Mental Health Nursing: Key Concepts and Care

Mental Health as a Disease of Exclusion

• Definition: Mental health conditions are often referred to as a "disease of exclusion" because their symptoms can mimic various medical issues.

• Mimicked Conditions: These can include:

  • Cardiac issues: Heart problems.

  • Thyroid issues: Imbalances in thyroid hormones.

  • Brain problems: Such as tumors or hormone imbalances.

  • Examples:

    • Older women with low estrogen levels may experience mood changes.

    • Older individuals with Urinary Tract Infections (UTIs) can exhibit confusion or delirium.

    • Concussions: A head injury can cause confusion and other neurological symptoms, which must be ruled out before attributing symptoms to mental health.

• Clinical Approach: In mental illness, the number one priority is always to treat medical issues first and rule them out before initiating antidepressant or antipsychotic medications.

Key Terms in Mental Illness

• Psychosis:

  • Definition: A disconnection from reality, often involving hallucinations and delusions.

  • Clinical Example: "ICU psychosis" refers to psychiatric symptoms experienced by patients in intensive care units.

• Delusions:

  • Definition: False ideas or beliefs that are firmly held by an individual, despite evidence to the contrary. They are very real to the person experiencing them.

  • Common in: Schizophrenic patients often experience delusions, such as believing people are "out to get them" or their loved ones.

  • Nursing Interventions (Do's and Don'ts):

    • Don't: Argue with the patient.

    • Don't: Agree with or entertain the delusions.

    • Do: Focus on reality. For example, if a patient states there's a cat attacking them, respond with, "I only see you and I in the room."

    • Don't: Look for non-existent threats (e.g., searching for a cat) as this can elevate the patient's anxiety and mania.

    • Don't: Turn your back on a patient experiencing delusions or hallucinations.

• Hallucinations:

  • Definition: False sensory perceptions experienced without any external stimulus or basis in reality.

  • Types: Can be visual, auditory, olfactory (smell), gustatory (taste), or tactile (feel).

  • Examples:

    • Visual: Seeing things that aren't there.

    • Auditory: Hearing voices or sounds.

    • Olfactory: Smelling smoke when in a hospital setting.

    • Gustatory: Tasting something unusual.

    • Tactile: Feeling bugs crawling on one's skin (e.g., a patient picking at dandruff believing it's bugs).

  • Common in: Bipolar disorder and schizophrenia.

Causes of Mental Illness

• Medical Conditions: Cardiac issues, thyroid problems, brain tumors, hormone imbalances.

• Natural Causes:

  • High fever.

  • Genetics (e.g., autism).

  • Injury (e.g., concussion).

  • Substance abuse.

  • Poor nutrition.

  • Sleep deprivation (can lead to delirium or irritability).

  • Brain chemistry imbalances: Such as serotonin and dopamine levels being off, commonly seen in depression and anxiety.

Role of the Nurse in Mental Health

• Self-Awareness: Nurses must be aware of their personal beliefs, values, and biases.

• Non-Bias: Maintain a non-biased approach when interacting with patients.

• Managing Bias:

  • Self-Check: Reflect on personal feelings and potential judgments.

  • Masking: Adopt a professional demeanor to maintain objectivity.

  • Assignment Change: If personal bias is high (e.g., caring for a cancer patient after losing a family member to cancer), communicate with the charge nurse to consider a different patient assignment.

  • Peer Support: Seek support from colleagues if struggling, especially if a bias is realized later in a shift.

• Establishing Rapport: Crucial from the first moment of contact, as it shapes the patient's perception of the nurse for the entire shift.

• Building Trust:

  • Follow Through: Do what you say you will do (e.g., if you say you'll be back in 30 minutes, return in 30 minutes).

  • Respect: Show respect through eye contact, addressing them as "Yes, ma'am/sir,"

  • Genuineness: Be genuine in interactions.

  • Active Listening: Avoid overtalking; ask open-ended questions and wait for answers, even when busy.

  • Appropriate Positioning: Sit at eye level with the patient rather than hovering. If they are bed-bound, raise the bed to facilitate eye-level communication.

Empathy vs. Sympathy

• Empathy:

  • Definition: The ability to understand and share the feelings of another person because you've had a similar, though not necessarily identical, experience.

  • Nurse's Role: Recognize and acknowledge the patient's feelings and emotions based on a shared human experience.

• Sympathy:

  • Definition: Feeling bad or sorry for someone's situation without necessarily having experienced it yourself.

  • What Not to Say: Avoid phrases like "At least you're still alive" or trying to find a "silver lining." This often invalidates the patient's current distress.

  • Effectiveness of Words: It is rare that anything a nurse says can genuinely make someone feel better. Sometimes, silence and supportive presence are more effective.

Transference vs. Countertransference

• Transference:

  • Definition: The patient unconsciously projects feelings, emotions, and past experiences (e.g., with an overbearing parent) onto the nurse.

  • Example: A patient feeling controlled by an overbearing parent now reacts negatively to the nurse's instructions for medication, viewing the nurse as the controlling figure.

• Countertransference:

  • Definition: The nurse unconsciously projects their own beliefs, feelings, emotions, and past or current experiences onto the patient.

  • Example: A nurse whose parent was an addict and who grew up in foster care treats a patient with substance abuse disorder with the same negative emotions they have towards their parent.

• Nurse's Responsibility: Nurses must check themselves to prevent countertransference and maintain professional boundaries.

• Recognizing Potential Issues: When getting a patient report, inquire about the patient's attitude, rest, and meal intake. Also consider their admitting diagnosis (e.g., detoxing) to anticipate potential issues. If a personal history (e.g., a former high school coach as a patient) evokes strong emotions, nurses must go into "nurse mode" to provide objective care and maintain boundaries.

Therapeutic Environment: Safety and Trust

• Priority: The number one priority is always safety for both the patient and the nurse.

• Safe Environment Interventions:

  • Suicidal Patients:

    • Remove sharp objects.

    • Place them close to the nursing station.

    • Implement regular rounding.

    • One-to-one sitter.

  • Manic/Schizophrenic Patients (Combative):

    • Start with least restrictive interventions: redirection, comfort measures.

    • Pharmacological intervention: Administer prescribed medications.

    • Restraints (progress from least to most restrictive):

      • Hand mitts.

      • Soft wrist restraints.

      • Two-point restraints.

      • Locking key restraints (in psych wards).

• Approaching a Patient in Psychosis/Delusions/Hallucinations:

  • Maintain a calm demeanor.

  • Position yourself closest to the door for escape route if needed.

  • Ensure the patient sees you approach.

  • Avoid physical touch unless permission is explicitly given or it's medically necessary and safe.

  • Do not argue with the patient.

Therapeutic Communication

• Components: A combination of verbal, nonverbal, and touch.

  • Verbal: Spoken words.

  • Nonverbal: Body language, facial expressions, eye contact.

  • Touch: Only when welcomed and appropriate.

• Key Principles:

  • Presence: Sit with the patient, engaging them, even while charting (position computer so both the nurse and patient can see it, allowing for quick engagement).

  • Concreteness: Use concrete language; avoid figurative speech, slang (e.g., "FOMO"), or anything open to interpretation.

  • Welcomed Touch: Always assess if touch is welcome. For example, if a patient is crying, ask, "Is it okay if I hold your hand?"

  • Facial Expressions: Be mindful; a mask can help if your facial expressions might convey unintended judgments.

  • Body Language: Avoid closed off postures (hands on hips, arms crossed). Sit with an open posture (e.g., ankles crossed, not legs).

  • Vocal Cues: Be aware of your volume, tone, pitch, intensity, emphasis, speed, and pauses.

• Overall Goal: Make the client feel most comfortable to encourage open communication and better care.

• Nursing Process: Assess the patient, create a safe environment, use therapeutic communication, and structure the environment for the situation.

Medication Awareness and Common Medications

• Importance: Knowing what medications patients are taking and why is crucial due to potential side effects and impact on brain chemistry.

• Examples of Common Medications:

  • Beta Blockers: Used for hypertension, anxiety, and sometimes migraines.

  • Benzodiazepines (Benzos): Primary use for anxiety, but also seizure disorders.

  • Gabapentin/Lyrica: Used for nerve pain (epilepsy) and anxiety.

  • Lithium: A mood stabilizer primarily for bipolar disorder, but also used for cluster headaches.

• Clinical Application: If a patient is normally on a beta blocker for anxiety at home but isn't on it in the hospital, and their anxiety is high, the nurse should advocate for the physician to order it.

Nursing Mental Health Assessments

• Mental Status Exam (MSE): A general assessment for mental status.

• CAGE Questionnaire: An assessment tool for alcohol use disorder.

• GAD-7: A generalized anxiety disorder 7-item scale, used to screen for and measure the severity of anxiety.

General Treatments

• Treatments can include Electroconvulsive Therapy (ECT), various medical interventions, antidepressants, and psychotherapy.

Psychosis Care

• Demeanor: Maintain a positive, nonjudgmental demeanor.

• Communication: Use respectful communication, active listening, and a supportive presence.

• Goals: Build trust, reduce stigma, foster open communication, and promote emotional safety.

• Touch: Do not touch a psychotic patient without explicit permission, as they may perceive it as a threat (e.g., a "dragon attacking them").

• Reorientation: The approach to reorientation depends on the level of psychosis. Sometimes redirection is appropriate (e.g., "You're in the hospital"), but direct reorientation might not always be effective or safe.

Validating Feelings and Grounding Techniques

• Validating Feelings:

  • Use reflective listening: "It sounds like you're feeling overwhelmed right now."

  • Normalize feelings: "It's completely understandable to feel sad after what you've been through."

  • Ask open-ended questions: Encourage expression of feelings rather than suppressing them.

• Grounding Techniques (No Order Required): These can be done by a bedside nurse.

  • 5-4-3-2-1 Technique: Name 5 things you see, 4 things you feel, 3 things you hear, 2 things you smell, and 1 thing you taste.

  • Deep breathing exercises.

  • Describe the environment.

  • Counting (e.g., counting imaginary sheep).

  • Verbal support: "Let's take a moment to take a deep breath together."

• Distraction Techniques:

  • Engage in conversation (e.g., ask about breakfast, a TV show).

  • Offer a stress ball or chewing gum.

  • Puzzles, coloring (if not suicidal).

  • Go for a walk around the unit.

  • Counting patterns (e.g., counting squares on the floor).

• Trigger Identification: Assess the patient's background history to identify triggers for their symptoms. Patients can sometimes share insights, even amidst some ramblings.

• Offer Choices: Empower patients by offering choices rather than taking them away.

• Command Hallucinations (Psychosis): Crucially important to ask: "What are you hearing?" "Where do you see this person?" and "What is it telling you to do?" This helps assess risk of self-harm or harm to others.

Depression and Suicide Assessment/Prevention

• Depression Definition: Feeling sad for ext{2 weeks or greater}, accompanied by an inability to perform Activities of Daily Living (ADLs) like brushing teeth, bathing, and eating.

• Clustered Symptoms ( ext{5-6} Symptoms): Inability to feel pleasure, changes in weight/appetite, sleep disturbances, low energy, poor concentration, difficulty making decisions, low self-esteem, withdrawal from previously enjoyed activities (e.g., a runner no longer wanting to run).

• Risk: Can lead to suicidal ideation or attempts.

• Constant Assessment: Suicidal ideation is a key assessment in all mental health issues.

• Communication: Continue therapeutic communication with depressed patients.

• Detailed Suicide Assessment:

  • Ask directly: "Are you having thoughts of killing yourself in the past two weeks?"

  • Ask about a plan: "Do you have a plan to kill yourself?"

  • Behavioral Red Flags: Be aware if a previously depressed patient suddenly becomes "super happy," calling loved ones to say goodbye. This can indicate a firm decision to commit suicide and a sudden surge of energy to execute a plan.

    • Personal Example: An ex-boyfriend, previously depressed, made a last-minute call to the speaker before committing suicide, having acquired a gun after a previous attempt with Tylenol.

  • Increased Risk: Suicidal individuals may also express intentions to harm others alongside themselves.

• Priority Interventions for Actively Suicidal Patients:

  • One-to-one sitter.

  • Rounding: Every 15 minutes (for sitter), every 30 minutes (for nurse).

  • Documentation: Document the patient's exact location in the room during rounds.

  • Medication Administration: Observe patient opening their mouth and give something to eat/drink afterwards to ensure they are not "saving up pills."

  • Open Communication: Maintain open lines of communication.

  • Building Trust: Vital for patients to disclose suicidal thoughts.

• Decoding Indirect Statements: If a patient says, "I just want to leave this earth," inquire further: "Where do you want to go when we leave?" to differentiate between wanting to go home and suicidal intent.

• Nonverbal Cues: Be aware of subtle signs of suicidal intent.

• Post-Disclosure: Patients may feel relieved after discussing suicidal thoughts. Nurses should decrease isolation by maintaining presence (sitter, staff).

• Resources: Crisis hotlines and support groups.

• Sleep Patterns: Sudden significant changes in sleep (e.g., sleeping excessively) require investigation for medication seeking (if not on a psych floor) or drug use.

Antidepressants

• Tricyclic Antidepressants (TCAs) (e.g., Amitriptyline):

  • Side Effects (Anticholinergic): Dry mouth, increased risk for seizures, decreased urine output, constipation (ensure hydration).

  • Withdrawal: Missing doses can lead to withdrawal symptoms.

  • Safety: High fall risk due to orthostatic hypotension.

• Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) (e.g., Fluoxetine, Citalopram, Escitalopram, Sertraline):

  • Serious Side Effects:

    • Suicidal Risk: Increased risk, especially when beginning treatment or changing doses.

    • Sexual dysfunction.

  • Onset/Taper: Slow onset of therapeutic effects and slow taper off. Patient education is crucial to prevent abrupt discontinuation.

  • Serotonin Syndrome (Rare but Potentially Life-Threatening): Occurs due to too much serotonin in the body.

    • Symptoms: Sweating, significant fever (101^ ext{o}F - 105^ ext{o}F), irregular heartbeat, tachycardia, muscle rigidity, passing out.

    • Onset: Can occur within a few hours to days of starting medication.

    • Nursing Actions:

      • Page the doctor immediately.

      • STOP the medication.

      • Monitor vital signs (especially temperature).

      • Administer IV fluids for hydration.

      • Consider muscle relaxants (e.g., dantrolene).

      • DO NOT give Tylenol as the fever is from muscle activity and central changes, not typical infection.

      • Provide supportive care.

• Monoamine Oxidase Inhibitors (MAOIs):

  • Risk: Rarely prescribed due to a very narrow therapeutic window; small variations can lead to massive hypertension (hypertensive crisis) or serotonin syndrome.

  • Food Interactions: Avoid fermented foods, which contain tyramine:

    • Beer, wine.

    • Yogurt, sauerkraut, pickles, kefir, sourdough bread.

  • Medication Interactions:

    • Do NOT give with other antidepressants.

    • Avoid over-the-counter NSAIDs, antacids, and calcium.

    • If taking antacids, take them ext{2 hours} before MAOIs.

  • Suicide Risk: Increased risk of suicide, as increased energy from medication may empower a patient to act on a pre-existing plan.

Electroconvulsive Therapy (ECT)

• Procedure: Tiny electrodes apply an electrical current to the patient's brain, inducing a controlled seizure (30 ext{ seconds} - 1 ext{ minute}) while the patient is under general anesthesia.

• Indications:

  • Severe major depression.

  • Bipolar disorder.

  • Can be effective for catatonic patients.

Bipolar Disorder

• Characterized by: Severe, extreme highs (mania) and extreme lows (depression), with constant cycling between these states.

• Bipolar I (Focus): Defined by at least one manic episode.

• Depressive State: Sadness, fatigue, hopelessness (usually follows mania).

• Manic State (High Energy):

  • Increased: Agitation, euphoria, rapid thought patterns, promiscuity, impulsivity.

  • Decreased: Attention span, awareness of illness.

  • Behaviors: Too busy to eat or sleep, engaging in grand (and often unrealistic) ideas, clearing savings, quitting jobs, rapid changes (e.g., discarding all belongings to buy new ones).

• Medical Emergency Risk: Due to:

  • Potential for harm to self or others.

  • Severe sleep deprivation.

  • Dehydration (due to not eating/drinking).

  • Progression to suicidal ideation during depressive phases.

• Nursing Focus and Interventions:

  • Medication Adherence: Ensuring patients take their prescribed medications.

  • Room Safety: Providing a safe, private environment (e.g., a single room, removing potential hazards).

  • Hydration and Nutrition: Monitoring and ensuring adequate intake.

  • Calm Environment: Maintaining a low-stimulus, quiet atmosphere.

  • Realistic Goals: Setting achievable behavioral goals (e.g., brush teeth for 60 seconds).

  • Sleep Promotion: Encouraging naps (e.g., "Let's turn off the lights for 30 minutes").

  • Frustration Monitoring: Watch for signs of increasing frustration.

• Treatment:

  • Medical stabilization.

  • Transcranial Magnetic Stimulation (TMS) for depression.

  • ECT.

  • Psychotherapy: Helps identify patterns, cope, problem-solve, and understand the connection between feelings, thoughts, and actions.

  • Medication.

Schizophrenia

• Presentation (Alice in Wonderland Analogy): Seeing shape-shifting landscapes, talking animals, being disconnected from reality.

• Symptoms:

  • Often overlaps with psychosis (hallucinations, delusions).

  • Positive Symptoms: Disorganized thoughts and behavior (e.g., randomly all over the place).

  • Negative Symptoms: Lessened emotion, catatonic-like behavior.

• Diagnosis: Requires at least 2 of these symptoms for ext{6 months}, or 1 symptom for the first ext{3 months} (nurses observe and report findings to aid diagnosis).

• Differentiation from Psychosis: While psychosis shares hallucinations and delusions, schizophrenia specifically includes disorganized thoughts/behavior and flattened affect. Psychosis can be transient due to sleep deprivation, substance abuse, or other conditions.

• Nursing Assessment and Treatment:

  • Assess for positive and negative symptoms (delusions, hallucinations, disorganized behavior).

  • Interview family to determine symptom duration.

  • Observe for pacing, rocking, or abnormal eye movements.

  • Referral to group therapy, behavioral therapy, and community support.

Mood Stabilizers

• Uses: Bipolar disorder and schizophrenia.

• Lithium (Common Example):

  • Therapeutic Range: Narrow therapeutic range; toxicity occurs above 1.5 mEq/L.

  • Fluid & Salt Balance: Teach patients to increase fluids and salt intake to prevent dehydration and hyponatremia; avoid dehydration.

  • Avoid: Diuretics, caffeine (dehydrating).

  • NSAID Interaction: Hold NSAIDs as they interact negatively with lithium.

  • Environment: Ensure adequate hydration, especially in hot climates or during exercise.

• Alternatives (if lithium not tolerated):

  • Valproic acid (Divalproex).

  • Carbamazepine (Tegretol).

Antipsychotics

• Types: Typical (first-generation) and Atypical (second-generation).

• Uses: Bipolar disorder and schizophrenia.

• Neuroleptic Malignant Syndrome (NMS): Rare but life-threatening complication of antipsychotic use (both typical and atypical).

  • Symptoms: High fever, severe muscle rigidity, blood pressure changes, difficulty swallowing (dysphagia).

  • Interventions:

    • Discontinue medication immediately.

    • Administer dantrolene (a muscle relaxant).

    • Cooling measures (ice packs, cooling blankets) – Tylenol is ineffective for this fever.

    • Monitor for elevated White Blood Cell (WBC) count and Creatinine Kinase (CK) levels.

    • Intubation may be required for severe dysphagia.