Mental Health 1.2

Mental Health: Lecture 2

Content

• The Nursing Process.
• Therapeutic communication (Varcarolis: Chp. 8).
• Therapeutic relationship (Varcarolis: Chp. 9).
• Eating disorders (Varcarolis: Chp. 14).
• Varcarolis: Chp. 7

Nursing Process in P-MH Nursing

• Assessment
  • MSE (Mental Status Examination).
  • Psychosocial & physical assessment.
  • History taking.
  • Interview.
  • Rating scales.
• Nursing Diagnosis
  • Identify problem & cause.
  • Construct nursing dx and problem list.
  • Prioritize nursing dx.
• Planning
  • Identify safe & evidence-based actions.
  • Use culturally-relevant interventions.
  • Document using appropriate terminology.
• Implementation
  • Coordination of care.
  • Health teaching/promotion.
  • Milieu therapy.
• Outcome Identification
  • Identify attainable outcomes.
  • Document as measurable goals, include time estimate.
• Evaluation
  • Document results; if outcomes not reached- gather additional data, reassess, and revise plan.

Standard 1: Assessment

• A patient’s assessment is continuously evolving; new problems may become evident.
• The psychiatric nurse needs to know upon admission:
  • Past and present medical history.
  • A physical examination.
  • Any acute physical complaints (and must document!).
• Collect this info utilizing therapeutic techniques:
  • “I am going to ask you some questions about what brought you here today. It is normal for people to feel uncomfortable as we talk about private thoughts. We can take breaks if this feels too overwhelming.”
• Involve the patient, family, and other support systems if appropriate (remember- this is not a substitute for what the patient tells you).
• Establish Rapport.
• Obtain understanding of current problem.
• Review physical status and obtain baseline vital signs.
• Assess for risk factors affecting safety of patient or others (suicide/homicide).
• Assess mental status.
• Assess psychosocial status (How would we do this?).
• Identify goals for treatment.
• Formulate POC that prioritizes immediate needs.
• Document.

Assessment Cont.

• Review of Systems
  • Ask focused questions about physical & psychiatric symptoms.
  • Prioritize systems relevant to patient’s presentation.
  • Assess medication effects.
  • Document positives and negatives.
• Laboratory Data
  • Medical disorders can mimic mental health disorders (Ex- hypothyroidism can appear as depression, hyperthyroidism can appear to be a manic episode).
  • Simple blood tests can rule out such.
  • Tox screens.
• Psychosocial
  • Chief complaint.
  • History- substance abuse, self-harm, family psych hx, psych treatment, personal background.
  • Current stressors/coping.
  • Support system.
  • Weaknesses, strengths, goals.
• Spiritual
  • Spirituality- meaning, hope, purpose.
  • Religion- external system of beliefs, worship, symbols.
  • Can impact how a patient understands purpose in their life and use judgement to solve problems.
• MSE
  • Aids in collecting objective data.
  • Includes physical behavior, nonverbal communication, appearance, speech patterns, mood and affect, thought content, perceptions, cognitive ability, and insight and judgement.
• Cultural
  • Nurses must have increased understanding of cultural/social factors that affect health and illness.
  • Helps avoid stigma, labels, & stereotypes.
  • Improved patient outcomes= incorporation of culture.
  • Always use an interpreter if not fluent.

Example 1: MSE

• APPEARANCE AND BEHAVIOUR: Middle aged white male; well kempt; intermittent eye contact; at times tearful; fiddling with ring on finger, seemed anxious.
• SPEECH AND FORM OF THOUGHT: Quite quiet but otherwise normal rate and tone.
• MOOD, AFFECT AND ASSOCIATED FEATURES:
  • Subjectively and objectively low mood.
  • Anhedonia.
  • At times tearful when discussing loss of contact with family and past events.
  • Appetite ok.
  • Sleep difficult on ward due to noise.
  • Denies current suicidal ideation.
• ANXIETY, TRAUMA AND ASSOCIATED FEATURES: Some anxiety from discussing particular topics with regards to relapsing and loss of family seems appropriate.
• THOUGHT CONTENT: Normal - concerns re future. Daughter does not want to speak to him. Flat in a mess. Feels a failure due to recent relapse.
• PERCEPTIONS: No hallucinations.
• COGNITION & INSIGHT: Orientated to time, place, person. Continues to agree to informal admission for detox. Keen to continue abstinence.

Example 2: MSE

• A&B: A tall young British male of mixed origin holding a novel - XXXXX XXXXX by XXXXX XXXXXX Entered the room for interview. He good rapport was established. He was clean-shaven and did not show any evidence of self-neglect of self-harm. He was dressed in t-shirt and jeans.
• Speech: normal in rate, tone, and volume.
• Mood: Sub: normal, Obj: Euthymic rates it as 8 on a scale of 1-10.His sleep and appetite are normal.
• Thoughts and perception: no thought interference/delusions or hallucinations. No 1st rank symptoms.
• Cognition: Intact in time place and person.
• Insight: He is aware that he had stopped his epileptic medications, which lead to a relapse of epilepsy on this occasion. He is willing to take medications.

Concepts of mental health

• Self-Awareness
• Assertiveness
  • Important skill for nurses.
  • Improves communication.
  • Honest and legitimate expression of one’s opinions, needs, wants, feelings w/o violating rights of others.
• Personal biases.
• Personal beliefs.
• Personal experiences (ACEs, trauma).

Standard 2: Diagnosis Nursing Diagnosis

• Problem/ unmet need (Ex: self-mutilation).
• Etiology- factors that contribute to development of problem (Ex: self-mutilation r/t disturbed body image).
• Defining characteristics- supporting signs and symptoms (Ex: self mutilation r/t disturbed body image AEB self-cutting, impulsivity, and statements that cutting helps relieve painful feelings of inadequacy).
• Risk Diagnosis
  • High probability a future event may occur.
  • Dx made to prevent a dangerous future event.
  • Ex: Risk for falls r/t sedation from psychotropic medications AEB recent medication changes.
• Health Promotion Diagnosis
  • When clinical observations and/or patient/family/group statements indicate a willingness to enhance specific health behaviors.
  • Ex: Readiness for enhanced coping r/t expressed desire to manage stress more effectively AEB verbalizing willingness to learn stress management techniques.

Standard 3: Outcome Identification

• Outcome criteria: optimal goal outcomes that reflect the maximal level of patient health that can realistically be achieved through evidence-based nursing interventions.
• Outcomes reflect desired change.
• Outcome characteristics: specific, measurable, achievable, relevant, time-bound (remember SMART goals).
• Ex: The patient will identify two coping strategies to manage distress within 48 hours.

Standard 4: Planning

• Procedures must be compatible with other therapies and patient’s personal, spiritual, and cultural values (as well as facility rules).
• Safety: Procedures must be safe for all patients, staff, and family
• Individualized
  1. Realistic within patient’s capabilities
  2. Consider patient’s preferences, goals, and developmental level
  3. Reflective of available resources and technology
• Appropriate
• Evidence-based: Use of best available research, trends, and scientific evidence
• Planning is the development of strategies and alternatives to assist the patient in attainment of expected outcomes.

Standard 5: Implementation

• Coordination of Care
  • Coordinates and implements plan.
  • Communicates w/ family and other other members of healthcare team.
  • Advocates for respectable care.
  • Helps patient and family find alternatives to care (and documents).
• Health Teaching & Health Promotion
  • Promotes health & safe environment.
  • Integrates psychoeducational strategies.
  • Identifies health education needs.
  • Provides teaching on coping skills, self- care activities, stress management, etc.
  • Identifies resources for prevention and recovery services in community.
• Milieu Therapy
  • Provides, structures, and maintains a safe, therapeutic, recovery-oriented environment in collaboration w/ patient, family, and other health care team members.
  • Milieu therapy: orienting patients to their rights and responsibilities, informing patients about need for structure, a safe environment, and limits within facility.
  • May include selecting individual and group therapy
• Therapeutic Relationship & Counseling
  • Uses therapeutic relationship and counseling interventions to assist patients in their individual recovery by improving their coping abilities, fostering mental health, and preventing mental disability
• Pharmacological, Biological, & Integrative Therapies
  • Incorporates knowledge of pharmacological biological, and complementary interventions with applied skills
  • Has knowledge regarding intended action, therapeutic dosage, adverse reactions, and safe blood levels of medications
  • Must provide education regarding medication

Standard 6:Evaluation

• Evaluation must be systematic, ongoing, and criterion based
• Allows for revisions of nursing diagnoses, changes to more realistic outcomes, or identification of more appropriate interventions

Documentation Notes

• Should include:
  • Changes in patient condition
  • Informed consent
  • Reaction to medications
  • Documentation of symptoms
  • Concerns of patient
  • Incidents in clinical setting
  • Patient progress

Nonadherance Documentation

• Do not use “noncompliant” or “patient did not comply”; does not protect you
• Instead use “nonadherence”; only document objective info
• Document rationale for treatment, clear explanation of what you need patient to do, and whether the patient complied with advice
• Systems
  • Charting must be retrievable for quality assurance monitoring, research, etc.
  • Use nursing process as guide for charting
  • Documentation must conform to legal principles

Communication Process

• Stimulus: The need to communicate with another
• Sender: Person sending the message
• Media: Vehicle of how message is sent (auditory, visual, tactile, olfactory, etc)
• Receiver: Person receiving the message
• Message: Information sent or expressed to another
• Feedback: Response to sender

Communication

• Verbal: All words spoken by a person. When we speak, we communicate:
  • Our beliefs and values
  • Perceptions and meanings
  • Interest and understanding or insult or judgement
  • Messages clearly or convey conflicting or implied messages
• Nonverbal: Nonverbal behaviors comprise 65% to 95% of a sent message
  • Refers to any body gesture (facial expressions, body posture, eye contact, yawning, “sighs”, hand movements)
  • Also includes tone and pitch of a person’s voice, as well as pace of speech
  • This can vary with culture

Effective Communication

• Silence
  • Encourages patient to open up
  • Not the absence of communication; creates a channel for transmitting and receiving messages
  • Patient may use silence- may have feelings of embarrassment, shyness, or discomfort around uncomfortable topics
  • Therapeutic silence: provides moments of reflection for both patient and nurse
  • It is common for us to want to “break” the silence due to anxiety, or even embarrassment; this can cause the roles to be reversed
• Active Listening
  • Observing patient’s nonverbal behaviors
  • Listening & understanding verbal messages
  • Listening & understanding the person r/t their social and cultural setting
  • Listening for inconsistencies
  • Providing feedback on things patient may be unaware of
  • Undivided attention- enhances self esteem & encourages patient to solve problems
• Clarifying Techniques: Helps both nurse & patient identify major differences in their frame of thinking. Provides the opportunity to correct misinterpretations before they cause misunderstanding

Clarifying Techniques

• “My life has no meaning” Nurse: “What does your life lack?” or “What kind of meaning is missing?”
• Paraphrasing: ”Was I correct in saying…?” “I’m not sure I understand” “In other words, you seem to be saying…”
• Reflecting of Feelings: ”You sound as if you have had many disappointments” “You look sad.”
• Restating
• Exploring: “Tell me more about xyz” “Describe xyz” “Give me an example of xyz”. These statements offer general leads for the patient

Projective Questions

• Presupposition Questions
  • Miracle questions
  • “Suppose you woke up in the morning and a miracle happened and this problem had gone away. What would be different? How would it change your life?
  • Helps imagine conflicts, values, behaviors
  • “If you had 3 wishes, what would you wish for?”
  • “What if you could go back and change how you acted; what would you do differently now?”
  • “What would you do if you were given $1 million, no strings attached?”

Nontherapeutic Techniques

• Excessive Questioning
  • Asking multiple questions at same time
  • Close-ended questions
  • Makes nurse an interrogator
  • Coveys lack of respect
  • Ex: “Why did you leave your wife? Did you feel angry at her? What did she do to you? Are you going back to her?
  • What can we do instead?
• Giving Approval/Disapproval
  • Giving approval: “You did a great job in the group telling John what you thought about how rudely he treated you.” Why is this an issue?
  • Giving disapproval: “You really should not cheat, even if you think everyone else is doing it.” What can we say instead?
• Advising
  • Giving advice interferes with patient’s ability to make personal decisions
  • Can foster dependency
  • Can undermine competence and adequacy
  • Instead: help the patient identify the problem and what is needed to make an informed decision, suggest alternatives when appropriate
• Asking “Why” Questions
  • Implies criticism
  • Can be interpreted as intrusive and judgement
  • Instead of asking “why”; ask “what”

Cultural Competence

• Communication Style
• Touch
• Eye Contact
• Cultural Filters

Nurse-Patient Therapeutic Relationship

Core concepts

1. Dignity and respect
2. Information sharing
3. Patient and family participation
4. The patient’s feeling of being heard and understood

Therapeutic Relationship

• Refrain from judgement & transferring own beliefs to patient
• Being held accountable by more experienced clinician
  • Delaying judgement
  • Supervision
  • Accountability: You are responsible for your conduct & consequences
• Clinical Competence: Using evidence-based practice as foundation for care
• Focus on patient needs 1st consideration is best interest of patient, not yourself

Social Relationship

• A relationship that is primarily initiated for the purpose of friendship, socialization, enjoyment, or accomplishment of task.
• Mutual needs are met
• Giving advice
• Meeting basic dependency needs (ex- lending money)
• Not appropriate with psychiatric patients

Crossing Boundaries

• Overhelping: Doing for patients what they are capable of doing
• Controlling: Assuming control “for their own good”
• Narcissism: Needing to find flaws in patient to feel helpful rather than focusing on their strengths

Phases of the Nurse-Patient Relationship

• Preorientation: Reviewing patient info, self-reflecting, & managing biases
• Orientation: Nurse & patient meet, establish trust, and define goals of relationship
• Working: Nurse & patient collaborate to address issues and work toward achieving goals
• Termination: Relationship concludes as goals are met

Preorientation Phase

• Identify concerns about working with psychiatric patients
• Conduct research regarding various diagnoses and behaviors
• Obtain resources and support
• Know what to do in unsafe situations

Orientation Phase

• The first time a patient and nurse meet
• Initial interview
• Create an atmosphere in which rapport can grow
• Clarify nurse’s role and responsibilities of both nurse and patient
• Discuss details of contract (time, place, date, during of meetings)
• Discuss confidentiality &extreme situations
• Discuss & introduce terms of termination
• Become aware of any transference or countertransference issues
• Articulate patient problems and mutually agree on patient’s goals

Working Phase

• Maintain the relationship
• Gather further data
• Promote the patient’s problem-solving skills, self- esteem, and use of language
• Facilitate behavioral change
• Overcome resistance behaviors
• Evaluate problems and goals, redefine as necessary
• Promote practice and expression of alternative adaptive behaviors
• Discuss termination when appropriate

Termination Phase

• Final phase
• Summarize the goals achieved in relationship
• Discuss ways for patient to incorporate coping strategies into daily life
• Review situations that occurred during the time spent together
• Exchange memories and validate all feelings involved with termination= closure

Factors that Hamper Positive Nurse- Patient Relationship

• Inconsistency
• Unavailability
  • Ex- a nurse is too busy to address concerns, leaving the patient feeling neglected or uncared for
  • Ex- a nurse frequently changes the care plan or provides conflicting info about treatment (creates feelings of uncertainty)

Factors that Enhance Growth

• Genuineness
  • Self-awareness of feelings & ability to communicate them
  • Conveyed by listening to & communicating without distorting message
• Empathy
  • Signifies a central focus and feeling with and within the patient’s world
  • “Temporarily living in the other’s life, moving about it delicately without making judgments”
  • How is this different from sympathy?
• Positive Regard
  • Focuses on respect
  • Every patient is worthy of being cared for and has potential

The Client Interview: Preparing

• Setting
• Seating
  • Assume same height as patient
  • Avoid face-to-face stance
  • Provide safety (patient should never be positioned between nurse and door)
  • Avoid desk barrier
  • Establish a setting that enhances feeling of security
  • Usually occurs in clinic, outpatient unit, office, patient’s home
  • Promote privacy

The Client Interview: Introductions & Initiation

• Introductions
• Initiation of interview
  • “Where should we start?”
  • “Tell me a little bit about what has been going on with you.”
  • “Tell me about your difficulties.”
  • “What are some stresses you have been coping with recently?”
  • Think orientation phase
  • Ask patient how they would to be addressed

The Client Interview: Attending Behaviors

• Eye Contact
  • Consider cultural background
  • Displays attentiveness
• Vocal Qualities
  • Loudness, pitch, rate, fluency
  • “Not what you say but how you say it”
  • Positive: gentle and soft tone
  • Negative: Rapid, high-pitched tone
• Body Language
  • Positive: leaning into speaker, maintain attentive posture, matching one’s facial expressions to patient’s
  • Negative: Rolling eyes, slumped posture, sitting with arms crossed
• Verbal Tracking
  • Tracking what patient says
  • Pacing the interview by sticking closely with patient’s speech content
  • Providing neutral feedback, NOT advice or personal opinion

Eating Disorders

• Anorexia Nervosa (AN)
  • Self-starvation, intense fear of gaining weight, disturbance in self- evaluation of weight
  • Intense rational beliefs r/t shape and weight
• Bulimia Nervosa (BN)
  • Repeated episodes of binge eating followed by inappropriate compensating behaviors (binge-purge behaviors)
  • Self-induced vomiting, laxatives, diuretics, excessive exercise

Anorexia: Assessment

• SCOFF Assessment:
  • Sick: Do you make yourself sick or vomit after a meal because you feel uncomfortably full?
  • Control: Do you fear loss of control over how much you eat?
  • One stone: Has the patient lost 14 lb in a 3-month period?
  • Fat: Do you believe you are fat even when others tell you that you are too thin?
  • Food: Does food dominate your life?
• Psychosocial Assessment
  • Pt’s perception of problem
  • Ritualistic eating patterns
  • Methods used to achieve weight control
  • Comorbid mental health issues
  • Alcohol or substance misuse
  • Selfharm or suicidal ideation
• Terror of gaining weight
• Preoccupation with thoughts of food
• View of self as fat even when emaciated
• Peculiar handling of food (cutting food into small bits, pushing pieces around plate)
• Possible development of rigorous exercise regimen
• Possible self-induced vomiting, use of laxatives and diuretics
• Cognitive distortions; self-worth depends on weight
• Controls eating to feel powerful to overcome feelings of helplessness
• Physical symptoms: Always assess & monitor VS/labs
  • Malnutrition- poor circulation, dizziness, palpitations, fainting, pallor
  • Menstrual of other endocrine disturbances- amenorrhea
  • Cachectic appearance- severely underweight w/ muscle wasting
  • Lanugo- growth of fine, downy hair on face and back

Anorexia: Diagnosis & Planning

• Nursing diagnoses focused on physiological consequences of AN; malnutrition, vomiting, dehydration
  • Ex- Impaired nutritional status and risk for injury r/t cardiac output, electrolyte imbalances, imbalanced fluid volume
• Nursing diagnoses focused on psychological consequences
  • Ex- Disturbed body image, negative self-image, low self-esteem, difficulty coping
• Planning
  • Immediate physiological stabilization; refeeding, nutritional plans, weight restoration
    • Refeeding syndrome; deadly- transition from catabolic state to anabolic state= shift in fluids and electrolytes (can cause heart failure, arrythmias, respiratory failure, muscle breakdown, & death)

Anorexia: Implementation

• Weigh the patient regularly (usually daily at same time) before breakfast, in same attire after voiding
• Observe or sit with the patient while eating
• Choice of foods will be made in consultation with a nutritionist
• Patient is given a limited time to complete a meal
• Continue supervision of the patient after eating meal
• Consider privileges for the patient when weight is gained (reward system)
• Tube feedings and liquid supplements may used if weight continues to be lost by patient or if patient is not finishing meals
• Ensure no use of laxatives or diuretics
• Milieu therapy, teaching, counseling
• Therapies found to be effective in treating eating disorders:
  • Cognitive-behavioral therapy (CBT): used to diminish distortions in the patient’s thinking that result in problematic attitudes and eating-ordered behaviors
  • Enhanced CBT (CBT-E): A structured, time-limited treatment specifically for eating disorders. Primary focus is to establish a regular pattern of stable, flexible eating and to address factors that reinforce the eating behaviors
  • Dialectal behavioral therapy (CBT): A form of CBT adapted to address emotional dysregulation
• Pharmacological treatment: SSRI or atypical antipsychotic

Bulimia: Assessment

• May not appear to be physically or emotionally ill; often slightly above ideal body weight
• May have enlarged parotid glands, dental erosion, and caries r/t induced vomiting
• May have skin problems and problems r/t dehydration
• Acute desire to be thin and are overly concerned w/ weight and appearance
• Symptoms of anxiety, depression, impulsivity, compulsivity are common
• Guidelines
  • Medical stabilization 1st
  • Thorough physical exam & labs (electrolyte levels, glucose level, thyroid function, CBC, EKG)
  • Psychiatric eval- usually coexisting psychiatric disorders
  • Risk assessment due to increased risk for suicide and self-harm
  • Assess use of diuretics, vomiting, laxatives, diet pills, amphetamines, energy pills, diet teas

Bulimia: Diagnosis & Planning

• Nursing diagnoses similar to AN; Impaired nutritional status, risk for injury r/t cardiac output, electrolyte imbalances, and imbalanced fluid volume/ Disturbed body image, low self-esteem, difficulty coping r/t binge-purge behaviors
• Planning:
  • Patient may be treated for life-threatening complications such as gastric rupture, electrolyte imbalance, cardiac dysrhythmias

Bulimia: Implementation

• Assess mood and presence of suicidal thoughts and self-harm
• Monitor physiological parameters (VS, electrolytes) as needed
• Monitor patient’s weight as needed (at same time of day)
• Explore dysfunctional thoughts that maintain the binge-purge cycle
• Educate the patient that fasting can lead to continuation of the binge-purge cycle
• Monitor the patient during and after meals to prevent throwing away food and/or purging (continue supervision 1 to 3 hr; yes this means going with patient to restroom to avoid purging)
• Observe patient for other compensatory behaviors including excessive exercise
• Acknowledge the patient’s overvalued ideas of body shape and size without minimizing or challenging the patient’s perceptions
• Encourage the patient to keep a journal
• Pharmacological treatment: Fluoxetine (Prozac)- SSRI is FDA approved for BN

Binge-Eating Disorder

• A variant of compulsive overeating
• Recurrent episodes of eating a large amount of food in a short period of time and having feels of guilt afterward
• Pattern is similar to BN but has no compensatory behaviors (self-induced vomiting, diuretics, laxatives)
• Usually occurs with other psychiatric disorders (bipolar disorder, depression, anxiety, SUD)
  • Close association with overeating and depression (self-soothing via eating)