Exhaustive Psychiatric-Mental Health Nursing Study Guide

Foundations of Mental Health and Historical Perspectives

• WHO Definition of Health: A state of complete physical, mental, and social well-being, not merely the absence of disease.
• Physical and Mental Health Relationship: These states are interconnected; mental illness can exacerbate physical conditions, and physical illness can negatively impact mental health.
• Mental Health Definition: A state of emotional, psychological, and social well-being that enables individuals to cope with stress, function effectively, and contribute to society.
• Attributes of Mental Health:   - Positive self-esteem   - Emotional regulation   - Ability to form relationships   - Productivity   - Adaptability   - Reality-based thinking   - Resilience
• Mental Illness Definition: A clinically significant disturbance in cognition, emotional regulation, or behavior that results in distress or impaired functioning.
• Mental Health Continuum: A range extending from optimal mental health to mental illness.   - Mental Health End: Characterized by coping, productivity, and fulfillment.   - Mental Illness End: Characterized by distress, impaired functioning, and symptoms.
• Resilience: The capacity to adapt and recover from stress, adversity, or trauma.
• Stigma: Negative attitudes, beliefs, and discrimination directed toward individuals with mental illness.
• Historical Views of Mental Illness:   - Ancient: Attributed to supernatural causes, with exorcism as a primary treatment.   - Middle Ages: Viewed as punishment, leading to confinement in asylums.   - $1800s$: Introduction of moral treatment pioneered by Dorothea Dix.   - Modern: Focused on the biopsychosocial model and a recovery-oriented approach.
• Diathesis-Stress Model: Proposes that mental illness results from a combination of genetic vulnerability (diathesis) and environmental stressors.
• Recovery: A personal process involving living a meaningful life despite the presence of mental illness.

National Initiatives and Legal Framework in Mental Health

• Decade of the Brain: A $1990s$ initiative aimed at advancing the understanding of brain structure, function, and disorders.
• Human Genome Project: Mapped all human genes with the goal of identifying genetic links to diseases, including mental illness.
• QSEN Principles:   - Patient-centered care   - Teamwork and collaboration   - Evidence-based practice   - Quality improvement   - Safety   - Informatics
• Mental Health Parity Act ($1996$): Required health insurance plans to provide equal lifetime and annual limits for mental and physical health coverage.
• Wellstone-Domenici Parity Act ($2008$): Expanded parity requirements to include copays, deductibles, and treatment limits.
• Affordable Care Act (ACA):   - Classified mental health as an essential health benefit.   - Expanded coverage and enforced parity.
• Inpatient and Outpatient Prevention Levels:   - Primary: Focuses on education.   - Secondary: Focuses on screening.   - Tertiary: Focuses on rehabilitation.

Epidemiology and Nursing Roles in Mental Health

• Epidemiology: The study of disease distribution.   - Leading cause of disability worldwide: Depression.   - Comorbidity: The presence of two or more disorders (e.g., Depression + substance use disorder).   - Incidence: Refers to new cases.   - Prevalence: Refers to total cases.
• Clinical Epidemiology: The study of treatment effectiveness and outcomes.
• Classification Systems:   - DSM-$5$-TR: Dominant system in the US.   - ICD-$10$: International classification system.
• Psychiatric-Mental Health Nursing: A specialty focused on promotion, prevention, and treatment of mental health conditions.
• Phenomena of Concern: Include thoughts, emotions, behaviors, coping, relationships, stress responses, and symptoms of mental illness.
• Education Levels and Roles:   - ADN/BSN: Responsible for assessment, medication administration, and maintaining the milieu.   - MSN/PMHNP: Qualified for therapy, diagnosis, and prescribing.   - Doctorate: Focused on leadership and research.
• Cultural Competence: The ability to provide care that respects cultural beliefs, values, and practices.

Psychological Theories and Developmental Models

• Sigmund Freud (Psychoanalytic): Focuses on levels of awareness and personality systems.   - Levels of Awareness:     - Conscious: Current awareness.     - Preconscious: Easily recalled material.     - Unconscious: Repressed thoughts.   - Personality Systems:     - Id: Governed by the pleasure principle.     - Ego: Governed by the reality principle.     - Superego: Governed by the moral conscience.   - Ego Defenses: Unconscious, reality-distorting mechanisms developed to manage anxiety (e.g., denial, projection).
• Freud Psychosexual Stages:   - Oral: Satisfaction via mouth; task is weaning; outcome is trust.   - Anal: Satisfaction via bowel; task is control; outcome is autonomy.   - Phallic: Satisfaction via genitals; task is identity; outcome is gender role.   - Latent: Satisfaction via social skills; task is competence; outcome is skills.   - Genital: Satisfaction via sexual intimacy; task is relationships; outcome is connection.
• Psychoanalysis Concepts:   - Transference: Patient redirecting feelings for others onto the therapist.   - Resistance: Patient blocking the therapeutic process.   - Inpatient Application: Psychoanalysis is rare today due to being time-intensive.
• Harry Stack Sullivan (Interpersonal Theory): Emphasizes that the goal of interpersonal therapy is to improve relationships and communication; highly effective for depression and grief.
• Hildegard Peplau: Defined the nurse-patient relationship and defined specific nursing roles.
• Behavioral Theorists:   - Pavlov: Classical conditioning (stimulus-response).   - Skinner: Operant conditioning (behavior-consequence via reinforcement).   - Watson: Radical behaviorism.
• Abbreviated Behavioral Definitions:   - Positive Reinforcement: Adding a stimulus to strengthen behavior.   - Negative Reinforcement: Removing a stimulus to strengthen behavior.   - Extinction: Behavior fades without reinforcement.
• Cognitive Theories:   - Rational-Emotive Therapy (Ellis): Challenging irrational beliefs.   - Cognitive Behavioral Therapy (Beck): Identifying automatic thoughts and cognitive distortions (e.g., all-or-nothing thinking, catastrophizing).
• Maslow’s Hierarchy of Needs: Physiological → Safety → Love → Esteem → Self-actualization.
• Erikson’s Stages of Development:   - $1$. Trust vs Mistrust   - $2$. Autonomy vs Shame   - $3$. Initiative vs Guilt   - $4$. Industry vs Inferiority   - $5$. Identity vs Role Confusion   - $6$. Intimacy vs Isolation   - $7$. Generativity vs Stagnation   - $8$. Integrity vs Despair

Ethics and Legal Rights in Psychiatric Nursing

• Ethical Principles:   - Autonomy: Respecting the patient's right to make decisions.   - Beneficence: Acting in the patient's best interest.   - Nonmaleficence: Avoiding harm.   - Justice: Fairness in care distribution.   - Fidelity: Keeping promises.   - Veracity: Telling the truth.
• Commitment Types:   - Voluntary: Patient consents to admission.   - Involuntary: Requires danger to self/others or grave disability.   - Writ of Habeas Corpus: Legal challenge for patients held without cause.   - Emergency Commitment: Short-term involuntary hold for immediate safety.
• Torts:   - Intentional: Assault, battery, false imprisonment.   - Unintentional: Negligence, malpractice.
• Documentation Requirements: Must be objective, timely, accurate, nonjudgmental, and remains a legal record.

The Anxiety Continuum and Defense Mechanisms

• Anxiety Definition: A vague feeling of uneasiness, worry, or fear occurring in response to a perceived threat, involving physical and emotional symptoms.
• Levels of Anxiety:   - Mild: Perceptual field is wide; patient is alert and attentive; improves performance and productivity.   - Moderate: Perceptual field narrows; difficulty concentrating occurs; increased heart rate and sweating.   - Severe: Perceptual field is very narrow; impaired thinking; physical symptoms include headache, nausea, and dizziness.   - Panic: Perceptual field is extremely limited; terror and distorted perceptions occur; functioning is impossible; physical symptoms include palpitations and chest pain.
• Select Defense Mechanisms:   - Altruism: Helping others to relieve personal stress.   - Compensation: Emphasizing strengths to hide weaknesses.   - Conversion: Emotional conflict manifesting as physical symptoms (e.g., paralysis with no medical cause).   - Displacement: Shifting feelings to a safer target (e.g., yelling at family instead of a boss).   - Projection: Attributing one's own feelings to someone else.   - Reaction Formation: Acting the opposite of true feelings.   - Regression: Reverting to earlier developmental behaviors (e.g., adult temper tantrums).   - Splitting: Viewing people or situations as all good or all bad.   - Sublimation: Redirecting unacceptable impulses into acceptable actions (e.g., exercising when angry).   - Suppression: Consciously pushing thoughts aside.

Anxiety-Related and Obsessive-Compulsive Disorders

• Specific Anxiety Disorders:   - Separation Anxiety: Fear of separation from attachment figures.   - Social Anxiety: Fear of judgment in social settings; commonly starts in adolescence.   - Panic Disorder: Recurrent panic attacks with persistent worry lasting at least $1\,month$ after an attack.   - Agoraphobia: Fear of situations where escape is difficult.   - Generalized Anxiety Disorder (GAD): Excessive worry for most days over at least $6\,months$.
• Obsessive-Compulsive Disorder (OCD):   - Obsessions: Intrusive, unwanted thoughts.   - Compulsions: Repetitive behaviors performed to reduce anxiety.   - Time Requirement: Behaviors usually consume more than $1\,hour/day$.
• OCD-Related Disorders:   - Body Dysmorphic Disorder: Obsession with perceived body flaws.   - Hoarding Disorder: Persistent difficulty discarding items.   - Trichotillomania: Hair pulling disorder.   - Excoriation: Skin picking disorder.

Pharmacological and Nursing Interventions for Anxiety

• Nursing Interventions for Severe to Panic Anxiety:   - Maintain a calm manner; remain with the patient.   - Minimize environmental stimuli.   - Use simple statements and speak slowly.   - Reinforce reality and attend to safety needs.   - Assess for suicidal ideation, as severe anxiety increases hopelessness.
• Medication Classes for Anxiety:   - SSRIs (Sertraline, Paroxetine, Fluoxetine): First-line treatment; takes weeks for effect; monitor for suicidal ideation.   - SNRIs (Venlafaxine, Duloxetine): Used for GAD; monitor blood pressure.   - Benzodiazepines (Lorazepam, Diazepam, Alprazolam): Used for acute anxiety/panic; high risk of dependence and sedation.   - Buspirone: Non-sedating; takes $2-4\,weeks$ for effect.
• Antianxiety Drug Teaching:   - Do not change dosage or stop medication abruptly.   - Avoid alcohol, caffeine, and other sedatives.   - Benzodiazepine withdrawal symptoms include anxiety, insomnia, tremors, and seizures.

Trauma, Stressor-Related, and Dissociative Disorders

• Trauma-Informed Care: Recognizes the impact of trauma (including ACEs - Adverse Childhood Experiences) and focuses on safety and empowerment.
• PTSD (Posttraumatic Stress Disorder):   - Symptoms: Re-experiencing (flashbacks, nightmares), Avoidance, Increased arousal (hypervigilance), Mood alterations (guilt, detachment).
• Acute Stress Disorder: Occurs within $3\,days$ to $1\,month$ after trauma; requires $9$ or more symptoms (numbing, derealization, etc.).
• Adjustment Disorder: Stress response following a life event; occurs within $3-6\,months$.
• Dissociative Disorders:   - Dissociative Amnesia: Inability to recall personal info; may involve "Fugue" (sudden travel away from home).   - Depersonalization/Derealization: Feeling detached from self or surroundings.   - Dissociative Identity Disorder (DID): Characterized by two or more distinct personality states; first priority is ensuring patient safety.
• Grounding Techniques: Used to reduce dissociation (e.g., naming objects in the room, holding a cold object).

Somatic Symptom and Factitious Disorders

• Somatic Symptom Disorder: Distressing physical symptoms with excessive thoughts/behaviors; symptoms persist typically >6\,months.
• Illness Anxiety Disorder: Preoccupation with having a serious illness despite minimal or absent symptoms.
• Conversion Disorder: Neurological symptoms (paralysis, blindness) without medical explanation; often involves "la belle indifference" (lack of concern).
• Factitious Disorder: Intentional fabrication of symptoms to assume the "sick role" (internal motivation). If imposed on another, it is "Imposed on Another."
• Malingering: Intentional production of symptoms for external gain (money, avoiding jail).

Eating and Feeding Disorders

• Anorexia Nervosa: Characterized by energy restriction and intense fear of weight gain.   - Severity by BMI: Mild ($\ge 17$), Moderate ($16-16.99$), Severe ($15-15.99$), Extreme (< 15).   - Refeeding Syndrome: Dangerous metabolic complication involving electrolyte shifts (hypophosphatemia, hypokalemia) when nutrition is reintroduced too rapidly.
• Bulimia Nervosa: Binge eating followed by compensatory behaviors (vomiting, laxatives, exercise).   - Signs: Parotid swelling, dental caries, Russell sign (calluses on hands).   - Medication: Fluoxetine is the only FDA-approved drug.
• Binge-Eating Disorder: Bingeing without purging. Treatment may include Lisdexamfetamine (Vyvanse).
• Feeding Disorders:   - Pica: Eating non-nutritive substances.   - Rumination: Repeated regurgitation.   - ARFID: Avoidance of food without body image distortion.

Schizophrenia Spectrum and Psychotic Disorders

• Diagnosis: Requires $2$ or more symptoms for at least $1\,month$ (delusions, hallucinations, disorganized speech, etc.) with signs for $6\,months$.
• Symptom Categories:   - Positive: Hallucinations (most common: auditory), Delusions (grandiose, persecutory), Clang association (rhyming), Neologisms (made-up words), Echolalia (repeating words).   - Negative: Anhedonia (no pleasure), Avolition (no motivation), Alogia (poverty of speech), Flat affect.   - Cognitive: Concrete thinking, anosognosia (lack of insight).
• Antipsychotics:   - $1st$ Generation (Typical): e.g., Haloperidol; high risk for EPS (Acute dystonia, Akathisia, Parkinsonism, Tardive dyskinesia).   - $2nd$ Generation (Atypical): e.g., Clozapine, Risperidone; lower EPS, higher metabolic risk.   - Neuroleptic Malignant Syndrome (NMS): Life-threatening; symptoms include high fever, muscle rigidity, and autonomic instability.

Mood Disorders: Bipolar and Depression

• Bipolar I: At least $1$ manic episode.
• Bipolar II: Hypomania plus major depression; no full mania.
• Cyclothymic: Chronic hypomania and mild depression for $\ge 2\,years$.
• Lithium: Used for mania. Therapeutic range (acute): $0.8-1.2\,mEq/L$. Toxicity signs: vomiting, diarrhea, tremors.
• Major Depressive Disorder (MDD): $5$ or more symptoms for $2\,weeks$, including depressed mood or anhedonia.
• Serotonin Syndrome: Emergency caused by excess serotonin; symptoms include agitation, hyperthermia, and tremors.
• MAOI Precautions: Avoid tyramine-rich foods (aged cheese, wine) to prevent hypertensive crisis.

Suicide Prevention and Non-Suicidal Self-Injury

• Lethality Assessment: Firearms, hanging, and jumping are high lethality; superficial cutting and low-dose overdose are low lethality.
• Suicide Precautions: Include $1:1$ observation, removal of harmful objects, and frequent documentation.
• Non-suicidal Self-Injury (NSSI): Self-harm without intent to die; often used to cope with emotional pain.

Sexual Dysfunctions, Gender Dysphoria, and Paraphilic Disorders

• Sexual Dysfunctions: Includes Erectile disorder, Female orgasmic disorder, and premature ejaculation. Many meds (SSRIs, Propranolol) can cause dysfunction.
• Gender Dysphoria: Distress due to mismatch between assigned sex and gender identity.
• Paraphilic Disorders:   - Exhibitionistic: Genital exposure.   - Voyeuristic: Secretly observing others.   - Pedophilic: Sexual interest in children (poses greatest risk to others).

Impulse Control and Substance Use Disorders

• Impulse Control:   - Oppositional Defiant Disorder (ODD): Argumentative, defiant.   - Conduct Disorder: Violation of others' rights (e.g., cruelty to animals).   - Intermittent Explosive Disorder (IED): Aggressive outbursts with remorse.
• Substance Use:   - Opioid Overdose: Pinpoint pupils, slow respirations; treat with Naloxone.   - Alcohol Withdrawal: Risk for Delirium Tremens (DTs) which is a medical emergency.   - Medications: Methadone/Buprenorphine for opioid maintenance; Benzodiazepines for alcohol withdrawal.

Neurocognitive Disorders: Delirium and Dementia

• Delirium: Acute, sudden onset; reversible; perceptual disturbances (illusions: rope = snake; hallucinations: seeing bugs).
• Dementia/Alzheimer’s: Gradual, progressive, irreversible decline.   - Terms: Aphasia (speech loss), Apraxia (movement loss), Agnosia (recognition loss), Confabulation (filling gaps).
• Assessment: Delirium is a medical emergency.

Personality Disorders and Management

• Cluster A (Odd/Eccentric): Paranoid, Schizoid, Schizotypal.
• Cluster B (Dramatic/Erratic):   - Borderline: Emotional lability, splitting (all good/bad), self-harm, fear of abandonment.   - Antisocial: No empathy, manipulative, criminal behavior.   - Narcissistic: Grandiosity.
• Cluster C (Anxious): Avoidant, Dependent, OCPD.

Anger, Aggression, and Violence Management

• Predictors of Violence: History of violence is the single best predictor.
• De-escalation: Use calm voice, maintain safety, describe requirements, avoid arguing.
• Seclusion and Restraint: Used as a last resort for imminent risk of harm; requires a provider order and continuous or $15-minute$ observation.

Family Violence and Sexual Assault Response

• Cycle of Violence: Tension-building → Acute battering → Honeymoon.
• Abuse Indicators: Injuries in various stages of healing, malnutrition, fearfulness.
• Sexual Assault Drugs: GHB (CNS depressant), Rohypnol (Benzodiazepine), Ketamine (Dissociative).
• SANE: Sexual Assault Nurse Examiner specially trained for forensic exams.
• Reporting: Mandatory reporting laws apply to children and vulnerable adults.

End-of-Life Care, Grief, and Loss

• Hospice vs Palliative Care: Hospice is for terminal illness ($\sim 6\,months$ or less); Palliative is for any stage of serious illness.
• Kubler-Ross Stages: Denial → Anger → Bargaining → Depression → Acceptance.
• Advance Directives: Includes Living Wills and Durable Power of Attorney.
• Approaching Death: Symptoms include Cheyne-Stokes respirations and skin mottling.

Geriatric Psychiatry and Aging Concerns

• Age Groups: Young-old ($65-74$), Old-old ($85-99$), Centenarians ($100+$).
• Polypharmacy: Use of $\ge 5$ medications; increases risk of falls and drug interactions.
• PAINAD: Assessment tool for pain in advanced dementia.
• Depression: Often underdiagnosed in elders; may present as somatic complaints.