a patient to significant figures in the nurse's past
    For example: “My parents were alcoholics and often neglected our family.”

• Autonomy:

  • Supported when the nurse helps a patient weigh alternatives and their consequences before the patient makes a decision.

• Cards of Appreciation:

  • The nurse must consider the meaning, timing, and value of the gift.

  • In this instance, the nurse should accept the patient’s expression of gratitude.

• Promoting Autonomy

  • Nurses should encourage patients to work at their optimal level of functioning, which in turn promotes autonomy.

• Starting Point for Relationship

  • Begin at the orientation phase.

• Therapeutic Relationship Boundaries:

  • The invitation creates a social relationship rather than a therapeutic relationship.

• Boundary Blurring

  • When the role of the nurse and the role of the patient shift, boundary blurring may arise.
    For example: “I am the only one who truly understands this patient. Other staff members are too critical.”

• Caring

  • Caring evidences empathetic understanding as well as competency.

• Termination Phase

  • Focus dialogues with the patient on problems that may occur in the future.

  • Help the patient express feelings about the relationship with the nurse.

• Coping Phase

  • Seek ways to use the understanding gained from childhood to help patients cope with their own illnesses.

• Behaviors for Trust

  • Sitting behind a desk, facing the patient Introducing self to a patient and identifying own role

  • Introducing self to a patient and identifying own role

  • Using facial expressions to convey interest and encouragement

Chapter 09: Therapeutic Communication

• Clarification:

  • Helps the nurse examine the meaning of the client’s statement.

  • Example: Asking for a definition of "stoned."

• Therapeutic Responses:

  • Address the underlying feelings or thoughts the client’s message conveys

  • Use the therapeutic technique of reflection.

• Incongruous Messages:

  • Involve transmission of conflicting messages by the speaker.

  • Example: Saying "My marriage is just great" while fidgeting and twirling a shirt button."

• "Offering Self"

  • Helps to build trust and convey that the nurse cares about the client."
    Example:I’d like to sit with you for a while to help you get comfortable talking to me.

• Restating

  • Allows the client to validate the nurse’s understanding of what has been communicated.

• Clarification
  Asking, Am I correct in my understanding of that ? permits clarification to ensure that both the nurse and client share mutual understanding of the communication.

• Most Therapeutic Response
  By asking if the client does not believe that progress has been made, the nurse is reflecting or paraphrasing by putting into words what the client is hinting. By making communication more explicit, issues are easier to identify and resolve.

• Analysis
  When a verbal message is not reinforced with nonverbal behavior, the message is confusing and incongruent.

• Nonverbal Communication
  Eye contact and body movements are considered nonverbal communication

• Cultural Interpretations
  Touch has various cultural and individual interpretations. Nurses should refrain from using touch until an assessment is completed regarding the way in which the client will perceive touch.

• Nonverbal Techniques
  Making observations and encouraging the client to describe perceptions are useful therapeutic communication techniques for this situation.
  For example:I notice you keep looking toward the door

• Client Focus
  Having the client speak in specifics rather than globally will help the nurse understand the client’s perspective. This approach will help the nurse engage the client.

• Cultural Diagnosis
  The nurse should have assessed the client’s culture before making this diagnosis and plan.

• Ethnicity
  The most likely answer is that the client’s behavior is culturally influenced.
  Therefore:A ethnic client uses dramatic body language when describing emotional discomfort.

• Personal Questions
  When a client tries to focus on the nurse, the nurse should refocus the discussion back onto the client.

• Silence
  Silence can be helpful to both participants by giving each an opportunity to contemplate what has transpired, weigh alternatives, and formulate ideas.

• Advise
  Giving advice fosters dependence on the nurse and interferes with a client’s right to make personal decisions. It robs the client of the opportunity to weigh alternatives and develop problem-solving skills. Furthermore, it may contribute to a client’s feelings of personal inadequacy.

• Therapeutic Response:
  When a school age child tells the school nurse, “Other kids call me mean names and will not sit with me at lunch. Nobody likes me.” The correct response uses exploring, a therapeutic technique: Tell me more about how you feel.

• Acute Depression:
  A client diagnosed with acute depression states, “God is punishing me for my past sins.” The nurse reflects the client’s comment, a therapeutic technique to encourage sharing for perceptions and feelings: You sound very upset about this.

• Facilitate Communication:
  Reflecting (I can see that you feel sad, This is very painful for you) and giving information (Crying is a way of expressing hurt) are therapeutic techniques.

• Telehealth*
  Benefits are most associated with use of telehealth technologies for example Cost savings for clients,Maximize care management ,Access to services for clients in rural areas.

Chapter 10: Stress Responses and Stress Management

• Depression and Physical Illness:

  • Negative emotions and prolonged stress interfere with the body’s ability to protect itself and can increase the likelihood of illness.

• Guided Imagery:

  • Replacing dysfunctional images with positive coping images.

  • Visualize feeling relaxed and taking regular deep breaths when leaving home.

• Exercise and Depression:

  • Research has found significantly higher concentrations of cytokines that cause systemic inflammation in subjects with major depressive disorder compared with control subjects.

  • Recovery from depression is associated with reduction to normal levels of most of the cytokines.

• Cultural Expression of Stress:
  Many people from Central American cultures express distress in somatic terms

• Counteracting Sympathetic Nervous System:

  • Stimulating the parasympathetic nervous system will counter the sympathetic nervous system’s arousal, normalizing these vital sign changes and reducing the physiological demands stress is placing on his body

  • directing the client in slow and deep breathing using abdominal muscles.

• Significant Stressors:

  • A person returning to college after losing a job is dealing with two significant stressors simultaneously.

• Spiritual Practices and Health:

  • Studies show that spiritual practices can enhance immune system function and coping abilities
    Suggest a client “Maybe I should start going to church again.”

• Social Support:

  • Discuss how divorce support groups could increase coping and social support
    High-quality social support enhances mental and physical health and acts as a significant buffer against distress.

• Supporting Spiritual Measures:
  Many clients find that spiritual measures, including prayer, are helpful in mediating stress. Studies have shown that spiritual practices can enhance the sense of well-being.

• Anticipation of Surgery:
  The client would experience stress associated with anticipation of surgery. In times of stress, the sympathetic nervous system takes over (fight or flight response) and sends signals to the adrenal glands, thereby releasing norepinephrine. The circulating norepinephrine increases the heart rate. Respirations increase, bringing more oxygen to the lungs

• Best Initial Nursing Response:
  "Let’s talk about what is going on in your life and then look at possible options” Further assessment is indicated before potential solutions can be explored.

• Cognitive Reframing: