Exam 1 Mental Health

DSM IV-TR Identify the five Axis of the DSM

* "Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision" * Offers standard criteria for the classification of mental disorders * Must meet the criteria to give the diagnosis * Focuses on clinical research and educational purposes * Started in 1880, 7 categories Axis I: ALL of the clinical disorders, disorders found in infancy and childhood: depression, bipolar, substance abuse issue (cannabis, cigarettes, caffeine, cocaine), sexual perversion (frauderism-person is in crowded place and begins to fondle somebody victim often freezes, necrophilia), dementia, eating disorders, anxiety disorders, sleep disorders, impulse disorders, and many more. Axis II: Personality disorders and mental retardation: disorders are persavive, cause difficulty in life Axis III: Medical disorders that relate somehow to the clinical disorder in axis I. Examples; diabetes (affects body image etc), Chrone's disease (limitng her to go out because she cant get to a bathroom soon enough) Axis IV: Psychosocial and environmental stressors. Ex: Single mom of 3 kids with no child support going to court has to take time off work. Finances, single parenting, always put mild, moderate or severe. Axis V: Global assessment functioning scale: 1-10 the person is in persistent danger to harm themselves, inability to maintain personal hygiene, or a suicidal attempt that could've affected them. 11-20 some danger. 21-30 behavior is considerably impaired by delusions, inability to function. 31-40 some impairment in communication, major impairment in work school mood. 41-50 severe suicidial idealation, non functioning. 50-60 moderate symptoms falt affect, circumstantial speak, occasional panic attack, some dysfunction. 61-70: some depressed mood, generally functioning pretty well, has some meaningful relationships. 71-80: if symptoms are present they're transient, normal reactions to what's going on I ntheir life, no mre than a little impairment to social and occupational, 81-90: absent or minimal symptoms, mild anxiety before exam, good functioning in almost areas, socially affective, genrally satisfied with life, 91-100: superior functioning in a wide range in acitivities, no symptoms. Identify the five Axis of the DSM - on EXAM * Axis I: principal disorder that needs immediate attention; e.g., a major depressive episode, an exacerbation of schizophrenia, or a flare-up of panic disorder. It is usually (though not always) the disorder that brings the person "through the office door." * All mental health disorders that are the focus of treatment * Pretty much everything (e.g. caffeine abuse, eating disorders, childhood disorders, learning disabilities, drug abuse/dependence, frotteurism, depressive disorders, mood disorders, sexual disorders.) * Axis II: personality disorder that may be shaping the current response to the Axis I problem. Axis II also indicates any developmental disorders, such as mental retardation or a learning disability, which may be predisposing the person to the Axis I problem. For example, someone with severe mental retardation or a paranoid personality disorder may be more likely to be "bowled over" by a major life stressor, and succumb to a major depressive episode. * Personality disorders and mental retardation * Axis III: any medical or neurological problems that may be relevant to the individual's current or past psychiatric problems; for example, someone with severe asthma may experience respiratory symptoms that are easily confused with a panic attack, or indeed, which may precipitate a panic attack. * Medical conditions that are relevant to psychiatric pathology * Example: 16 year old girl who comes in for depression and has diabetes * Weight gain from depression * Think about: Stress, Diet, Social Seclusion, body image * Axis IV: the major psychosocial stressors the individual has faced recently; e.g., recent divorce, death of spouse, job loss, etc. * Environmental stressor * must say mild, moderate or severe * Poverty, abuse * Axis V: the "level of function" the individual has attained at the time of assessment, and, in some cases, is used to indicate the highest level of function in the past year. This is coded on a 0-100 scale, with 100 being nearly "perfect" functioning * GAF: global assessment function scale * 0 have no information * 1-10: suicidal, poor coping skills, lowest level of functioning * If under 50, they will probably be inpatient * Try to give them a higher level of care * 75-85 good coping skills * 90-100: best coping skills, people may come to them for advice * 100: dalai lama (buddhist)

Nursing process

* Nursing Process * Assessment * Construct database * Mental status examination * Psychosocial assessment * Physical exam * History taking * Interviews * Standardized rating scales * Verify the data * Diagnosis * Identify problem and etiology * Construct nursing diagnoses and problem list * Prioritize nursing diagnoses * Outcomes Identification * Identify attainable and culturally expected outcomes * Document expected outcomes as measurable goals * Include time estimate for expected outcomes. * Planning * Identify safe, pertinent, evidence-based actions * Strive to use interventions that are culturally relevant and compatible with health beliefs and practices * Document plan using recognized terminology. * Implementation * Basic level and Advanced Practice Interventions * Coordination of care * Health teaching and health promotion * Milieu therapy * Pharmacological, biological, and integrative therapies * Advanced Practice interventions: * Prescriptive authority and treatment * Psychotherapy * Consultation * Evaluation Document results of evaluation If outcomes have not been achieved at desired level: Additional data gathering Reassessment Revision of pain The nursing process: 1. Assessment: interviewing the pt & family, family history, overall appearance (disheveled, inappropriate clothes for weather, how women apply their makeup (may chart very bright makeup-may indicate thought process), watching how family and pt interact, a lot of observing non verbals. Consult other team members. Reviewing their records. Physical exam-always want to rule out any physical issues. a. Members of the psychiatric team i. Psychiatrist-diagnose, prescribe meds, admitting process (only a psychiatrist can admit), can do therapy but usually don't ii. Psychologist-diagnose, treatment, can NOT prescribe, psych testing (only a psychologist can do psych testing), thearpy iii. Advanced Practice Nurse (APN): diagnose, treatment, prescribe meds, group therapy. APN can give therapy and meds all at one time iv. Case manager: TEST QUESTION: looking at quality and cost. Patient x has been here for 2 weeks with no imprpovement lets look at meds. They talk to insurance companies to ask for days etc. Trying to figure out affordable care act. v. Occupational therapy: Help with ADLs, help with getting a person back to being ready to work vi. Rec therapist: help them manage their leisure time, what can they put in place to structure their time and find enjoyment vii. Mission and spiritual care, music therapy, chaplain, pet therapy: if you add therapy to your title you have to have advanced education 2. Diagnosis: analyze the assessment and data, and diagnose. APN can give medical diagnoses. Nurses can give nursing diagnoses. 3. Outcome identification: the purpose and goals that will influence health outcomes and improve the patient's health status. Want them to be measurable, time oriented, realistic. Don't just say "I want to go to group today" because that's a given. Be specific "I will identify 4 support people for discharge" "I will identify 6 triggers that make me want to drink" 4. Planning: interventions. How can I help the patient reach the goals 5. Implementation: Pulling everything together. TEST: When a nurse is pulling everything together into a care plan, her interventions are INDEPENDENT of the rest of the treatment team. She only considers the other thoughts of the treatment team. If the rec therapist says pt has no activities to do at discharge-the nurse may put things like go to art group etc. 6. Evaluation: What is the client's response? Were the goals met?

Only MD has what privlege

* Only a MD has admitting privileges

Psychiatrist mostly does what

* Psychiatrist is almost exclusively medication management

Only psychologist can do what

* Psychologist is the only one that can do psych testing

Identify two types of group behaviors that can be challenging and the corresponding intervention

. Dealing with challenging member behaviors: encourage members to share. Use "I" statements not "you" Monopolizing member; compulsive speech of a person who monopolizes the group may be an attempt to deal with anxiety. Complaining member who rejects help: conflicting feelings about their dependency or connection with the group, mistrust of authority figures but likes the attention from the leader. Demoralizing member: self centered, angry, depressed, lack hope. Listen to the comments objectively, ask what is causing the anger, acknowledge anger Silent member: may be observing until they decide the group is safe, may believe they are not so competent as other, more assertive group members. Doesn't mean theyre' not engaged. Try to include the silent person. Monopolizing Member ▪ The compulsive speech of a person who monopolizes the group may be an attempt to deal with anxiety. ▪ Address the entire group with a reminder that, during group work, everyone should have an equal chance to contribute and that members should consider whether or not they are dominating the groups time. ▪ Request a response from the group members who have not had a chance to talk about the day's topic. ▪ If behavior continues, it may be necessary to speak directly to the monopolizing group member, either privately or in the group setting. ▪ In the group setting, the leader may ask group members if they would like to share observations or feedback about other members. Complaining Member who rejects help ▪ Patient generally has high conflicting feelings about his or her own dependency or connection with the group; any notice from the leader temporarily increases the patient's self-esteem. ▪ Leader should acknowledge the patient's pessimism but maintain a neutral effect. ▪ Leader should encourage the patient to look at the habitual "yes... but" behavior objectively. Demoralizing Member ▪ Some people whose behavior is self-centered, angry, or depressed may lack empathy, hope, or concern for other members of the group. ▪ They refuse to take any personal responsibility and can challenge the group leader and negatively affect the group process. ▪ Group leader should listen to the comments objectively ▪ The leader may choose to speak to the group member in private and ask what is causing the anger. ▪ Leader can focus on positive group members whose comments may reduce the hostility of the negative group members. ▪ Leaders must empathize with the patient in a matter-of-cat manner, such as, "you seem angry that the group wants to support you in putting sobriety ahead of your dental needs" Silent Member ▪ Allowing the person to have extra time to formulate his or her thoughts before responding. ▪ Make an assignment that every person in the group respond to a certain topic or question. ▪ Sometimes partnering with another group member will give the silent member the courage he or she needs to participate. ▪ Follow-up privately with a silent member will safely identify the non-participatory behavior as well as allow for personal discussion of what may be inhibiting his or her participation.

Counselors

: mental health counselors are out on the floor. Have a bachelor's degree, some may have master's. They are running the groups, but can't do group therapy

Describe a situation where the nurse may have a different value than the patient that may cause an ethical problem or conflict.

Abortions, affairs * Patient may want an abortion which is against the nurse's beliefs * Nurses must be sensitive and accepting of different beliefs and values Ethical concepts: Ethics: study of philosophical beliefs about what is considered right or wrong in society Bioethics: study of specific ethical questions that arise in health care. 5 basic principles of bioethics: 1. Beneficence: the duty to act to benefit or promote the good of others 2. Autonomy: respecting the rights others to make their own decision 3. Justice: the duty to distribute resources or care equally, regarless of personal attributes 4. Fidelity: maintinaing loyalty and commitment to the patient and doing no wrong to the patient 5. Veracity: one's duty to communicate truthfully Ethical dilemma: conflict between 2 or more courses of action, each carrying unfavorable consequences. Ethics: Science that deals with the rightness and wrongness of actions. Constantly challeneged with ethical issues in health care. Do not test on theories. Utilitarianism: what produces the most good for the most people in the end Khantinims: actions led by a sense of duty Christian ethics:do unto others as you would do to you Ethical egoism: decisions based on what is best for the individual making the decision Go to ethics committee There are steps how to make decisions 5 ethical principesl TEST 1. autonomy: emphasizes the person who has the right to determine their own life, make their own decisions about what they want 2. beneficieince: one's duty to promote the good 3. non maleficence: acting carefully to avoid harm, avoiing harming the patient 4. Justiice: Duty to treat all individuals fairly and equally. Everyone gets same treatment 5. Veracity: one's duty to always be truthful

Advanced practice:

Advanced practice: can do everything at the basic level PLUS medication prescription and treatment, psychotherapy, and consultation. Licensed RN with MSN or DNP In psychiatric nursing. May be nurse practioniner or clinical nurse specialist (as long as CNS has achieved prescription authority).

8. Review the nursing assessment process

Assessment: interviewing the pt & family, family history, overall appearance (disheveled, inappropriate clothes for weather, how women apply their makeup (may chart very bright makeup-may indicate thought process), watching how family and pt interact, a lot of observing non verbals. Consult other team members. Reviewing their records. Physical exam-always want to rule out any physical issues. Standard 1: Assessment: -holistic view -assess past and present medical history, a recent physical exam, and any physical complaints, document any observable physical conditions or behaviors -Must give HIPPA consent -primary source is the patient, secondary sources are family members, friends, neighbors etc -conduct assessment in place of minimal anxiety Age considerations Assessment of children: be familiar with basic cognition and sofical/development of children. Gather data from a variety of sources. Assess developmental level. Age appropriate communication strategies. Use a combination of interview and observation, watching children play. Assessment of adolescents: especially concerned with confidentiality. Threats f suicide, homicide, sexual abuse, or behaviors that put the patient or others at risk for harm must be shared with other professionals and parents. Identify risk factors. Use a brief, structured interview technique. EX: HEADSSS H (home environment) E (education and employment) A (activities) D (drug, alcohol, tobacco use) S (sexuality) S (suidicde risk or symptosm of depression or other mental disorder) S (savagery, violent abuse) Assessment of older adults: 5 senses and brain function begin to diminish. Do not stereotype older adults into thinking they are physically and/or mentally deficient. Be aware of physical limitations, make accomdations for patient. Language barriers: have a thorough understanding of the complex cultural and social factors that influence health and illness. Awareness of individual cultural beliefs and health care practices. Interpretor (more likely to unconsciously try to make sense of (interpret) what is the patient is saying and therefore inserts their own udnerstandin gof the situation into the database. Translator (tries to avoid interpreting). Do not use untrained interpretors. Use of trained transloator is the law. Psychiatric mental health nursing assessment: purpose: establish rapport, obtain an understanding of the current problem or chief complaint, review physical status and obtain baseline vital signs, assess for risk factors affecting the safety of the patient or others, perform a mental status exam, assess psychosocial status, identify mutual goals for treatment, formulate a plan of care Gathering data 1. Review of systems: mind body connection is significant. Need a physical exam. Baseline set of vital statstics, a historical and current review of body systems, and a documentation of allergic response. Physical illness may mimic psychiatric illnesses, so causes of symptoms ust be rule dout. Pscychiatric disorders can result in physical or somatic symptoms such as stomach aches, headaches, lethargy, insomnia, intense fatigue, and even pain. Some medical diagnoses may be more prone to psychiatric disorders. Mental status examination Some medical conditions that may mimic psychiatric illness: Depression: • Neurological disorders: cerebrovascular accident (Stroke), Alzheimer's disease, brain tumor, huntington's disease, epilepsy, multiple sclerosis, parkinson's diease • Infections: mononucleosis, encephalitits, hepatitis, tertiary syphilis, HIV • Endocrine disorders: hypothyroidism and hyperthyroidism, cushings syndrome, addisons disease, parathyroid disease • GI diosrders: liver cirrhosis, pancreatitis • Cardiovascular disorders: hypoxia, congestive heart failure • Respiratory disorders: sleep apnea • Nutritional disorders: thiamine deficiency, protein deficiency, B12 deficiency, B6 deficiency, folate deficiency • Collage vascular diseases: lupus erythematous, rheumatoid arthritis • Cancer Anxiety: • Neurological disorders: Alzheimer's disease, brain tumor, storke, huntington's disease • Infections: encephalitis, meningitis, neurospyhilis, septicemia, • Endocrine disorders: hypothyroidism and hyperthyroidism, hypoparathyrodism, hypoglycemia, pheoghromocytoma, carcinoid • Metabolic disorders: low calcium, low potassium, acute intermittent porphyria, liver failure • Cardiovascular disorders: angina, CHF, pulmonary embolus • Respiratory disorders: pneumothorax, acute asthma, emphysema • Drug effects: stimulants, sedatives (withdrawal) • Lead mercury posining Psychosis • Medical conditions: temporal lobe epilepsy, migrane headaches, temporal arteritis, occipital tumors, narcolepsy, encephalitis, hypothyroidism, Addison's disease, HIV infection • Drug effects: hallucinogens, phencyclidine, alcohol withdrawal, stimulants, cocaine, corticosteroids 2. Laboratory data: blood test. Looking for thyroid problems, abnormal liver enzymes, tox screen etc. 3. Mental status examination: evaluate individuals current cognitive processes. Appearance, behavior, speech, mood, disorders of the form o fthought, perceptual disturbances, cognition, ideas of harming self or others 4. Psychosocial assessment: central or chief complaint, history of violent/suificidal/self mutilating behaviors, alcohol and/or substance abuse, family psychiatri history, personal psychiatric treatment including meds and complementary therapies, stressors and coping methods, quality of activities of daily living, personal background, social background including support system, weaknesses/strengths/goals for treatment, racial/ethnic/cultura beliefs and practices, spiritual beliefs or religious practices. The psychosocial history is most often the subjective part of the assessment 5. Spiritual/religious assessment: a. Spirituality: internal phenomenon and is often understood as addressing universal human questions and needs. 3 dimensions: cognitive, experiential, behavioral. Part of us that seeks to understand life b. Religion: external system that includes beliefs, patterns of worship, and symbols. Person connects personal spiritual beliefs with a larger organized group or institution. 6. Cultural and social assessment: plan care around unique cultural health care bleifs, values, and practices. Validating the assessment: electronic medical records, ED records, old medical records, police reports, past inpatient information, consent forms Using rating scales: measure depression, anxiety, substance use disorders, OCD behavior, mania, schizophrenia, abnormal movements, general psychiatric assessment, cognitive function, family assessment, eating disorders

Describe why it might be common place to misdiagnose a mental illness with someone from another culture.

Barriers to quality mental health services Communication barriers: speaking different langauges, different non verbals. Hhave a professional interpreter. Stigma of mental illness: US associate mental illness with moral weakness. Fear or bias aginast mental health. Other cultures-mental illness may be failure of family, reflects poorly on family. Stigma and shame leed to reluctance to seek help. Misdiagnosis: misdiagnosed with wrong mental disorder. May be use of inappropriate psychometric instruments and other diagnostic tools. Somatization: psychological distress is experienced as physical problems Culture bound syndromes: sets of signs and symptoms that are common in a limited number of cultures but virtually nonexistent in most other cultural groups Genetic variation in pharmacodynamics: genetic variation to drug responses. Focuses how genes affect individual responses to medicines. May affect drug metabolism ○ Use of culturally inappropriate psychometric instruments and other diagnostic tools ■ Psychological distress is manifested in different cultures in different ways ○ Culture-bound syndromes: sets of signs and symptoms that are common in a limited number of cultures but virtually non-existent in most other cultural groups

Basic level: RN

Basic level: RN with no advanced degree. Interventions: coordination of cre, health teaching and health maintenance, milieu therapy, pharmacological, biological, and integrative therapies. After 2 years of full time work, 2000 clinical work in psych nursing, and 30 hours of continuing ed in psych a baccaluarente RN can take a certification exam-they become board certified

Identify the 5 basic principles of bioethics

Bioethics: study of specific ethical questions that arise in health care. 5 basic principles of bioethics: 1. Beneficence: the duty to act to benefit or promote the good of others 2. Autonomy: respecting the rights others to make their own decision 3. Justice: the duty to distribute resources or care equally, regarless of personal attributes 4. Fidelity: maintinaing loyalty and commitment to the patient and doing no wrong to the patient 5. Veracity: one's duty to communicate truthfully 5 ethical principesl TEST 1. autonomy: emphasizes the person who has the right to determine their own life, make their own decisions about what they want 2. beneficieince: one's duty to promote the good 3. non maleficence: acting carefully to avoid harm, avoiing harming the patient 4. Justiice: Duty to treat all individuals fairly and equally. Everyone gets same treatment 5. Veracity: one's duty to always be truthful o Beneficence: ▪ The duty to act to benefit or promote the good of others (spending extra time to calm an extremely patient) o Autonomy: ▪ Respecting the rights of others to make their own decisions (acknowledging the patient's right to refuse medication promotes autonomy) o Justice: ▪ The duty to distribute resources or care equally, regardless of personal attributes (an ICU nurse devotes equal attention to someone who has attempted suicide as to someone who suffered a brain aneurysm. o Fidelity: ▪ (nonmaleficence) maintaining loyalty and commitment to the patient and doing no wrong to the patient (maintaining expertise in nursing skill through nursing education). o Veracity: ▪ One's duty to communicate truthfully (describing the purpose and side effects of psychotropic medications in a truthful and non-misleading way.

Case manager:

Case manager: TEST QUESTION: looking at quality and cost. Patient x has been here for 2 weeks with no imprpovement lets look at meds. They talk to insurance companies to ask for days etc. Trying to figure out affordable care act

Discuss reasons in which nurses/mental health nurses need to be culturally aware.

Changing demographics: more minority populations emerging Culturally competent care: Cultural competence: nurses adjust their practices to meet their patients cultural beliefs, practices, needs, and preferences. Cultural awareness: the nurse recognizes the enormous impact culture makes on what patients' health calues and practices are, how and when patients decide they are ill and need care, and what treatments they will seek when illness occurs. Examine own cultural beliefs and beliefs of others. Examin assumptions and expectations of cultures. Cultural knowledge: attened cultural events and programs, form friendships, attend in service programs. Study resources. Study ethnic and religious cultures: beliefs, values, worldview, non verbal communication, family roles of psychosocial norms, etiquette norms, family roles and psychosocial norms, cultural views about mental health and illness. Cultural encounters: sets a foundation, that cultural guidelines cannot tell us anything about a particular patient. Prevents stereotyping Stereotyping: tendency to believe that every member of a group is like all other members. Cultural skill: ability to perform a cultural assessment in a sensitive way. Ensure that meangiful communication can occur. Use cultural assessment tools. Ask apporporiate questions, promote openness. Acknowledge cultural values and practices Cultural desire: indiciates that the nurse is not acting out of a sense of duty but from a sincere and genuine concern for patients' welfare

Cognitive BEhavioral therapy

Cognitive behavioral therapy: based on both cognitive psychology and behavioral theory. People with depression generally had stereotypical patterns of negative and self critical thinking that seemed to distort their ability to think and process information. Feelings and behaviors are largely determined by the way people think about the world and their place in it. Their cognitions are based on attitudes or assumptions developed from previous experiences, may be accurate or distorted. Thearpy designed to identify, reality test, and correct distorted coneptualizations and the dysfunctional beliefs underlying them Schemas: unique assumptions about themselves, others, and the world in general = Automatic thoughts: rapid, unthinking responses based on schems Cognitive distortions: irrational and lead to false assumptions and misinterpretations Common cognitive distrotions: All or nothing thinking, overgenrealiation, labeling, mental filter (focusing on a negative detail and allowing it to taint everything else, disqualifying the positive, jumptin gto conclusions), mind reading, fortune telling error, magnification or minimization, catastrophizing, emotional reasoning, should and mus statemetns, personaliiazation Implications for psychiatric mental health nursing: recognizing interplay between events, negative thinking, and negative responses. Identify negative thought patterns. * Based on both cognitive psychology and behavioral theory * Cognitions (verbal or pictorial events in streams of consciousness) are based on attitudes or assumptions developed from previous experiences (may be accurate or distorted) * Identify, reality test, and correct distorted conceptualizations and the dysfunctional beliefs that underlying them - change the way a person thinks and therefore reduce symptoms

● When communicating with patients, what should be considered in terms of cultural differences?

Cultural considerations: health care professionals need to be familiar with the cultural meaning of certain verbal and nonverbal communications. Cultural awareness. Communcation style: people may communicate in an intense and highly emotional manner, others may mask severe distress. Depends on culture. Eye contact: presence or absence of eye contact should not be used to assess attentiveness, judge truthfulness, or make assumptions on the degree of engagement one has with a patient. Culture norms dictate a person's comfort with eye contact. Touch: therapeutic use of touch-may be useful or detrimental based on culture of patient Cultural fillers: in the process of socialization we develop cultural filters through which we listen to the world around us. Cultural filters are a form of cultural bias or cultural prejudice that determines what we pay attention to and what we ignore. Build acceptance and understanding of cultural diversity ○ Communication style ○ Eye contact ○ Touch ○ Cultural filters (prejudices and biases that determines what we pay attention to or ignore)

What are the exceptions to the confidentiality Act?

Exceptions to the rule 1. Duty to warn and protect third parties: psychotherapist has a duty to warn a patient's potential victim of potential harm. Duty to protect the other person in harm's way. 2. Statutes for reporting child and elder abuse: definition of child abuse, list of persons required or encouraged to report abuse, an dthe governmental agency disgnated to receive and investigate reports. Must report child or elder or disabled persons abuse. State laws vary

Identify several types of psychiatric inpatient admissions.

Due process in involuntary admission: -Writ of habeas corpus: patient can challenge commitment by having a formally written order to free the person -Least restrictive alternative doctrine: mandates that the least drastic measures be taken to achieve a specific purpose Admission procedures: based on several fundamental guidelines: • NEither voluntary nor involuntary admisision determines a patient's ability to make informed decisions about his or her health care • A medical standard or justification for admission must exist • A well defined psychiatric problem must be established • The presenting illness should be an immediate crisis situation or that other less restrictive alternatives are inadequate or unavailable • There must be a reasonable expectation that the hospitalization and treatment will improve the presenting problem Informal admission: voluntary admission similar to general hospital admission in which there is no formal or written application. Patient free to stay or leave Voluntary admission: patient applies in writing for admission to the facility. Right to request and obtain release, but may be reevaluated Temporary admission: used for people who are confused or demented that they cannot make their own decisions, or for people who are so ill they need emergency admission. Involuntary admission: admission without consent. NEessary when they need psychiatric treatment, presents a danger to self or others, unable to meet his or her basic needs. Requires the patient has the right to retain freedom from unreasonable. Physcans and someone familiar with the patient have to agree to that their mental health status is bad enough for institutionalization Long term involuntary admission: extended care and treatment of the mentall ill. Admitted through medical certification, judicial review, or administrative action Involutntary outpatient commitment: usually tied to receipt of goods and services, patient is mandated to participte in treatment, and may face inpatient admission if they fail to participate Informal Admission: one type of voluntary admission that is similar to any general hospital admission in which there is no formal or written application ▪ The normal doctor-patient relationship exists, and the patient is free to stay or leave, even against medical advice. Voluntary Admission: occurs when a patient applies in writing for admission to the facility. ▪ If person is under 18, patient, legal guardian, custodian or next of kin may have authority to apply on person's behalf. ▪ Patients have the right to request and obtain release, however, patients may be reevaluated and a decision may be made on the part of the care provider that an involuntary admission be initiated Temporary Admission: ▪ Used (1) for people who are so confused or demented they cannot make decisions on their own or 2) for people who are so ill they need emergency admission. ● Primary purpose is observation, diagnosis, and treatment of those who have mental illness or pose a danger to themselves or others. Involuntary Admission: admission to a facility without the patient's consent. ▪ Necessary when a person is in need of psychiatric treatment, presents a danger to self or others, or is unable to meet his or her own basic needs. ▪ When a patient is committed, that is involuntary admission Long-term Involuntary Admission: has as its primary purpose extended care and treatment of the mentally ill. ▪ Those who undergo extended involuntary hospitalization are admitted through medical certification, judicial review, or administrative action. Involuntary Outpatient Commitment: alternative to forced inpatient treatment.

4. Identify Erikson's eight stages of development

Erikson: developmental stages • Crisis in each stage that needs to be resovled Infant: birth to 18 months: trust vs. mistrust o Trust is accomplished when baby cries and mom comes to take care of them. Bonding, providng crae for infant, peek a boo (mom leaves and comes back), baby is remembering mom's smell, voice, feels safe and trust develops. Attunement is very important: know the baby's feelings o Baby needs to develop trust to the mother figure Success: Able to relate to other, trusts others, faith and hope in future Unsuccessful: Difficulty relating to others, suspicion, fear of future Early childhood: 18 months-3 years: autonomy vs shame and doubt o The kid will gain self control and independence in the environment. In normal functioning household we will see the three year old saying "NO NO NO"-if we shame the three year old, the kid will feel shame and not feel autonomous. IF we give them the choice they feel autonomous. That does not shame her, and it provies choices. If she throws a shoe, go in time out, then the kid comes out and we ask if we are ready to go on with our day, do not bring up old tantrum Success: Sense of self-control and adequacy, will power unsuccessful: Fear conflict, severe feelings of self-doubt Late childhood (preschool): 3-6 years: Initiative vs guilt o Developnig a sense of purpose o Successful: I like to help mommy set the table for dinner. Ability to initiate activities, sense of purpose o Unscucessful: I wanted the candy so I took it. Aggression, sense of inadequacy or guilt School age: 6-12 years: industry vs. inferiority o Gains confidence through performing and receiving recognition o Bullying happens at school-can suppress this developmental stage. If person is trying to develop confidenc and is getting bullied, when people my age are bullying in when I want to fit in, someone says im ugly and should kill myself it is catstrophic. Can cause depression, suicidal behavior o Developing social, physical, and school skills Success: Competence, ability to work Unsuccessful: Sense of inferiority, difficulty learning and working Adolescence: 12-20 years: identity vs role confusion o Integrting all the previous tasks into a secure sense of self. Devleoping our sexual identity-kids that are struggling with gender identity or feeling shame because they think they are interested in same-sex. Saying that's 'gay' is a microaggression-it's unkind, may hurt someone in the area. o Making transition from childhood to adulthood: developing sense of identity o Successful: Im going to college to become an engineer. Sense of personal identity, fidelity o Unsucessful: I belong to the gang because without them I'm nothing. Confusion about who one is, weak sense of self Young adult hood: 20-35: intimacy vs isolation o Forming Intense lasting relationships to a purpose, cause, relationship. Interest in love, interest in nursing, interest in global health. Interested in something beyond yourself. o Establishing intimate bonds of love and friendship Success: Ability to love deeply and commit oneself unsuccessful: Emotional isolation, egocentricity Adulthood: 35-65: generativity vs stagnation (self-absorption) o Achieving life goals while achieivnig welfare of others. Finding work meaningful, putting out a good product at work. Find meaning in my work, life. Stagnating is a cat lady o Succesful I'm joining the policitcal committee to help people get the health care they need. Ability to give and to care for others o Unsuccessful: After I work all day, I just want to watch tv and don't want to be around people. Self-absorption, inability to grow as a person Old age: 65 to death: ego integrity vs despair o Holding on to your ego. Knowing who you are, liking who you are, being proud of past achievements, talking to young folk about life o Can we derive meaning from negative and positive things from life? Can we find the positives of life. Avoid having regrets and apologies at the end of life. o Looking over one's life and accepting its meaning Success: Sense of integrity and fulfillment, willingness to face death Unsuccessful: Dissatisfaction with life, denial of or despair over death Erik Erikson's Ego theory: See class notes. The successful or unsuccessful completion of each stage will affect the individual's progress to the next Implications for psychiatric mental health nursing: essential component of patient's assessment. Helps nurses determine interventions tailored to developmental level

name Erikson's stages and ages for infancy, early childhood, late childhood/preschool, school age, adolescence, young adulthood, adulthood, and old age

Infant: birth to 18 months: trust vs. mistrust Early childhood: 18 months-3 years: autonomy vs shame and doubt Late childhood: 3-6 years: Initiative vs guilt School age: 6-12 years: industry vs. inferiority Adolescence: 12-20 years: identity vs role confusion Young adult hood: 20-35: intimacy vs isolation Adulthood: 35-65: generativity vs stagnation (self-absorption) Old age: 65 to death: ego integrity vs despair

Identify the 3 phases of the nurse-patient relationship

Phases of the therapeutic relationship -Maintian trust -Promote client's insight and perception of realtiy -Client uses problem solving towards goal -Continue to evaluate problem Peplau's model of the nurse patient relationship: preorientation phase, orientation phase, working phase, termination phase Professional nurse patient relationship: consist of nurse who has skills and expertise and a patient who wants to alleviate suffering, find solutions to problems, explore different avenues to increased quality of life, and/or find an advocate Preorientation phase: might feel anxious about meeting the patient, wooried about escalations Orientation phase: first time the nurse and patient meet and is the phse in which the nurse conducts the intital interview. An atmosphere is established in which rapport can grow, the nurse's role is clarified and the responsibilities of both the patient and the nurse (parameters) are defined, the contract containing the time, place, date, andduration of the meetings is discussed, confidentiaility is discussed and assumed, the terms of termination are introduced (these are also discussed throughout the orientation phase and beyond), the nurse becomes aware of transference and countertransference issues, patient problems are articulated, and mutually agree upon goals are established Esablishhing rapport: provide an atmosphere in which trust and understanding, or rapport can grow. Demonstrate genuineness and empathy, develop positive regard, show consistency, and offer assistance in problem solving and providing support Parameters of the relationship: patient needs to know about the nurse and the purpose of the metings Formal or informal contract: contract emphasizes the patient's participation and responsibility. Contract: either stated or written, contains the place, time, date, and duration of the meetings. Mutual agreement on goals Confidentiality: patient has a right to now who else wil be given the information shared with the nurse and that the information may be shared with specific people like the physician or staff. Patient needs to know the information will not be shared with relatives, friends or others outside the treatment team except in extreme situations. Extreme situations: child or elder abuse, threats of self harm or harm to others, intention not to follow through with treatment plan. Terms of termination: planning for termination (last phase), date of termination should be clear. Working Phase: maintain the relationship, share information, gather further data, promote the patient's problem solving skills/self esteem/use of language, facilitate behavioral change, evaluate progress, support the practice and expression of alternative adaptive behaviors. Patient and nurse identify and explore areas that are causing problems in life, problem behaviors, identify unconscious motivations and assumptions Termination phase: final, integral phase of the relationship. Terminatio Is discussed during the first interview, and during the working stage. Tasks: summarizing the goals and objectives achieved in the relationship, discussing ways for the patient to incorporate into daily life any new coping strategies learned, reviewing situations that occurred during the nurse patient relationship, exchanging memories which can help validate the experience for both nurse and patient and facilitate closure of the relationship. Do NOT maintain contact after discharge ○ Orientation phase ■ First time patient and nurse meet, nurse conducts initial interview ■ Establish rapport, introduction/parameters of relationship, formal or informal contract, confidentiality, explain terms of termination ○ Exploitation phase ■ Patient takes full advantage, explores possibilities. ○ Working phase ■ Maintain relationship, share information, gather further data, promote problem-solving skills, self-esteem, and use of language, facilitate behavior change, evaluate progress, support the practice and expression of alternative adaptive behaviors ○ Termination phase ■ Summarize goals and objectives, discuss incorporation of new coping skills into daily life, review situations that occurred during the nurse-patient relationship, exchange memories

What factors promote a patients growth?

Factors that encourage and promote patietns' growth: 3 personal characteristics of the nurse that help promote change and growth in patients: 1. Genuineness, 2. Empathy 3. Positive regard Genuineness: self awareness of one's feelings as they arise within the relationship and the ability to communicate them when appropriate, helps build trust Empathy: complex. Helpng person attempts to understand the world from the patient's perspective. "temporarily living in other's life, moving about in it delicately without making judgments". Empathy vs sympathy: empanthy we understand the feelings of others, and in sympathy we feel the feelings of others. Sympathy is associated with feelings of pity and commiseration. Empathy is important in building a trusting and therapeutic relationship Positive regard: implies respect. Ability to view another person as being worthy and caring about and as someone who has strengths and achievement potential. Communicated by attitudes and actions Attitudes: willingness to work with the patient, Actions: Attending: nurses must pay attention to their patients in culturally and individually appropriate ways. Attending is a special kind of listening that refers to an intensity of presence, or being with the patient. Posture, eye contact, nonverabals are signs of attending Suspending value judgments: nurse guards against using their own value systems to judge patients' thoughts, feelings, or behaviors. Steps to eliminate judgmental thinking: 1 recogize your judgemnts 2. Identify how or where you learned these responses to the patient's behavior 3. Construct alternaive ways to view the patient's thinking and behavior Helping patients develop resources: the nurse becomes aware of patients' strengths and encourages patients to work at their optimal level of functioning. Encourage patients to use their own resources helps minimize feelings of helplessness and depdency and validates their potential for change. ○ Genuineness, empathy, positive regard (respect), attitude of the nurse showing a willingness to work with the patient, suspension of value judgments, attending (nurse paying attention to patient)

2. Define the Id, ego and superego

Freud: basic character is froemd around 5 y/o. Revolves around id, ego, superego • Id: present at birth: inner instinct, drives, pleasure principle. Id wants to go out and party! • Ego: 4-6 months: rational self, maintains harmony with external world, ego is trying to keep id in balance. Pulls together the superego and the id and compromise. You have to develop an ego to survive. Katula's job: Identify what the ego is attached to, and unattach. She was the good girl middle child, her ego got attached to being the good girl because that's how she got attention and how she survived. Then she got older and still did th good girl thing because her ego is attached it. Unconsciously carry ego attachment through life making good and bad attachments through life. Look at ego attachment and where our cores have been wounded. The more conscious you are, the more you evolve. • Superego: 3-6 years of age-perfection principle: assists ego to gain control over id impulses. The "mom". Personality structure 1. Id: present at birth, source of all drives, instincts, reflexes, needs, genetic inheritance, and capacity to respond, as well as what motivates us. Seeks pleasure. Hungry screaming infant 2. Ego: within the first few years of life as child begins to interact with other ego develops. Ego is the problem solver and reality tester. Delay gratification, keeps id in line. Implement reality to implement a plan to decrease tension 3. Superego: moral component of personality. Consists of the conscience nd the ego ideal. Represents the ideal rather than real; it seeks perfection as oppose to pleasure. All three work together. If id is too powerful, the person will lack control over impulses, if superego is too powerful, the person may be too self critical Id (developed at birth) * Source of all drives, instincts, reflexes, needs, genetic inheritance, capacity to respond, motivation * Cannot tolerate frustration or problem solve (not logical) * Operates on pleasure principle, only cares about own needs * Example: hungry, screaming infant * Pleasure principle is related to one's sex drive * If too powerful, person will lack control over impulses Ego (develops within first few years of life as interaction with others begins) * Problem solving and reality testing (factors in reality to implement a plan and decrease tension) * Able to differentiate subjective experiences, memory images, and objective reality * Attempts to negotiate with outside world * Reality principle - says to id "you have to delay gratification for now" and sets a course of action * Example: a hungry man who feels tension arising from the id (wants to be fed) so plans where he can eat and seeks that destination * Mediator between the id and superego Superego (develops last) * Moral component of personality * Contains the conscience ("should nots") and the ego ideals ("should") * Seeks perfection rather than pleasure or engaging in reason * If too powerful, person will be self-critical and feel inferior

Identify the 3 major informal roles found in groups; give an example of each.

Group member roles: task roles: keep the group focused. EX: coordinator, elaborator, energizer, evaluator, information giver, information seeker, initiator-contributor, opinion giver, orienter, procedural technician, recorder Maintenanec roles: keep the group together and included. EX: compromiser, encourager, collower, gatekeeper, group observer, harmonizer, standard setter Individual roles: nothing to do with helping the group but instead relate to specific personal needs met by shifting the group's focus to them. EX: aggressor, blocker, dominator, help seeker, playboy, recognition seeker, self confessor, special interest pleader Task Roles ▪ Function: ● Coordinator: tries to connect various ideas and suggestions ● Elaborator: gives examples and follows up meaning of ideas ● Energizer: encourages the group to make decisions or take action. ● Evaluator: measures the group's work against objectives ● Information Giver: provides facts or shares experience as an authority figure. ● Information Seeker: tries to clarify the group's values. ● Initiator-contributor: offers new ideas or a fresh outlook on an issue. ● Opinion giver: shares opinions, especially to influence group values ● Orienter: notes the progress of the group toward goals. ● Procedural technician: supports group activity with physical tasks (distributing papers, arranging seating) ● Recorder: keeps notes and accts as the group memory Maintenance roles ▪ Functions: ● Compromiser: during conflict, yields to preserve group harmony ● Encourager: praises and seeks input from others ● Follower: agrees with the flow of the group ● Gatekeeper: monitors the participation of all members to keep communication open and equal. ● Group observer: notes different aspects of group process and reports to the group. ● Harmonizer: tries to mediate conflicts between members ● Standard setter: verbalizes standards for the group. Individual roles ▪ Functions: ● Aggressor: criticizes and attacks others' ideas and feelings ● Blocker: disagrees with and halts group issues; oppositional. ● Dominator: Tries to control other members of the group with flattery or interruptions. ● Help Seeker: asks for sympathy of group excessively ● Playboy: acts disinterested in group process ● Recognition seeker: seeks attention by boasting and discussing achievements ● Self-confessor: verbalizes feelings or observations beyond the scope of the group topic. ● Special-Interest pleader: advocates for a special group, usually with own prejudice or bias.

Different disciplines that run the groups: Therapeutic group vs group therapy

Group therapy: has a sound theory base, and leaders have advanced degree Therapeutic group: it's a group and it's therapeutic. Based less on theory, person does not need master's degree RNs, counselors, social workers all can run groups. Need advanced degree for group therapy

Identify ways in which you can protect patient's confidentiality in Psychiatry

HIPPA: in psychiatry don't talk about patients in the elevator, at the nurse station, be careful of leaving computer open, only go into the charts for your patient, don't tell people who you see in the hospital Patients have right to confidentiality. If someone is calling the unit, and the patient hasn't assigned a passcode yet you say "I can not acknowledge that this person is here". Rights regarding confidentiality: Confidentiality is privacy of care. Health insurance portability and accountability act: right to privacy.Cannot share information, can only speak with those who are treating patient, in a secure place. Confidentiality after death: do not divulge information after death. Confidentiality of professional communications: legal protect the confidentiality of certain professional. Allows patient to feel comfortable sharing info. Confidentiality and HIV status: some states have enacted mandatory or permissive statues that direct helth care proviers to warn a spouse if a partner is HIV positive Exceptions to the rule 1. Duty to warn and protect third parties: psychotherapist has a duty to warn a patient's potential victim of potential harm. Duty to protect the other person in harm's way. 2. Statutes for reporting child and elder abuse: definition of child abuse, list of persons required or encouraged to report abuse, an dthe governmental agency disgnated to receive and investigate reports. Must report child or elder or disabled persons abuse. State laws vary o Box 6-2, page 105 o HIPAA o Confidentiality after death ▪ Dead Man's Statute protects confidential information about individuals when they are not alive to speak for themselves.

7. Identify Maslow's hierarchy of needs

Humanistic theories: focus on human potentional and free will to choose life patterns that are supportive of personal growth Abraham Maslow's humanistic psychology theory: self actualized personality associated with high productivity and enjoyment of life. Include love, compassion, happiness, exhilaration, and well being Hierarchy of needs: (lowest to highest) physiological needs, safety needs, belonging and love needs, esteem needs, self actualization. He later added cognitive and aesthetic needs. Some characteristics of self actualized people: accurate perception nof reality, not defensive, acceptance of themselves/toehrs/nature, spontaneity simplicity and naturalness, problem centered orientation, pleasure in being alone, active social interest, freshess of appreciation, creative, resistance to conformity, light hearted etc Implications for psychiatric mental health nursing: emphasis on human potential and patient's strengths. Prioritize patients needs at the moment. * Focus of psychology must include experiences of love, compassion, happiness, exhilaration, and well-being * Humans are active participants in live, striving for self-actualization (human need fulfillment * When lower level needs are met, higher needs are able to emerge * Pyramid: High (more distinctly human needs) to low (strongest, most fundamental needs) * Self-Transcendence & Self-Actualization - becoming everything one is capable of * Esteem - self-esteem related to competency, achievement, and esteem from others * Love and Belonging Needs - affiliation, affectionate relationships, and love * Safety Needs - Security, protection, stability, structure, order, and limits * Physiological Needs: Food, water, oxygen, elimination, rest, and sex

Identify 3 non therapeutic techniques

Identify 3 non therapeutic techniques Nontherapeutic technique • Do not give false reassurance: It gets better, I know its going to be okay. Do not put a bow around everything and make it better. When you do that you don't let the client say all of their feelings • Being a cheerleader is not therapeutic • Rejecting: refusing to consider a client's ideas or behaviors • Approving or disapproving: don't be approving or disapproving. Don't want to judge people (disapproving). Approving (your hair is so pretty every day). She thinks her value is in how cute she looks, she feels like she has to look cute everyday to get approval. A client thinks she is hideous, not going to tell her 'no youre not' but instead explore feelings • Do not agree or disagree: you're letting client know if they're right or wrong • Do not give advice: different than offering resources. "What should I do?" you say "What do you think?" Come up with pros and cons • Do not probe or push too hard or grilling like questions: pushing for answers can cause the client to feel used and valued for only what they share. Don't push when they're not ready. IT can retraumatize the patient with the abuse they experienced. o THE MOST IMPORTANT THING IS THE THERAPIST MEETS THE CLIENTS NEEDS. NEEDS TO BE A CONNECTION BETWEEN CLIENT AND PATIENT • Defending: to defend what the patient says. Don't defend staff members. Makes the client feel like they don't have rights, shuts them down instead of listening to their feelings. The staff should know we do not defend each other, never take anything personally, its not really about you. • How power is used: how you use yorur power • Do not belittle feelings • Do not make stereotypical comments, expressions: "everything will be ok, it's not that bad, things could be worse" • Be aware of your use of denial Nontherapeutic communication techniques: shut down nurse patient interaction. Giving premature advice, minimizing feelings, falsely reassuring, making value judgments, asking why quetisons, asking ecessive questions, giving approval/agreeing, disapproving/disagreeing, changing the subject Excessive questioning: asking multiple questions consecutively or rapidly. Conveys lack of respect and sensitivity Giving approval or disapproval: patient wants to please the nurse and get their approval. Nurses should not show signs of approval or disapproval. Disapproval implies that the nurse has the right to judge the patient's thoughts or feelings. Observations should be made instead Giving advice: giving advice interferes with the patient's ability to make personal decisions. Give information to make informed decisions. Asking "why" questions: why demands an explanation and implies wrong doing

Provide a definition and an example of therapeutic use of self.

In the nurse client relationship, this is the foundation, the client is a unique human being and they are having an experience in their mental health life. Therapeutic use of self. Paul joining someone playing the piano. If you are good at poetry and art, join a patient in this. Use your skills to establish relatedness and structure to the nursing interventions. Must use this consciously. Therapeutic use of self: our gifts that we can learn to use creatively to form positive bonds with others. The ability to use one's personality consciously and in full awareness in an attempt to establish relatedness and to structure nursing interventions * The ability to use one's personality consciously and in full awareness in an attempt to establish relatedness and to structure nursing interventions * Example: learning about Pokemon for a patient that likes it, singing with patient who is musical * Finding ways to relate with the patient to help them open up

Identify 3 therapeutic communication techniques

In therapeutic communication theres several techniques: LOOK IN BOOK • Silence: allows the patient to take control of the conversation. If the silence goes too long, client can get anxious. • Accepting, portraying a positive regard: suspend judgements, conveying acceptance of what they share, there's established trust • Giving recognition: acknowledging something their experiencing or feeling • Offering of self: making yourself available, but not overly available. • Gving broad openings: maybe asking a question, or making a omment making it broad. "Tell me more about that" "I'm wondering how that made you feel" "that sounds like that was very painful". o Don't switch the topic because you're uncomfortable • Offering leads: encourages person to continue. Nodding head, saying mhm, tell me more about that o Pseudo ambisilady: you might know what they mean but make them clarify more. I'm not sure what youre saying, can you tell me more about that • Placing event in time or sequence. Tell me what happened prior to that? • Verbalize patient perceptions • Encourage comparisons • Restating: lets the clinent know if a statement was understood. Do you mean blah bla • Reflecting: directs feelings back at client. Redirect nonvrbals: you see client is starting to cry-I can see you're upset tell me more about what upsetting you • Help patient focus: focus in on an event, idea, word • Explore: delve more into an idea, subject • Seek clarification: havethe client explain what is vague • Presenting reality: clarifying misconceptions. "Let me tell you about the rules, and why the PM shift said no. Tell me how you feel about the confines of the rules. Are you feeling trapped?" help them narrow in Therapeutic communication techniques: nurses must become aware of their own interperosonal methods, eliminationg obstructive, nontherapeutic communication techniques and developing additional responses that maximize nurse patient interactions and increase the use of therapeutic communication techniques: silence, active listening, clarifying techniques, questions. Silence, accepting, giving recognition, offering self, offering gerneal leads, giving broad openings, placing the events in time or sequence, making observations, encouraging description of perception, encouraging comparison, restating, reflecting, focusing, exploring, giving information, seeking clarification, presenting reality, voicing doubt, seeking consensual validation, verbalizing the implied, encouraging evaluation, attempting to translate into feelings, suggesting collaboration, summarizing, encouraging formulation of a plan of action Using silence: signifiscant menas of influencing and being influenced by others. Active listening; observing patient's nonverbal behaviors, understanding and reflecting on the patient's verbal message, understanding the patient in the context of the social setting of the patient's life, detecting "False notes" (inconsistencies or things the patients says that need more clarification), providing feedback about himself or herself of which the patient might not be aware. Clariifying techniques: nurse requests feedback on the accuracy of the message received. Allow patient to correct misunderstandings Paraphrasing: accomplished by restating in a different (often fewer) words the basic content of a patient's message Restating: nurse mirrors the patient's over and covert messages, so the technique may be used to echo feeling as well as content. Repeating the same key words the patient has just spoken. Reflecting: assiting patients to better understand their own thoughts and feelings Exploring: technique that enables the nurse to examine the important idease, experiences, or relationships more fully is exploring. Questions: Open ended questions: encourage patients to share information Close ended questions: when used sparingly, can give you specific and needed information. Projective questions: start with "What if" to help people articulate, explore, and identify thoughts and feelings. Presupposition questions: miracle questions-if a miracle happened what would be different, what would change your life.

What is meant by the "least restrictive" environment?

Least restrictive environment: setting that provides the necessary care allowing the greatest personal freedom Due process in involuntary admission: -Writ of habeas corpus: patient can challenge commitment by having a formally written order to free the person -Least restrictive alternative doctrine: mandates that the least drastic measures be taken to achieve a specific purpose o The least restrictive alternative doctrine mandates that the least drastic means be taken to achieve a specific purpose

10. Identify the components of the Mental Status Exam

Mental status examination: evaluate individuals current cognitive processes. Appearance, behavior, speech, mood, disorders of the form o fthought, perceptual disturbances, cognition, ideas of harming self or others Appearance Grooming: Well ٱ Poor ٱ Frail ٱ Disheveled ٱ Older ٱ or Younger ٱ than stated age. Hygiene Poor ٱ Fair ٱ Good ٱ Posture Normal ٱ Relaxed ٱ Slumped ٱ Stiff ٱ Other ٱ Behavior Friendly ٱ Cooperative ٱ Hostileٱ Suspicious ٱ Guarded ٱ Agitated ٱ Aggressive ٱ Strikes out ٱ Other ٱ Alertness Alert ٱ Sleepy ٱ Lethargic ٱ Hyper-alert ٱ Other ٱ Movement Normal ٱ Slow ٱ Slightly restlessٱ Tremors ٱ Akathisia ٱ Tics ٱ Agitated ٱ Aggressive ٱ Other ٱ Speech Clear ٱ Pressure ٱ Soft ٱ Disorganized ٱ Monotone ٱ Dysarthria ٱ Expressive Aphasia ٱ Receptive aphasia ٱ Rapid ٱ Slow ٱ Loud ٱ Soft ٱ Other ٱ [Dysarthria - difficult, poorly articulated speech; Expressive aphasia-words cannot be formed or expressed; Receptive aphasia-language is not understood] Mood " ___________________________________" Irritable ٱ Depressed ٱ Anxious ٱ Happy ٱ Elated ٱ Labile ٱ Sad ٱ Angry ٱ Other ٱ Affect Appropriate ٱ Blunted ٱ Flat ٱ Apathetic ٱ Bizarre ٱ Other ٱ Memory Examples of recent Examples of remote/long term Orientation Place Person Place/Situation Month/Date/Year Thought Process Coherent ٱ Loose Associations ٱ Tangential ٱ Perseveration ٱ Confabulation ٱ Disorganized ٱ Flight of ideas ٱ Neologism ٱ Concrete thinking ٱ Thought blocking ٱ Word saladٱ Other ٱ Thought Content Thought insertion ٱ Thought broadcasting ٱ Depersonalization ٱ Hypochondriasis ٱ Ideas of reference ٱ Magical thinking ٱ Nihilistic ideas ٱ Obsession ٱ Phobia ٱ Delusions Self-harm/suicide ⌂ Harm to others ⌂ Perceptions Illusions ٱ Hallucinations: Auditory ٱ Visual ٱ Tactile ٱ Gustatory ٱ Olfactory ٱ Other ٱ Reasoning/Judgment Good ٱ Fair ٱ Poor ٱ Provide Evidence: Insight - ability to perceive and understand cause and nature of own's and other's situation Good ٱ Fair ٱ Poor ٱ Provide evidence - Reliability - nurse's impression that information reported by client is accurate and complete.

8. Describe Milieu Therapy

Milieu therapy: use of the total environment to treat disturbed children. Create a comfortable, secure environment (or milieu) in which psychotic children were helped to forma new world. The people (patients and saff), setting, and emotional climate are all important to healing. Implications for psychiatric mental health nursing: basic intervention in nursing practice. Constantly involved in the assessment and provision of safe and effective milieus for their patients. Safe environment, referring abused women to safe house, advocating for children * Describe Milieu Therapy * "therapy community" - use of total environment * People (patient and staff), setting, structure, and emotional climate are important to healing * Promoting adaptive coping skills & relationship skills * Programming is meant to be very structured * Helps to meet the patient's needs, keep patients safe, and ease anxiety * People, setting, structure, and emotional climate all important to healing * Important to observe what is going on, the dynamics * It is the nurse's responsibility to help create a Milieu conducive to healing and positivity * Basic assumptions... * The health of every individual is realized and has the potential to grow * Every interaction has the opportunity to be therapeutic * The client owns their own environment (autonomy) * The client owns their own behavior (including consequences) * Peer pressure is a useful and powerful tool * Inappropriate behaviors are addressed as they occur * Restrictions and punishments should be avoided o Conditions that promote a therapeutic community * Basic physiological needs are met * Democratic form of government * Physical facilities are conducive to the needs of therapy * Responsibilities are assigned according to client capabilities o Conflict in the Milieu * Conflict can be positive & negative * Diversity is good! o Role of the nurse * Observe the process * Most of the time, the nurse is in charge (medical model)

Identify 3 nonverbal communications.

Nonverbal communication: tone or pitch of voice, pace, emphasis of words, posture, eye contact, hand gestures, sighs, fidgeting yawning. Body behaviors, facial expressions, eye expression and gaze behavior, voice related behaviors, observable autonomic physiological responses, personal appearance, physical characteristics

Nurse

Nurse: right now nurses are comfortable behind the desks, behind the computer, just doing meds The nursing process: 1. Assessment: interviewing the pt & family, family history, overall appearance (disheveled, inappropriate clothes for weather, how women apply their makeup (may chart very bright makeup-may indicate thought process), watching how family and pt interact, a lot of observing non verbals. Consult other team members. Reviewing their records. Physical exam-always want to rule out any physical issues. a. Members of the psychiatric team i. Psychiatrist-diagnose, prescribe meds, admitting process (only a psychiatrist can admit), can do therapy but usually don't ii. Psychologist-diagnose, treatment, can NOT prescribe, psych testing (only a psychologist can do psych testing), thearpy iii. Advanced Practice Nurse (APN): diagnose, treatment, prescribe meds, group therapy. APN can give therapy and meds all at one time iv. Case manager: TEST QUESTION: looking at quality and cost. Patient x has been here for 2 weeks with no imprpovement lets look at meds. They talk to insurance companies to ask for days etc. Trying to figure out affordable care act. v. Occupational therapy: Help with ADLs, help with getting a person back to being ready to work vi. Rec therapist: help them manage their leisure time, what can they put in place to structure their time and find enjoyment vii. Mission and spiritual care, music therapy, chaplain, pet therapy: if you add therapy to your title you have to have advanced education 2. Diagnosis: analyze the assessment and data, and diagnose. APN can give medical diagnoses. Nurses can give nursing diagnoses. 3. Outcome identification: the purpose and goals that will influence health outcomes and improve the patient's health status. Want them to be measurable, time oriented, realistic. Don't just say "I want to go to group today" because that's a given. Be specific "I will identify 4 support people for discharge" "I will identify 6 triggers that make me want to drink" 4. Planning: interventions. How can I help the patient reach the goals 5. Implementation: Pulling everything together. TEST: When a nurse is pulling everything together into a care plan, her interventions are INDEPENDENT of the rest of the treatment team. She only considers the other thoughts of the treatment team. If the rec therapist says pt has no activities to do at discharge-the nurse may put things like go to art group etc. Evaluation: What is the client's response? Were the goals met

Peer pressure:

Peer pressure is powerful and useful tool-Victoria we really want to watch th Cubs game can we please change the channel, peer pressure may alter her to change the change. Peer pressure is something might be useful. Patients vote for the channel-taking control of their environment for how they want the meeting to go.

5. Identify the contributions Ms. Peplau made to Psychiatric nursing

Peplow: nursing theorist-systematic framework. Look at it from relationships Apply interpersonal theory Interpersonal relationship between the client and nruse and how they work and grow together Correlate stages of development from childhood to the stges of medical disease • Helpful when both the nurse and patient grow • Nursing: human relationship between individual who is sick and the nurse the one that can help • Psychodynamic nursing: how your behavior helps others identify difficulties and human relations to problems that arise during the being sick experience. Knowing yourself, who you are, the relationship, how is this going ot affect the helping person to the patient. Have self awareness so you can go through interpersonal exchange in a therapeutic way • Phases: can overlap o Stage 1: Orientation phase: work together to clarify and efine the problem. Learning to count on other people (infncy) o Identification: ptinent responds selectively to helping person. Learning to delay gratification (toddlerhood). Wait to start exercising after surgery etc. o Exploitation: patient is taking full advantage of services offered, comfortable, participating, exploriting possibilities (early childhood: identify stuff for onself o Resolution: client is freed from identification from the helping person and assume indpenedence (late childhood: developing skills and moving on from the helping person.) • Hildegard Peplau's theory of interpersonal relationships of nursing: first nurse to identify psychiatric mental health nurse both as an essential element of general nursing and as a specialty area that embraces specific governing principles. First nurse to describe the nurse patient relationship as the foundation of nursing practice. What nurses do WITH patients not TO patients. Illness is an opportunity for experiential learning, personal growth, and improved coping strategies. Identified stages of nurse patient relationships and also used the technique of process recording to help students hone their communication and relationship skills. Skills of nurse: observation, interpretation, intervention. Nurses are both aprticipants and observers in therapeutic conversations. Nurses need to observe the behavior of patients and themselves-self awareness. Think of the patient as a person • Implications for psychiatric mental health nursing: Peplau described the effects of different levels of anxiety (mild, moderate, severe, and panic) on perception and learning. Prmoted interventions to lower anxiety and improve patient abilities. * Developed first systematic theoretical framework for psychiatric nursing, established foundation for practice of psychiatric nursing * First to identify psychiatric mental health nursing as an essential element of general nursing * Described nurse-patient relationship: focus on what nurses do with patients rather than to patient * Much more patient centered * Believed illness offered a unique opportunity for experiential learning, personal growth, and improved coping strategies * Observing and listening to patient, developing impressions about the meaning of the patient's situations * Verbalize inferences and validate them with the patient * Art component of nursing: care, compassion, and advocacy * Science component of nursing: application of knowledge to understand a broad range of human knowledge and psychosocial phenomena, intervening to relieve patients' suffering and promote growth * "care for the person as well as the illness" * "think exclusively of patients as persons" * Promoted interventions to lower anxiety with the aim of improving ability to think and function at more satisfactory levels * 6 roles of a nurse: * Resource person * Counselor * Teacher * Leader * Tech expert * Surrogate (taking the role of someone else)

Structured programming

Structured programming decreases anxiety, helps meet patient's needs, helps keep patients safe

Identify populations at risk

Populations at risk for mental illness and inadequate care Immigrants: -Acculturation: learning the beliefs, values, and practices of their new cultural setting -Assimilation: Some immigrants adapt to the new culture quickly, absorbing the new worldview, beliefs, values, and practices rapidly until they are more natural than the ones they learned in their homeland. Refugee: special kind of immigrant, lef their home country to escape intolerable conditions and would have preferred to stay in the culture if that had been possible. Have stress being in new culture. Lot of trauma Cultural minorities: non whites, may be vulnerable to variety of disadvantages, including poverty and limited opportunities for education and jobs. More vulnerable to disordrs Immigrants ■ Often experience anxiety and depression while adjusting to new culture ■ Children may assimilate to new culture quickly while elders may maintain cultural beliefs, causing the children to feel lost between cultures and unsure of their cultural identity Refugees ■ Vulnerable to psychiatric disorders because of the trauma and loss they have experienced Cultural minorities ■ Poverty, limited opportunities for education and jobs ■ Those in poverty - 2-3x more likely to develop mental illness ■ Less likely to seek care because of perceived bias and experiencing culturally uncomfortable care from HCPs

9. Identify the purpose of the psychiatric mental health assessment

Psychiatric mental health nursing assessment: purpose: establish rapport, obtain an understanding of the current problem or chief complaint, review physical status and obtain baseline vital signs, assess for risk factors affecting the safety of the patient or others, perform a mental status exam, assess psychosocial status, identify mutual goals for treatment, formulate a plan of care * Establish rapport * Obtain an understanding of a current problem or chief complaint * Review physical status and obtain baseline vital signs * Assess for risk factors affecting the safety of the patient or others * Perform a mental status exam * Assess psychosocial status * Identify mutual goals of treatment * Formulate a plan of care

Psychoanalytic theory

Psychoanalytic theory is a method of investigating and treating personality disorders and is used in psychotherapy. Included in this theory is the idea that things that happen to people during childhood can contribute to the way they later function as adults.

Define a release AMA:

Release against medical advice AMA: disagreement between the mental health care providers and the patient as to whether continued hospitlizatio nis necessary, may be released AMA. No danger of patient or others o Disagreement between mental health care providers and patients as to whether continued hospitalization is necessary. o Patients may be released against medical advice.

Review the Statement of Patient Rights

Rights of the hospitalized patient: explain rights to patient on admission, any infringement of rights should be documented Typical items included in hospital statements of patients' rights: Right to be treated with dignitiy, right to be involved in treatment planning and decisions, right to refuse treatment including meds, right to request to leave the hospital even AMA, right to be protected against harming oneself or others, right to a timely evaluation in the event of involuntary hospitalization, right to legal counsel, right to vote, right to communicate privately by telephone an din person, right to informed consent, right to confidentiality regarding one's disorder and treatment, right to choose or refuse visitors, right to be informed of research and refuse to participate, right to least restrictive means of treatment, rght to send and receive mail and to be present during any inspection of packages received, right to keep personal belongings unless dangerous, right to lodge a complaint through a plainly publicized procedure, right to participate in religious in worship

Identify the 3 leadership styles.

Styles of leadership: 1. autocratic leader: exerts control over the group and does not encourage much interaction among members. ▪ For example, staff leading a community meeting with a fixed, time limited agenda may tend to be more autocratic. 2. Democratic leader: supports extensive group interaction in the process of problem solving ▪ Psychotherapy groups must often employ this empowering leadership style. 3. Lasseiz-faire leader: allows the group members to behave in any way the choose and does not attempt to control the direction of the group

In what ways does the psychiatric nurse keep the patient safe?

Safety: safe environment for patient, staff, and other patients. Patients don't have personal items on unit. Joint commission has national patient safety goals: identify patients correctly, use medicines safely, prevent infection, identify patient safety risk. Track atients's whereabouts and activities, monitor visitors, discourage intimate relationships between patients, specialized training against aggression and violence and elopement (escape) Unit design to promote safety: most common suicide in units is hanging. Use break bars (designed to hold a minimial amount of weight), windows locked, safety mirrors used, showers have non weight bearing showerheads, beds are platforms, doors open out instead of in, continuous hinges used on doors to preven hanging risk, furniture anchored in place, drapes mounted on a track that is firmly anchored to celinng, mini blinds contained withn window glass, bathroom towel bars eliminated, steel boxes installed around plumbing, mirrors ploshed stainless steel and not gass o Staff members check all personal property and clothing to prevent any potentially harmful items (medication, alcohol, or sharp objects). o Tracking patients' whereabouts and activities is done periodically or continuously, depending upon patients' risk for harming themselves or others. ▪Actively suicidal patients: one to one observation is essential o Visitors are another potential safety hazard ▪Visits may be overwhelming or provide patients with unsafe items ●Staff should inspect bags and purchases o Intimate relationships between patients are discouraged or expressly prohibited. o Aggression and violence may also occur as a result of living in close quarters with reduced outlets to manage frustration ▪Psychiatric staff should have specialized training that promotes healthy, safe, and appropriate interactions. o Patients on inpatient psychiatric units are considered at risk for suicide. o Unit Design Safety features: ▪Closets may be equipped with break bars designed to hold a minimal amount of weight ▪Windows are locked and are made of safety glass and safety mirrors are typically used ▪Showers may have non-weight bearing showerheads ▪Beds are often platforms rather than mechanical hospital beds than can be dangerous because of their crushing potential or looping hazards. o Hunt and Sine (2009) recommended other important design elements on inpatient psychiatric units. ▪Patient room doors should open out instead of in to prevent patients from barricading themselves in their rooms ▪Continuous hinges should be used on doors rather than three bunt hinges to prevent hanging risk ▪Furniture should be anchored in place with the exception of a desk chair ▪Drapes should be mounted on a track that is firmly anchored to the ceiling rather than curtain rods ▪Mini blinds that are contained within window glass provide significantly more safety than those whose mountings are accessible. ▪Bathroom towel bars should be eliminated in favor of breakable towel hooks ▪Steel boxes can be installed around plumbing. ▪Mirrors should be polished stainless steel and not glass.

Identify behaviors that nurses can use to help build therapeutic relationships.

Self awareness, self understanding, your beliefs about everything. WE have the potential to do something therapeutic (or untherapeutic) in every interaction. All moments have the potential to be therapeutic. Build trust, verbal (introducing yourself), non verbals (being present), following through on what you said, all builds trust and repore Establish trust, allows the client to have confidence in you, have a desire to be there, demonstrate your caring, having respect for the client (believing in the dignitity and worth of the client even if the patient is in the wrong), understand your biases, be empathetic, be genuine, be understanding Ask the elderly if they prefer to be called Mr. Smith, knock on door before entering Phases of the therapeutic relationship -Maintian trust -Promote client's insight and perception of realtiy -Client uses problem solving towards goal -Continue to evaluate problem * Identify and explore the needs to the patient * Being genuine * Establish clear boundaries * Use alternate problem-solving approaches * Develop new coping skills * Encourage behavior change * Assume accountability and responsibility for conduct and consequences of actions * Focus on patient needs * Be aware and incorporate the latest knowledge made available from research (clinical competence) *SELF AWARENESS IS IMPORTANT * Delay judgment * Work under clinical supervision

Distinguish the difference between a therapeutic and social relationship.

Social versus therapeutic: a relationship is an interpersonal process that involves two or more people. Social, intimate, or therapeutic relationships. Intimate relationships-occur between people who have an emotional commitment to each other. Social relationships: defined as a relationship that is primarily initiated for the purpose of friendship, socialization, enjoyment, or accomplishment of a task. Mutual needs are met during social interactions. Communication skills may include giving advice and meeting basic dependency needs. Superficial communication. Little emphasis on the evaluation of the interaction Therapeutic relationships: the nurse maximizes his or her communication skills, understanding of human behaviors, and personal strengths to enhance the patient's growth. Clinician's interactions address patient concerns, respect the patient as a partner in decision making, and use language that is straight forward. Focus on patient's problemsa and needs.The needs of the patient are identified and explored, clear boundaries are established, alternate problem solving approaches are taken, new coping skills may be developed, behavioral change is encouraged. Nurses need to have accountability, focus on the patient needs, clinical competence, delaying judgment, and supervision by a clinican or team. * It is important to have that connection/relationship in order for the helping process to work. * Social: relationship primarily initiated for the purpose of friendship, socialization, enjoyment, or accomplishment of a task * Roles may shift * Superficial communication * Little emphasis on evaluation of the interaction * Therapeutic: nurse maximizes communication skills, understanding of human behavior, and personal strengths to enhance patient growth * Relationship focused on patient's problems and needs (nurses needs met outside of relationship) * Focus on patient

Functions of group:

Socialization: teaching social norms is always occurring throughtout group. Wait for their turn, raise their hands, offer support Support: might see an actual support group, people coming together with shared concerns and worries Task completion: groups assisting in endeavors that is beyond the individual to be able to do it alone. Tasks that you want to do, task force, theres a task to do and it's going to end. Commarodity: individuals receive joy from interactions with people in group Informational: group members share knowledge Normative: different groups establish norms Empowerment: changes made by group when individuals alone is ineffective Shared Governance: leadership that is provided by groups rather than individuals. Huge tenant of magnet status for nursing.

Provide examples of blurring boundaries with Patients.

TEST: Transferance vs counter transfereance Transferance: (patient to nurse): projecting on to the therapist. Mallorie is talking to her therapist like she is her mom Counter transference; (nurse to patient): the therapist is responding to Mallorie's transference with what she's doing. There can be a transference without a counter transference. There can be a counter transference where Mallorie comes in and the therapist thinks she like her daughter, and she wants to take extra care for her because she reminds her of her daughter. Supervision is so important. Blurred boundaries. If there is too much of a conflict of interest, the therapist should be taken off the case. Going and getting supervision for problems with counter transference or when you don't know what to do. Establishing boundaries and roles Establishing boundaries: physical boundaries (general environment), the contract (set time, confidentiality, agreement etc), personal space (physical space, emotional space), Blurring of boundaries: 2 common circumstances when boundaries are blurred: when the relationship is allowed to slip into a social context and when the nurse's needs (for attention, affection, and emotional support) are met at the expense of the patient's needs. Boundaries are needed to protect the patient. Sexual violations are the worst violations. Blurring of roles: often a result of unrecognized transference or counter transference Transference: occurs when the patient unconsciously and inappropriately displaces (transfers) on to the nurse feelings and behaviors related to significant figures in the patient's past. Explore negative transference Counter transference: the nurse unconsciously and inappropriately displaes on to the patient feelings and behaviors related to significant figures in the nures's past. Frequently the patient's transference evolves countertransferene in the nurse. Recognize counter transference to empower the patient. Common countertransference reactions: boredom (indifference), rescue, overinvolvement overindentification, misuse of honesty, anger, hoplesness or helplessness Self-check on boundaries: reflect on thoughts and actions with patients. Do a nursing boundary index self check * Relationship slips into social context * When the nurse's needs (attention, affection, and emotional support) are met at the expense of the patient's needs

optimal group conditions

The most ideal group: 5-10, 8-12 people, sitting in a circle, close ended group.

Nursing process (class notes)

The nursing process: 1. Assessment: interviewing the pt & family, family history, overall appearance (disheveled, inappropriate clothes for weather, how women apply their makeup (may chart very bright makeup-may indicate thought process), watching how family and pt interact, a lot of observing non verbals. Consult other team members. Reviewing their records. Physical exam-always want to rule out any physical issues. a. Members of the psychiatric team 2. Diagnosis: analyze the assessment and data, and diagnose. APN can give medical diagnoses. Nurses can give nursing diagnoses. 3. Outcome identification: the purpose and goals that will influence health outcomes and improve the patient's health status. Want them to be measurable, time oriented, realistic. Don't just say "I want to go to group today" because that's a given. Be specific "I will identify 4 support people for discharge" "I will identify 6 triggers that make me want to drink" 4. Planning: interventions. How can I help the patient reach the goals 5. Implementation: Pulling everything together. TEST: When a nurse is pulling everything together into a care plan, her interventions are INDEPENDENT of the rest of the treatment team. She only considers the other thoughts of the treatment team. If the rec therapist says pt has no activities to do at discharge-the nurse may put things like go to art group etc. Evaluation: What is the client's response? Were the goals met

Identify 3 of Yalom's therapeutic factors found in group therapy.

Therapeutic factors common to all groups: instillition of hope, universality (you are not alone), imparting of information (teaching from leader or advice from peers), altruism (members gain profit from giving suppor to others, improve self value), corrective recapitulation of the primary family group, development of socializing techniques, imitative behavior, group cohesiveness, catharsis, existential resolution ▪ Instillation of hope: leader shares optimism about successes of group treatment, and members share their improvements. ▪ Universality: members realize that they are not alone with their problems, feelings, or thoughts. ▪ Imparting of Information: participants receive formal teaching by the leader or advice from peers. ▪ Altruism: members gain or profit from giving support to others, leading to improved self-value. ▪ Corrective recapitulation of the primary family group: members repeat patterns of behavior in the group that they learned in their families, with feedback from the leader and peers, they learn about their own behavior. ▪ Development of socializing techniques: members learn new social skills based on others feedback and modeling. ▪ Imitative behavior: members may copy behavior from the leader or peers and can adopt healthier behavior. ▪ Interpersonal learning: members gain insight into themselves based on the feedback from others during later group phases. ▪ Group Cohesiveness: arises in a mature group when each member feels connected to the other members, the leader, and the group as a whole, members can accept positive feedback and constructive criticism. ▪ Catharsis: through experiencing and expressing feelings, therapeutic discharge of emotions is shared. ▪ Existential Resolution: members examine aspects of life (loneliness, mortality, responsibility) that affect everyone in constructing meaning. ● Instillation of hope: by observing process of others in the group with similar problems, patient gets hope that their problems can be solved ● Universality: individuals come to realize that they're not alone in the problems, thoughts, feelings that they're expericining. Means that they're just not alone in the world. 'I found my people' ● Imparting information: group members sharing knowledge, leaders teach groups and provide information to the members. If leader is teaching a lamaz class or diabetic class, leader will impart information. But if leader is doing group therapy, don't tell them what to do or give advice ● Altruism: individuals provide assistance and support to each other. Promotes positive self growth. If we're doing a group and Jhustin is talking about difficulties, and then Joe says I had some of that too growing up and it was hard and I found focusing on school I was able to blah blah blah, and then Jhustin says thank you I'm going to try that, so helpful. Joe feels beter, he gave something, he offered something. ● Corrective recapitulation of the primary family group: Jhustin is talking about hardships living with his dad, so we know that about him, we're in an ideal group, Paul is a little older than Jhustin and reminds him of his dad. Paul says well you know what, I don't know what but I think you need to give your dad a break. Jhustin gets angry at Paul, you're just like my dad. As a leader, she will use the conflict, she will do work here asking what they're feeling, work through the emotions. Did what the mother did in his mind, but then apologized and sat with him in shared pain. This was a corrective movement. IF she hadn't had told the truth, she wouldn't have had the chance. 'I can push somebody to this extremem, but an adult can still forgive me and hold me and be for me'. If there is transference and countertransference, leader can go to corrective recapitulation of the primary family group. ● Development of socializing techniques: interaction from feedback from group, learn maladaptive social skills and adjust. Socializing needs to happen, correcting that is important, but also ask them about how their behaviors feel. ● Imitative behavior: group members who have mastered a skill are role models ● Interpersonal learning: learning from each other ● Group cohesiveness: sense of belonging, 'we' ● Catharsis: in the group expressing positive and negative feelings. When people have the opportunity to share their story ● Existential factors: group tells members to take control of their own lives, the quality of their existence and their life

What is meant by milieu management?

Therapeutic milieu: milieu refers to surroundings and physical environment. Offers patients sense f security and promotes healing. Include activities, unit rules, reality orientation practices, and unit environment. Intearctions between patitns, staff, other patients, visitors etc. Real life training ground for practicing communication and coping skills o Milieu: overall environment and interactions of the environment o Milieu management: Peplau (1989) referred to this as the therapeutic milieu. ▪A well-managed milieu offers patients a sense of security and promotes healing. ▪Structured aspects of the milieu include activities, unit rules, reality orientation practices, and unit environment. ▪Less tangible factors: interactions that occur among patients and staff, patients and patients, patients and visitors, and so forth. ▪Therapeutic milieu can serve as a real life training ground for practicing communication and coping skills to prepare for a return to the community.

Identify your own value system with: touch, time, eye contact, use of medicine, mental health care, death and dying.

Touch: I don't like to be touched a lot. Time: am very on time. Eye contact: shows resepct and that you're listening. Use of medicine: Yes if it helps you get better. Mental health care: important, should not have stigma. Death and dying: medicalized, part of life, religious aspect ○ Western perspective ■ Touch: indicates warmth and conveys caring ■ Time: linear/always moving forward, being on time is a sign of courtesy and responsibility ■ Eye Contact: attentiveness, politeness, respect, honesty, and self-confidence ■ Use of medicine: best treatment ■ Mental health care: mind and body are separate entities ○ Asian (Eastern culture) ■ Family as basis for one's identity ■ Family interdependence and group decision-making are the norm ■ Body-mind-spirit are single entity ■ No sense of separation between a physical illness and a psychological one ■ One is born into an unchangeable fate ■ Disease is caused by fluctuations in opposing forces (yin-yang energies) ■ Expression of emotion (negative or positive) is private ■ Exercise emotional restraint ■ Direct eye contact can show sign of disrespect ■ May not like to be touched by strangers ○ Latino-Hispanic ■ Based on shared language ■ Traditionally taught to avoid eye contact with authority figures ■ Accustomed to frequent physical contact ○ Native Americans (Indigenous culture) ■ Significance on the place of humans in the natural world ■ Basis on one's identity is the tribe, no concept of person ■ Person is an entity only in relation to others ■ Holism of mind-body-spirits ■ Disease is a lack of harmony of the individual with others or the environment ■ Disrespectful or sign of aggression to engage in eye contact ■ Listening is sign of respect

TEST: When a nurse is pulling everything together into a care plan, her interventions are..

When a nurse is pulling everything together into a care plan, her interventions are INDEPENDENT of the rest of the treatment team. She only considers the other thoughts of the treatment team. If the rec therapist says pt has no activities to do at discharge-the nurse may put things like go to art group etc.

How is the nurse's role unique to the multi-disciplinary treatment team?

Working as a team in inpatient care: Nurses lead the planning meeting for treatment. Nurses have continuous assessment findings, patients adjustment to unit, health concerns, psycho educational nees, deficiits in self care the patient may have. Nurses offer education and support in an individual or group format. 1. Psychiatric mental health RNs: diagnosing and treating responses to psychiatric disorders, coordinating care, counseling, giving meds and evaluating responses, education 2. Psychiatric mental health advanced practice RNs: master or doctoral degrees. Diagnose psychiatric conditions, prescribe psychotropic meds and integrative therapy, conduct psychotherapy; involved in case management, consulting, education, research o The team (including patient) generally formulates a full treatment plan. The nurse's role in this process is often to lead the planning meeting. o Nurses are in a unique position to contribute valuable information, such as continuous assessment findings, the patient's adjustment to the unit, and any health concerns, psycho educational needs, and deficits in self-care the patient may have. o Additionally, nurses have an integral function to facilitate a patient's achievement of therapeutic goals by offering education and support in an individual or group format. o Members of the Multidisciplinary treatment team (box 4-3 page 76) ▪ Psychiatric mental health registered nurses ●RNs w/ a focus on mental health ●Diagnose and treat responses to psychiatric disorders, coordinate care, counsel, give meds and evaluate responses, educate ▪ Psychiatric mental health advanced practice registered nurses ●Master's or Doctoral level ●CNS or NP ●Diagnose psychiatric conditions, prescribe psychtropic meds & integrative therapy, conduct psychotherapy ●Involved in case management, consulting, education, research ▪ Psychiatrists ●Admit the patient to the unit ●In-depth psychotherapy, medication therapy ●They are physicians ▪ Psychologists ●DO PSYCH TESTING; consultation for the team; individual, family, or marital therapy ●Master's or doctoral ▪ Social workers ●Basic level: Help with resources ●Licensed clinical: individual, family, and group therapies; often primary care providers ▪ Counselors ●Co-lead groups, provide basic supportive counseling, assist in psychoeducational & recreational activities ▪ Occupational, recreational, art, music, and dance therapists ▪ Medical advanced practice nurses, medical doctors, and physician assistants ●Provide diagnoses and treatments on a consultation basis ▪ Mental health workers (mental health specialists/psychiatric technicians) ●Work under direct supervision of RNs; meet pts basic needs ▪ Pharmacists

Identify patient rights in psychiatry

You can restrict someone's rights when they are at risk of harming themselves or someone else. They are informed in writing about their limitation of rights If someone is admitted inpatient, they lose the right to bear arms Patients' rights under the law 1. Right to treatment: medical and psychiatric care and treatment be provided to all persons admitted to a public hospital. Treament must meet the folliwng criteria: the environment must be humane, staff must be qualified and sufficient, the plan of care must be individualized 2. Right to refuse treatment: patients may withhold or withdraw consent at any time. People who have been committed to etain their right to refuse treatment. In an emergency to prevent a person fro mcausing serious and imminent harm to self or others a person may be medicated without a court hearing, after court hearing they must meet requirements. 3. Right to informed consent: patient's right to self determination. Patient must be informed of the nature of their problem or condition, purpose of a proposed treatment, risks and benefits of that treatment, the alternative treatment options, the probability that the proposed treatment will be successful, the risks of not consenting to treatment Competency: capacity to understand the consequences of ones decisions Implied consent: generally you prefer to obtain informed consent, instead of just a passive nod of the patient indicating implied consent 4. Rights regarding involuntary admission and advance psychiatric directives: patints can prepare an advance psychiatric directive document to express treatment choices 5. Rights regarding restraint and seclusion: use only in emergenies, when less restrictive measures are not useful. Restraint is any mechanical or physical device, equipment, or material that prevents movement. May be chemical restraint. Seclusion is confining a patient alone. Timeout is an intervention in which a patient chooses to spend time alone. Orders and documentation: there must be written or verbal ordr for restraints or seclusion (or right after in an emergency) NEVER PRN or STANDING ORDERS. Must be DC'd as soon as patient calms down. Document restraint and seclusion assess every 15-30 min, assess physical needs safety, comfort. Rights regarding confidentiality: Confidentiality is privacy of care. Identify under which conditions a patient would be committed to a mental hospital. Right to treatment ▪ Treatment must meet the following criteria: ● Environment must be humane ● Staff must be qualified and sufficient to provide adequate treatment ● Plan of care must be individualized o Right to refuse treatment ▪ Patients may withhold consent or withdraw consent at any time ▪ Does commitment mean that a person will be forced to take medication? ● No people who have been committed retain their right to refuse treatment ▪ Under what circumstances can someone be medicated against his or her will? ● In an emergency to prevent a person from causing serious and imminent harm to self or others, a person may be medicated without a court hearing. ● Following a court hearing, person can be medicated if: o 1. Person has serious mental illness o 2. Person's ability to function is deteriorating or he or she is suffering or exhibiting threatening behavior o 3. Benefits outweigh the harm of treatment o 4. Person lacks capacity to make reasoned decisions about treatment. o 5. Less restrictive services have been found inappropriate. o Right to Informed consent ▪ Based on a person's right to self-determination ▪ Consent for surgery, electroconvulsive treatment, or the use of experimental drugs or procedures must be obtained. ▪ Patients must be informed of the following: ● Nature of their problem or condition ● Nature and purpose of a proposed treatment ● Risks & benefits of treatment ● Alternative treatment options ● Probability that the proposed treatment will be successful ● Risks of not consenting to treatment ▪ Competency: capacity to understand the consequences of one's decisions. ▪ Guardians are typically selected from among family members ● 1. Spouse, 2. Children or grandchildren, 3. Parents, 4. Adult siblings, and 5. Adult nieces and nephews. ▪ Implied consent ● For example: if you approach the patient with a medication in hand, and the patent indicates a willingness to receive the medication, implied consent has occurred. o Rights regarding involuntary admission and advance psychiatric directives ▪ Psychiatric directive document can clarify the patient's choice of a surrogate decision maker and instructions about hospital choices, medications, treatment options, provider preferences, and emergency interventions;. o Rights regarding restraint and seclusion: ▪ Least restrictive means of restraint for the shortest duration is always the general rule ▪ Restriction can be any mechanical or physical device, equipment, or material that prevents or reduced movement of patient's legs, arms, body, or head. ▪ Restraint may also be chemical in nature ● Usually considered less restrictive than mechanical or physical interventions, but they can have a greater impact on the patient's ability to relate to the environment because psychotropic medication alters the ability to think and produces other side effects ▪ Seclusion: confining a patient alone in an area or a room and preventing the patient from leaving. ▪ Timeout: intervention in which a patient chooses to spend time alone in a specific area for a certain about of time. o Rights regarding confidentiality ▪ HIPAA and right to privacy ▪ Confidentiality after death: dead man's statute ▪ Confidentiality of professional communication ▪ Confidentiality and Human Immunodeficiency Virus Status ▪ Exceptions: ● Duty to warn and protect 3rd parties ● Statutes for reporting child and elder abuse

1. Describe Freud's three levels of psychological awareness

a. Conscious: here now, where you are, what you're doing b. Preconscious: temporarily forgotten, not thinking about it: what was for breakfast? c. Unconscious: can't remember the memory. In dreams. APN trys to bring the unconscious to conscious Levels of awareness: through use of talk therapy and free association, Freud came to the conlusion tht there were three levels of psychological aweareness in operation 1. Conscious: the tip of the iceberg. It contains all the material a person is aware of at any one time, including perceptions, memories, thoughts, fantasies, and feelings 2. Preconscious: just below the surface of awareness, contains material that can be retrieved rather easily through conscious effort 3. Unconscious: includes all repressed memories, passions, and unacceptable urges lyding deep below the surface. Trauma usually placed in unconscious. With therapy unconscious material can be brought into conscious awareness Describe Freud's three levels of psychological awareness (pg. 20) * *Can also be called the Topography of the Mind* Conscious * Tip of iceberg * All material a person is aware of at any one time (perceptions, memories, thoughts, fantasies, feelings) Preconscious * Just below the surface of awareness * Material that can be retrieved easily through conscious effort Unconscious/Subconscious * Deep below the surface of awareness * Repressed memories (too difficult to deal with), passions, and unacceptable urges * Individual usually unable to retrieve material without assistance of a therapist (can bring material to conscious)

3. Identify Freud's psychosexual stages of development

a. Psychosexual stages of development: b. -Oral (0-1 yr): mouth (sucking, biting, chewing), conflict-weaning, deired outcomes-develop trust, tasks-mastery of gratification of oral needs c. -Anal (1-3 yr): anal region satisfaction, conflict-toilet training, tasks-control over id/delay gratification, desired otucomes-control over impulses d. -Phallic (3-6 yr): genitals (masturbation), conflict-oedipus and electra, tasks-sexual identity with parent of same sex, begin development of supereogo, dsired outcomes-identification with parent of the same sex e. -Latency (6-12 yr): growth of ego functions and ability to care about and relate to others outside the home, desired outcomes-the development of skills needed to cope with the environment f. -Genital (12 yr and beyond): genitals (sexual intercourse), tasks-development of satisfying sexual and emotional relationhip, emancipation from parents, planning life goals, desired outcomes-ability to be creative and find pleasure in love and work Developmental stages of Freud g. Oral: birth-18 months: infant is directed soley by id, sucking, chewing, biting, exploring world through mouth h. Anal: 18 months-3 years: he's so anal-trying to hold onto their bowels and not let anything go, person is so tight and tightly wound. Task is to gain independence i. Phalic: 3-6 years old: Oedipus and electra complex: little girl wants to marry daddy, little boy marry mommy j. Latency: 6-12 years: less egocentric and more group centered, focused on rules, more group focused, more into same sex relationships k. Genital stage: 13-20 yrs: reawakening of drive in oral stge, now its in the genitals stage. Freud stops there. Stage-Source of satisfaction-Desired outcomes-Failure personality traits Oral (0-1yrs)-Mouth-Development of trust in environment, realization that needs can be met-Associated with passivity, guilibility, and dependence on the use of sarcasm, development of orally focused habits (smoking, nail-biting, etc.) Anal (1-3yrs)-Anal region-Control over impulses-Associated with anal retentiveness (stinginess, rigid thought patterns, OCD) or anal-expulsive behavior (messiness, cruelty) Phallic (3-6yrs)-Genitals-Identification with parent of the same sex-May result in reckless, self-assured, and narcissistic person, inability to love and difficulties with sexual identity Latency (6-12yrs) -- Development of skills needed to cope with environment-Can result in difficulty identifying with others and in developing social skill (leading to sense of inadequacy) Genital (12 and beyond)-Genitals-Ability to be creative and find pleasure in love and work-May derail emotional and financial independence, may impair personal identity and future goals, and disrupt ability to form relationships

Advanced Practice Nurse (APN)

i. Advanced Practice Nurse (APN): diagnose, treatment, prescribe meds, group therapy. APN can give therapy and meds all at one time

Mission and spiritual care, music therapy, chaplain, pet therap

i. Mission and spiritual care, music therapy, chaplain, pet therapy: if you add therapy to your title you have to have advanced education

Occupational therapy:

i. Occupational therapy: Help with ADLs, help with getting a person back to being ready to work

psychiatrist

i. Psychiatrist-diagnose, prescribe meds, admitting process (only a psychiatrist can admit), can do therapy but usually don't

psychologist

i. Psychologist-diagnose, treatment, can NOT prescribe, psych testing (only a psychologist can do psych testing), thearpy

i. Rec therapist:

i. Rec therapist: help them manage their leisure time, what can they put in place to structure their time and find enjoyment

Case manager: TEST QUESTION:

looking at quality and cost. Patient x has been here for 2 weeks with no imprpovement lets look at meds. They talk to insurance companies to ask for days etc. Trying to figure out affordable care act.

TEST: how do people chart-

make sure everything is filled in, write objective data, don't leave things blank. Describe the behavior. Different kinds of charting: SOAP (subjective, objective, assessment, plan). PIEP: problem, intervention, evaluation, plan. PIE: problem, intervention, evaluation. Narrative charting. Follow the plan of charting at your institution.

What encompasses cultural competence?

o Cultural competence: you can't be competent in all cultures. But you can go out there and learn about it. You can be culturally sensitive and embrace a culture. That's a lot differnent then 'tolerating' a culture. Culturally competent care: o Cultural competence: nurses adjust their practices to meet their patients cultural beliefs, practices, needs, and preferences. o Cultural awareness: the nurse recognizes the enormous impact culture makes on what patients' health calues and practices are, how and when patients decide they are ill and need care, and what treatments they will seek when illness occurs. Examine own cultural beliefs and beliefs of others. Examin assumptions and expectations of cultures. o Cultural knowledge: attened cultural events and programs, form friendships, attend in service programs. Study resources. Study ethnic and religious cultures: beliefs, values, worldview, non verbal communication, family roles of psychosocial norms, etiquette norms, family roles and psychosocial norms, cultural views about mental health and illness. o Cultural encounters: sets a foundation, that cultural guidelines cannot tell us anything about a particular patient. Prevents stereotyping o Stereotyping: tendency to believe that every member of a group is like all other members. o Cultural skill: ability to perform a cultural assessment in a sensitive way. Ensure that meangiful communication can occur. Use cultural assessment tools. Ask apporporiate questions, promote openness. Acknowledge cultural values and practices o Cultural desire: indiciates that the nurse is not acting out of a sense of duty but from a sincere and genuine concern for patients' welfare Nurses adjust their practices to meet their patients' cultural beliefs, practices, needs, and preferences ○ Five constructs: ■ Cultural awareness: nurse recognizes cultures enormous impact on what patients' health values and practices are ■ Cultural knowledge: attending cultural events or programs, forge friendships with members of diverse cultural groups, participate in in-service programs at which members of diverse groups speak about their cultural norms, and study print or online resources designed for HCPs ■ Cultural encounters: deters nurses from stereotyping and helps to develop confidence in cross-cultural interactions ■ Cultural skill: ability to perform a cultural assessment in a sensitive way (ensure meaningful communication, create openness, etc.) ■ Cultural desire: indicates that the nurse is not acting out of a sense of duty but from a genuine and sincere care for the patient's well being

● Types of groups

o Heterogeneous: A range of differences exists among members o Homogeneous: All members share central traits ▪ Men's group ▪ Group of pts w/ bipolar disorder o Closed: Membership is restricted; no new members added when others leave o Open: New members are added as others leave ▪ Inpatient group with transient membership o Subgroup: An individual or small group that is isolated w/in a larger group and functions separately ▪ Members may have greater loyalty, more similar goals, or more perceived similarities to one another than they do the larger group Types of groups: Task group Teaching group Support group

● Identify under which conditions a patient would be committed to a mental hospital.

o Neither voluntary nor involuntary admission determines a patient's ability to make informed decisions about his or her health care. o A medical standard or justification for admission must exist o A well-defined psychiatric problem must be established, based on current illness classifications in the DSM-5. o The presenting illness should be of such a nature that it causes an immediate crisis situation or that other less restrictive alternatives are inadequate or unavailable. o There must be a reasonable expectation that the hospitalization and treatment will improve the presenting problem.

● Phases of a group

o Orientation phase ▪ Group is forming ▪ Leader structures an atmosphere of respect, confidentiality, and trust ▪ Purpose is stated ▪ Members may be overly silent (not yet established trust) o Working phase ▪ Leader encourages a focus on problem solving that is consistent with the purpose of the group ▪ Members begin to feel safe within the group; conflicts may be expressed ▪ "Storming, norming, and performing" o Termination phase ▪ Leader encourages members to reflect on progress made & identify post termination goals ▪ Members may feel loss or anger about group's ending Group phases: 1. Orientation phase: leader and members work together to establish goals and rules. Leaders establish trust. Beginning. Members are suprficial 2. Middle or working phase: productive work toward completion of the task. If it's therapy group, we might be working on conflict. If they are in conflict, they are doing really good because they're working. Trust is established, people feel cohesives, conflict managed 3. Termination phase: some people feel sense of loss, grief process. Leader encourage group to discuss feelings of loss and reminisce about accomplishments made. Some patients might feel abandoned. IT's important to say good bye, have closure.

Provide an example of process versus content when working in a group setting.

o Process: the dynamics of interaction among the members (who talks to whom, facial expressions, body language, and progression of group work). o Content: all that is said in the group (groups topics).

SOLER:

sit squarely facing the client, Observe an open posture, lean forward toward client, establish eye contact, be relaxed

Identify ways in which nonverbal communications are different amongst cultures.

• Time: Americans like to be on time. Some cultures do not believe in time, they come and go as they please. • African Americans: not trusting medical professionals or diagnoses. Not a lot of diverse providers. Tuskegee incident was 1947. We've done a lot of research on white men so African Americans have different genetics o Many households are women led o Don't lump together African immigrants with African Ameircans o May practice folk medicine, receive care from granny, old lady, sprituatlist o Hypertension, sickle cell anemia, sarcadosis, all common in black • Native Americans o Fewer than half live on reservations o Touch is not highly regarded, may be inappropriate o Uncomoftabl expressing emotions o Family and tribe o Present time oriented o Shaman medicine man • Asian pacific islanders o Lot of different people o Little tricker to say how they use time and space because theres so many o Many younger Asian ammericans are totally acculturated o Soft spoken, to raise their voice may be seen as a loss of control o Touch is not considered totally appropriate o Family is emphasized o Educaiton is highly valued o REgliisou practice: Daoism, Christianity, Buddhism, Hinduism o Time orientation: past and present o Restore balance of ying and yang • Hspanic o Less mental illness, may be due to cohesive families o Group oriented o Large extended family o Presnt oriented o Roman Catholicism o Folk medicine, folk healer is called the curadera o Father head of household • Western Europeans o Body language and expressive, touching o Italy france and Greece o Strong alliance to cultural heritage o Father viewed as head of household • Western Americans o Present oriented, viewed as what happens is God's will o American culture, may have som esuperstiitons • Arab americans o Arabic is official language. o Might stand close together, touch between same sex, speech loud and expressive o Tme is present oriented, punctuality not serious o Man is head o Family is primary social organization, children loved o Women-modest, hijab o Health concerns: CV disease, sickle cell anemia o Islam is religion, no separataion fo church and state o Spiritual treatment-bad nerves, spirtual o Mental illness is stigma-symptoms are physical • Jewish o Spain, Portugal etc o Located in large urban areas o Not a race but a group ○ Western culture: nod means "yes", smiling and nodding means agreeing, thumbs up means "good", rolling eyes is an insult ○ Other cultures: raising eyebrows or rolling the head from side to side means "yes", smiling and nodding means "I respect you", thumbs up is an obscene gesture, pointing one's foot at another is an insult

Identify the ways in which America ethnic groups are changing

• We are getting more diverse. More minorities than white caucasions in 2040