Module 3 and 4 continue

Exam Review and Study Guidelines

• Review Blueprint and Materials: The instructor will provide a blueprint to help students prepare for the exam.

• Review Video: A 45-minute review video will be released where the instructor discusses the finer points of the blueprint.     * Timing: This video is released after the class on Thursday (or earlier if an archival video matches the content) to ensure it aligns perfectly with the final version of the exam.

• Study Habits and Expectations: Students are strongly warned against skipping study time for the first exam.     * While the exam does not require a "training montage," it is not an exam students can pass without reviewing the presentations and notes.     * Many students mistakenly believe they do not need to study for the first exam and later admit this error during post-exam meetings.

The Clinical Philosophy of Restraint and Seclusion

• Definition of a Restraint: If a patient cannot release themselves from a situation or device (e.g., being pushed up against a table so they are too weak to move, or locking a door from the outside) and the action is taken to limit movement or stop actions, it is legally defined as a restraint.

• Ethical Stance: Restraints are viewed as a "barbaric way of treating someone." They are traumatizing for both the patient and the staff involved.

• Priorities for Use: Restraints should only be used to stop a patient from hurting themselves or others. They are never to be used for:     * Establishing control.     * Asserting authority.     * Punishment.

• Risks associated with Restraint and Seclusion:     * This procedure has the highest rate of staff injury, patient injury, and patient death in the psychiatric field.     * Causes of death in restraints include asphyxiation due to restricted circulation/breathing or Myocardial Infarction (MI) due to the physical struggle.     * Legal cases often focus on whether the restraint was necessary, what other methods were tried first (talking the patient down, etc.), and the specific events leading to the decision.

Procedures and Best Practices for Physical Intervention

• Hierarchy of Restriction (Least to Most):     * Level 1 (Least Restrictive): Seclusion (placing a patient in a locked or padded room alone).     * Level 2: Physical Restraint OR Chemical Restraint (medication).     * Level 3 (Most Restrictive): Physical AND Chemical Restraints combined. This level is the most dangerous due to the combination of physiological stress and respiratory-slowing medications.

• Team Protocol: A nurse should NEVER attempt a physical hold alone. Always call security or follow hospital safety protocols to ensure a team assists.     * Intervening alone leads to injury.     * It is a medical procedure, not a "show of force" or a wrestling match.

• Physical Application (Ipsilateral Method):     * Restraints should be applied in an ipsilateral pattern: Left, Right, Left, Right.     * Applying restraints to one side of the body entirely first allows the patient to use the other side to flip themselves over. A restraint bed weighs approximately $115\,lbs$, and if flipped, it can cause the patient to asphyxiate.

• Monitoring Requirements:     * Patients in seclusion may be monitored by camera but must be checked consistently.     * Patients in physical restraints MUST have direct, one-to-one (1:1) observation by a staff member placed in the room or at the doorway, not just via camera.

• Special Considerations:     * Spit Guards: Face shields or spit guards can be used, but nothing should ever be placed directly over a patient's mouth or nose, as it restricts airflow, especially when the patient is tachypneic from struggling.     * Gradual Release: Restraints should be removed as soon as it is safe, often starting with one limb (e.g., a leg) to test if the patient can maintain safety.

Legal Regulations and Time Limits for Restraints

• Nurse Initiation: A nurse can initiate a restraint without a prior order in an emergency situation where a patient is "wilding out" or a danger to others.

• Physician/NP Involvement:     * The on-call physician or psychiatrist must be notified as soon as possible (ideally within one hour of initiation).     * The psychiatrist must conduct a face-to-face medical assessment within one hour to verify the order and ensure the patient is safely positioned.     * In some standalone facilities (like Shreveport), a Qualified Medical Professional (QMP) nurse may verify the order if a psychiatrist is not on-site $24/7$.

• Renewal Timeframes (Adults, 18+ years):     * An order lasts for $4\,hours$.     * It can be renewed once for another $4\,hours$ (total of $8\,hours$) via phone/digital communication.     * After $8\,hours$, the psychiatrist must return for a new face-to-face medical assessment before a new order can be written.

• Renewal Timeframes (Adolescents, 9-17 years):     * Orders last for $2\,hours$.     * Can be renewed once for a total of $4\,hours$ before a new face-to-face assessment is required.

• Renewal Timeframes (Children, under 9 years):     * Orders last for $1\,hour$.     * Can be renewed once for a total of $2\,hours$.     * Burrito Restraint: Children are often placed in a "burrito" style wrap/sleeping bag rather than a five-point mechanical restraint.

• PRN Orders: There is no such thing as a PRN (as needed) restraint order. Every instance requires a specific time-limited order.

Patient Rights, Ethics, and Advocacy

• Refusal of Medication: Patients often refuse medications like Haldol ($HALOPERIDOL$) because the side effects (extrapyramidal symptoms) are severe and uncomfortable. Nurses should listen to these concerns rather than bullying the patient into compliance.

• Advance Directives: Students are encouraged to create a will and advance directives (including psychiatric advance directives) when they get their first job. These allow patients to state their treatment wishes (e.g., "I do not want to be tranquilized") before a crisis occurs.

• Confidentiality and Employment:     * It is illegal for an employer to ask for a history of psychiatric care.     * Insurance companies cannot share specific medical diagnoses or treatment details with an employer.     * Hospitalization can be expensive (e.g., up to $47,000); using insurance is advised despite privacy fears.

• Legal Pleas:     * Insanity Plea: Used in only $0.2\%$ to $0.02\%$ of cases; succeeds only $2\%$ of the time. Running away from a crime scene usually proves the perpetrator knew what they were doing was wrong.     * Guilty but Mentally Ill: A newer judgment where the person is held responsible but receives specialized treatment or probation instead of standard prison.

Therapeutic Modalities and Environments

• Therapeutic Milieu: The "vibe" or environment of the unit. It includes the rules, norms, schedules, staff interactions, and conduct.     * Civility: Staff must model good behavior. If nurses argue or display incivility at the station, patients will not respect the rules of the unit.     * Not a Utopia: The unit should not be perfectly silent or devoid of conflict, as patients need to practice coping with the stressors they will face in the real world.

• Group Therapy: Usually led by nurses (ideal) or techs. A patient's role in their family (primary group) often transfers to their role in therapy groups.

• Specific Therapies:     * Electroconvulsive Therapy (ECT): A powerful treatment often used for severe depression.     * EMDR (Eye Movement Desensitization and Reprocessing): A trauma therapy where patients follow a light or movement with their eyes (peripheral vision) while processing trauma. The theory is that lateral eye movement mimics the threat-scanning state (fight or flight), making trauma more accessible for processing.     * Complementary and Alternative Medicine (CAM): Includes herbal supplements. Nurses must watch for supplements starting with "G" (Ginkgo, Ginseng, Garlic) as they can thin the blood.

Foundations of Psychopharmacology and Neurotransmitters

• Definition: Psychoactive medications alter the way a person thinks, acts, or feels. To be effective, there must be a noticeable change.

• Addiction and Debt: Meds that provide instant relief for bad feelings incur a physiological "debt" that the body eventually pays in the form of addiction or withdrawal.

• Key Neurotransmitters:     1. Dopamine ($D$): Excitatory. Involved in reward, addiction, and movement. Associated with Schizophrenia (excess) and Parkinson's (deficiency).     2. Norepinephrine ($NE$): Excitatory. Also called noradrenaline. Involved in the "fight or flight" response and depression (low levels).     3. Serotonin ($5-HT$): Generally excitatory but acts as a mood leveler/stabilizer. Low levels are associated with depression and suicidality.     4. Acetlycholine ($ACh$): Can be excitatory or inhibitory. Involved in memory, learning, Alzheimer's, and ADHD.     5. Glutamate: The most common excitatory neurotransmitter. Involved in Alzheimer's and mania. Autopsies of manic patients show glutamate levels $40$ to $100$ times higher than normal.     6. GABA ($\gamma-aminobutyric acid$): The most common inhibitory (relaxing) neurotransmitter. Involved in anxiety, sleep, and withdrawal. The instructor uses the mnemonic "GABA reads a bedtime story" to remember its calming effect.