Mental Health Exam 1

What are the two levels of suicide recognition?

-QPR -SAFE-T

Self Awareness

•Understanding one's own beliefs, thoughts, motivations, biases, limitations •Requires self-examination •- Can be uncomfortable •- Feedback from trusted others useful

True or False: Suicidal people are intent on dying

False

True or False: Suicide happens without warning

False

True or False: Suicide occurs more frequently during holidays

False

Suicide Across the Lifespan: Adults/Elders

- Suicide rates peak at mid age, then 75 years and older - Physical illness, finances common precipitants - Increasing rates among military, first responders

What is the nursing diagnosis for hearing voices?

"Alteration in sensory perceptions" is the NDX for a patient hearing voices. The evidence should relate to the DX. "Related to" biochemical imbalance or not taking medication, not "related to schizophrenia." They patient does not always hear voices, but they always have schizophrenia.

Hildegard Peplau

"Mother of Psychiatric Nursing" -Created nurse-patient relationship & therapeutic touch. -Moved towards autonomy and independence. -Wrote interpersonal relationships in nursing.

Suicide Across the Lifespan: Children/Young People

- 3rd leading cause of death children 10-14 years - 2nd leading cause of death people 15-34 years - 17% high schoolers reported serious SI (suicidal ideation)

What are the steps of a suicide assessment 5-step evaluation and triage?

1. Identify risk factors 2. Identify protective factors 3. Conduct suicide inquiry 4. Determine risk level/intervention 5. Documentation

Basic Level and Advanced Practice Psychiatric-Mental Health Nursing Interventions: Psychotherapy

Individual, couple, group, or family therapy using evidence-based therapeutic frameworks and the nurse-patient relationship

What is a healthy though process?

A systematic, well-organized, logical thought process. Any variations of this leads to unhealthy thought processes. For example: Circumstantiality Flight of Ideas Loose Associations Neologisms Tangentiality Clanging Echolalia Word Salad

Johari Window

A model that describes the relationship between self-disclosure and self-awareness.

Tangentiality

A thought disturbance that is marked by oblique speech in which the person constantly digresses to irrelevant topics and fails to arrive at the main point. In extreme form, it is a manifestation of loosening of associations, a symptom frequently seen in schizophrenia or delirium.

Word Salad

A word salad, or schizophasia, is a "confused or unintelligible mixture of seemingly random words and phrases", most often used to describe a symptom of a neurological or mental disorder. The term schizophasia is used in particular to describe the confused language that may be evident in schizophrenia.

Which of the following identifies the titles that registered nurses will use and what they are legally allowed to do? A. State Boards of Nursing B. Professional Organizations C. Custom as a Standard of Care D. Institutional Policies and Procedures

A. State Boards of Nursing

Eventually JS agrees to electroconvulsive therapy (ECT). Which member of the team is responsible for obtaining the client's informed consent? A. Physician B. Psychologist C. Case manager D. Registered nurse

A. Physician

Resilience

Ability and capacity to secure resources needed to support well-being

Nursing Care Plan: Interventions and Rationale

An "assessment" is not an intervention One-to-One ratio: 1:1 corresponding rationale. Factual and evidence based. Evidence based practice Provide reference Individualize for your patient Address multiple domains ◦ Biological ◦ Psychological ◦ Social

What is an affective disorder?

An affective disorder is characterized by dysfunctional moods (depression, bipolar disorder, anxiety, PTSD)

Basic Level and Advanced Practice Psychiatric-Mental Health Nursing Interventions: Pharmacological, biological, and integrative therapies

Applies current knowledge to assessing patient's response to medication, provides medication teaching, and communicates observations to other members of the healthcare team

SAFE-T: Determine risk level/intervention

Asking direct questions helps you to determine the level of risk and the best course of action to address the concern.

CASE STUDY JS, a 27-year-old male, is court committed by his parents to your unit with a diagnosis of paranoid schizophrenia. He lashes out at staff when they attempt to give him his medications. He states, "You are trying to poison me." JS continues to argue with staff. He is not aggressive but refuses all treatment. Legal and clients' rights are suspended when a client is hospitalized involuntarily. A. True B. False C. Depends on the state D. Depends on the physician assessment

B. False

A nurse was the case manager for a client with serious mental illness for 6 years. The client died by suicide 1 week ago. Today, the client's spouse asks, "I always wondered if my spouse was a victim of sexual abuse in childhood. What can you tell me about that?" Can the nurse disclose information to the surviving spouse? A. Yes B. No C. It depends on state law D. It depends on how damaging the physician feels this would be to all concerned.

B. No

Which worldview would the nurse anticipate from a client who says, "It is important to save enough money to take care of yourself in your old age. We should not rely on anyone else to take care of us." A. Eastern (balance) B. Western (science) C. Indigenous

B. Western (science) Individualism, autonomy, and preparing for the future

Before determining appropriate interventions for a suicidal patient, what must be determined first?

Before you can get to the interventions, you need to determine the level of suicidal ideation the patient is experiencing. -Modifiable risk factors make the overall risk less great than the nonmodifiable risks because they could potentially be changed. -Coping mechanisms are potentially modifiable risks. Whereas, age, gender, race, etc. are not modifiable risks

Ethnocentrism

Belief in the superiority of one's nation or ethnic group.

Common Psychiatric Mental Health Etiology

Biochemical imbalance: Not taking medications Lack of knowledge Impaired judgment Maladaptive coping skills Coping resources inadequate for stressors: maybe accustomed to stressors, but the stressors at present are especially great

Intervention Types: Biological domain

Biological Domain ◦ Self-Care Activities ◦ Sleep ◦ Activity/Exercise ◦ Nutrition ◦ Medications ◦ Relaxation

Which individual may need involuntary hospitalization? A. A person with alcoholism who has been sober for 6 months but begins drinking again B. An individual with schizophrenia who stops taking prescribed antipsychotic drugs C. An individual with bipolar disorder, manic phase, who has not eaten in 4 days D. Someone who repeatedly phones a national TV broadcasting service with news tips

C. An individual with bipolar disorder, manic phase, who has not eaten in 4 days

Which term refers to individualsʼ belief that their cultural values and practices are correct and superior to those of others? A. Assimilation B. Enculturation C. Ethnocentrism D. Somatization

C. Ethnocentrism

Least restrictive alternative doctrine

Care providers must take the least drastic measures.

Circumstantiality

Circuitous, indirect speech in which the individual digresses to give unnecessary and often irrelevant details before arriving at the main point. An extreme form, arising from disorganized associative processes, may occur in schizophrenia, obsessional disorders, and certain types of dementia.

Clanging

Clang associations are groupings of words, usually rhyming words, that are based on similar-sounding sounds, even though the words themselves don't have any logical reason to be grouped together. 1 A person who is speaking this way may be showing signs of psychosis in bipolar disorder or schizophrenia.

Cultural Barriers to Quality Mental Health Services

Communication barriers Stigma of mental illness (Shame; associated with moral weakness.) Misdiagnosis(some cultures are more likely to misdiagnose than others) Cultural concepts of distress Cultural, or culture-bound, syndromes (Clusters of SX that occur within specific groups) Cultural idioms of distress Cultural explanations Genetic variations in pharmacodynamics

Ethical dilemma

Conflict between two or more courses of action, each with favorable and unfavorable consequences (What are the pros and cons for a situation and how is the conflict resolved?)

Basic Level and Advanced Practice Psychiatric-Mental Health Nursing Interventions: Coordination of care

Coordinates implementation of the nursing care plan and documents coordination of care

Countertransference

Countertransference is the redirection of a therapist's feelings toward the client.

Cultural Competence for Psychiatric Mental Health Nurses: Cultural awareness

Cultural awareness Examine beliefs, values, and practices of own culture Recognize that during a cultural encounter, three cultures are intersecting Culture of the patient, nurse, and setting **SO be aware of your setting, your culture, the patient's , etc.

Cultural Competence for Psychiatric Mental Health Nurses: Cultural desire

Cultural desire Not acting out of a sense of duty but a Genuine concern for patients' welfare Willingness to listen until patients' viewpoint is understood Patience, consideration, and empathy

Cultural Competence for Psychiatric Mental Health Nurses: Cultural encounters

Cultural encounters Deter nurses from stereotyping Help nurses gain confidence in cross-cultural interactions Help nurses avoid or reduce cultural pain **No two members of a group are alike.

Cultural Competence for Psychiatric Mental Health Nurses: Cultural knowledge

Cultural knowledge Learn by attending cultural events and programs Forge friendships with diverse cultural groups Learn by studying Learning cultural differences helps nurse Establish rapport Ask culturally relevant questions Identify cultural variables to be considered

Cultural Competence for Psychiatric Mental Health Nurses: Cultural skill

Cultural skill Ability to perform a cultural assessment in a sensitive way -Use professional medical interpreter to ensure meaningful communication -Use culturally sensitive assessment tools Goal A mutually agreeable therapeutic plan -Culturally acceptable -Capable of producing positive outcomes

MSE: Harm Risk

Current thoughts: How likely are you to act on a scale of 1-10? Past thoughts, actions: Have they done so in the past? Plan: To hurt selves or others ◦ Specificity ◦ Lethality: Gun ◦ Accessibility: Do they have a gun? ◦ Proximity: Do they have a time frame? Is it likely their plan will be interrupted? Ability to resist acting on thoughts Coping resources: What do they have to prevent them from acting? Mobile apps (my 3-individuals that would be notified if you have a crisis), family, friends. No resources is concerning

DUE PROCESS IN INVOLUNTARY COMMITMENT

DUE PROCESS IN INVOLUNTARY COMMITMENT •Writ of habeas corpus •Least restrictive alternative doctrine

Basic Level and Advanced Practice Psychiatric-Mental Health Nursing Interventions: Advanced Practice Intervention

Description

Therapeutic Communication Techniques: Placing the events in time or sequence

Description: Puts events and actions in better perspective. Notes cause-and-effect relationships and identifies patterns of interpersonal difficulties. Example: "What happened before?" "When did this happen?"

Issues for African Americans

Disparities (Poverty, educational deficits, distrust in professional services and medicine.) Professional Services Legacy of mistrust/bias Socioeconomic factors Medication issues (Some AA metabolize medications more quickly than other ethnicities and may require higher doses.) Genetic differences Prescribing differences Role of faith/spirituality

True or False: People who talk about suicide do not complete it

False

Cultural explanations for causes of illness

Explanations: specific cultures have unique and specific explanations for the cause of an illness, such as Vietnamese people believing that spiritual disruptions cause seizures and therefore a religious leader is needed for healing

True or False: Improvement after a suicide means the risk is over

False

Eastern Tradition

Family basis for identity (family is everything) • Body-mind-spirit one entity • Time is circular and recurring (reincarnation) • Born into a fate; duty to comply (no coincidence) • Disease caused by fluctuations in opposing forces (Yin/yang, hot/cold, etc.) *Mental illness is shameful and therefore hidden *Physical and psychological illness is all one thing.

Cultural Competence for Psychiatric Mental Health Nurses

Five constructs 1. Cultural awareness 2. Cultural knowledge 3. Cultural encounters 4. Cultural skill 5. Cultural desire

Hallucinations vs. Delusions

Hallucinations: sensory perceptions (***Limited to 5 senses) ◦ Do you hear voices? ◦ What do the voices say? ◦ What makes the voices worse/louder? (what does the person see or hear? If they are hallucinating, you need more info. What are they saying? How loud are they? Are they difficult to ignore? Are they disruptive? Are they telling you to do something? How is this impacting the patient's life? Loud voices may be distracting to the patient. They may not be able to have a real conversation.) Delusions: fixed false beliefs (thought misperceptions) ◦ Grandeur: Not based in reality. They are real to the patient, but not the real world. ◦ Paranoia ◦ Religious: Have to know a little about common religious beliefs and what the baseline of the patient is. Did something change? Are they hearing God? Have to be careful. You need context. ◦ Somatic: A somatic delusion is a false belief that a person's internal or external bodily functions are abnormal. ◦ Persecutory

What physical ailments mimic depression?

Hypothyroidism Anemia Vitamin deficiency ***There are many, many more...p. 114

Cultural Idioms

Idioms: "informal" language that is not meant to be taken literally and thus it can be difficult for people of another culture to understand (e.g. "I am sick as a dog" does not mean I need to be treated by a veterinarian)

Populations at Risk of Mental Illness and Inadequate Care

Immigrants Refugees (escaped some intolerable condition and would have preferred to stay within culture, but couldn't) Cultural "minorities" (Those in poverty are 2-3 times more likely to experience mental illness.)

Issues for LGBTQ Americans

Impact of disparities Problem recognition Acceptance/shame (especially within a family) Health status Stigma Family issues Legacy of MH treatment (Family HX of mental illness)

Basic Level and Advanced Practice Psychiatric-Mental Health Nursing Interventions: Health teaching and health maintenance

Individualized anticipatory guidance to prevent or reduce mental illness or enhance mental health (e.g., community screenings, parenting classes, stress management)

SAFE-T: Identify protective factors

Internal • Non-violent problem solving skills • Coping mechanisms • Frustration tolerance • Cultural/religious beliefs External • Family/community support • Positive therapeutic relationships • Responsibility for children, pets • Access to effective, timely healthcare

Cultural Planning and Implementation

Interpreter if necessary Spiritual support • Nonjudgmental attitude • Honor religious practices Concept of Time Beliefs about healing Stigma issues

Western Culture-Personal Space

Intimate: 0 - 18" Personal Zone: 18" - 3' Social Zone: 3' - 6'

SAFE-T: Conduct suicide inquiry

Involves asking very direct and detailed questions: Are you suicidal? Do you have a plan?

Community Mental Health Center Act of 1963

JFK: Many laws underwent revision after the Community Mental Health Center Act of 1963 (JFK), promoting the deinstitutionalization of mental illness to more community based care from institutional care.

Why should medication use be monitored in a psychiatric patient?

Medication side effects, therapeutic levels should be monitored for some medications, how medications are excreted, kidney function/liver function can affect a patient (delirium)

Milieu therapy

Milieu therapy is a safe, structured, group treatment method for mental health issues. It involves using everyday activities and a conditioned environment to help people with interaction in community settings. Milieu therapy is a flexible treatment intervention that may work together with other treatment methods.

Nursing Care Plan: Goal and Outcomes

ONE long-term GOAL ◦ opposite of nursing diagnosis Several short-term OUTCOMES Outcomes should be ◦ S.M.A.R.T. ◦ Developed with the patient ◦ Documented

Echolalia

People with echolalia repeat noises and phrases that they hear. They may not be able to communicate effectively because they struggle to express their own thoughts. For example, someone with echolalia might only be able to repeat a question rather than answer it.

Phenomena of Concern for Psychiatric-Mental Health Nurses

Phenomena of concern for psychiatric-mental health nurses include: • Promotion of optimal mental and physical health and well-being • Prevention of mental and behavioral distress and illness • Promotion of social inclusion of mentally and behaviorally fragile individuals • Co-occurring mental health and substance use disorders • Co-occurring mental health and physical disorders • Alterations in thinking, perceiving, communicating, and functioning related to psychological and physiological distress • Psychological and physiological distress resulting from physical, interpersonal, and/or environmental trauma or neglect • Psychogenesis and individual vulnerability • Complex clinical presentations confounded by poverty and poor, inconsistent, or toxic environmental factors • Alterations in self-concept related to loss of physical organs and/or limbs, psychic trauma, developmental conflicts, or injury • Individual, family, or group isolation and difficulty with interpersonal relations • Self-harm and self-destructive behaviors, including mutilation and suicide • Violent behavior, including physical abuse, sexual abuse, and bullying • Low health literacy rates contributing to treatment nonadherence

Indigenous Culture

Places significance on place of humans in natural world Basis of identity is the tribe Person is an entity only in relation to others Disease—lack of harmony between individual and environment

Basic Level and Advanced Practice Psychiatric-Mental Health Nursing Interventions: Medication prescription and treatment

Prescription of psychotropic medications with appropriate use of diagnostic tests; hospital admitting privileges

Basic Level and Advanced Practice Psychiatric-Mental Health Nursing Interventions: Milieu therapy

Provides, structures, and maintains a safe and therapeutic environment in collaboration with patients, families, and other healthcare clinicians

Psychiatric Mental Health (PMH) Nursing Assessment: Psychiatric Diagnosis

Psychiatric Diagnosis ◦ Diagnostic & Statistical Manual, 5th Ed. (DSM-5): This is the main mental illness (bipolar, schizophrenic, major depressive)

Intervention Types: Psychological domain

Psychological Domain ◦ Counseling ◦ Behavioral ◦ Educational

Seven Types of Stigma

Public Stigma This happens when the public endorses negative stereotypes and prejudices, resulting in discrimination against people with mental health conditions. Self Stigma Self-stigma happens when a person with mental illness or substance-use disorder internalizes public stigma. Perceived Stigma Perceived stigma is the belief that others have negative beliefs about people with mental illness. Label Avoidance This is when a person chooses not to seek mental health treatment to avoid being assigned a stigmatizing label. Label avoidance is one of the most harmful forms of stigma. Stigma by Association Stigma association occurs when the effects of stigma are extended to someone linked to a person with mental health difficulties. This type of stigma is also known as "courtesy stigma" and "associative stigma." Structural Stigma Institutional policies or other societal structures that result in decreased opportunities for people with mental illness are considered structural stigma. Health Practitioner Stigma This takes place any time a a health professional allows stereotypes and prejudices about mental illness to negatively affect a patient's care.

Common Psychiatric Mental Health Nursing Diagnoses

Risk for harm to self or others (the harm is real) Ineffective coping Altered thought process: Delusions Altered sensory perception Ineffective denial: Denying the negative impacts of the problem Impaired self-health maintenance

Nursing Care Plan: Assessment data

SUBJECTIVE ◦ Precipitating problem ◦ Mood ◦ Thought processes ◦ Health & illness appraisal OBJECTIVE ◦ Past history ◦ General appearance ◦ Behavior ◦ Affect VITAL SIGNS (Should only be a part of the assessment if it is clinically relevant to the patient's diagnosis.) LABS (Should only be a part of the assessment if it is clinically relevant to the patient's diagnosis.)

Basic Level and Advanced Practice Psychiatric-Mental Health Nursing Interventions: Consultation

Sharing of clinical expertise with nurses or those in other disciplines to enhance their treatment of patients or address systems issues

Defamation of character

Slander (spoken) or libel (printed)

Intervention Types: Social Domain

Social Domain ◦ Group interactions ◦ Milieu management ◦ Family/Community ◦ Safety Interventions **Every intervention needs a corresponding rationale.

Somatization

Somatization is the expression of psychological or emotional factors as physical (somatic) symptoms. For example, stress can cause some people to develop headaches, chest pain, back pain, nausea or fatigue.

S.M.A.R.T.

Specific, Measurable, Attainable, Realistic, and Time Bound. *The more measurable and concrete and specific you make the SMART goal, the easier it is to implement for you and the patient. Be detailed.

Issues for Hispanic Americans

Stigma MH not discussed Beliefs about mental illness Language Barriers Misdiagnosis Legal status (Illegal immigrants are less likely to seek help if they need it.) Role of faith/spirituality (mental illness could signify a failure in one's faith) Source of strength, coping Reason for mental illness

Appraisal of Health and Illness

Stressors: Specific and current issues that lead to admission Strengths Weaknesses Resources: What resources the patient has or does not have ◦ Ability to meet ADLs ◦ Support system ◦ Daily activities ◦ Coping mechanisms: Maladaptive or adaptive?

What is SAFE-T?

Suicide Assessment 5-Step Evaluation and Triage. This is specific to healthcare providers. S-suicide A-assessment F-five step E-evaluation & T-triage

Cultural syndromes

Syndromes: specific set of symptoms that are a manifestation of mental illness within a particular culture, such as Hispanic patients expressing anxiety with complaints of headaches, stomach distress, etc instead of complaints to worry or nervousness.

Peplau's three phases of the nurse patient relationship:

The end point is established at the first meeting that determines the schedule. i.e. "We have an hour to talk. What would you like to work on?" or "I am going to be here once a week for the next four weeks. What goals do you have for our time together?"

Enculturation

The social process by which culture is learned and transmitted across generations

Ethics

The study of philosophical beliefs about what is considered right or wrong in a society (What is right or wrong within a society. Naturally, this is difficult because people all have a different idea about what is right or wrong.)

Cultural imposition

The tendency for a group to believe that their cultural beliefs should be the dominant way and everyone should think that way.

Mental Status Examination (MSE): Interaction

This describes what the patient is doing and whether or not the patient is willing to cooperate. There is always room to write a description of the interaction rather than leaving the boxes checked. It is better to be more descriptive about what is going on with the patient. Write a narrative because it could change over time

What is QPR?

This is a method of recognizing that a person may be suicidal. This is a suicide assessment that can be done by anyone, not just a healthcare professional. Q-Question P-Persuade R-Refer

Assault

This is a threat

Battery

This is the act of physically harming someone

Cultural assessment

To what cultural group do you belong? Were you raised in an ethnic community? How do you define health and illness? How do you define good and evil? What do you do to get better when you are physically or mentally ill? Whom do you seek help from when you are ill? By what cultural rules or taboos do you try to live? Do you eat (or refrain from eating) any special foods?

Asian American & Pacific Islanders

Tradition of disguise/denial • Related to embarrassment Culture-bound syndromes common Trauma-related conditions Suicide rates (suicide rates are high)

Transference

Transference is the redirection of feelings about a specific person onto someone else (in therapy, this refers to a client's projection of their feelings about someone else onto their therapist).

Informal admission

Treatment is sought out by the patient (usually for anxiety/depression)

Voluntary admission

Treatment is sought out by the patient's guardian

True or False: Any comment about suicide should be taken seriously

True

True or False: Historically, American Indians and Alaskan Natives are more likely to die by suicide. The second is white people. Hispanics, Black Americans, and Asian or Pacific Islanders are least likely by almost half to die by suicide.

True

True or False: Many people who die by suicide have given definite warnings

True

True or False: Most suicidal people are ambivalent about dying

True

True or False: Most suicides occur within 3 months of "improvement" due to energy, motivation changes

True

True or False: Suicide rates are lowest in Dec, peak in spring and fall

True

TORT LAW: Unintentional Tort

Unintentional tort—unintended acts against another that produce injury or harm • Negligence • Malpractice *Most common unintentional tort is negligence (failed to question an order, teach the patient etc.)

Bioethics

Used in relation to ethical dilemmas surrounding health care (Someone has diagnostic testing performed during gestation that determines the fetus is fatally or terminally ill. Who decides whether or not it is ethical to terminate that pregnancy.)

Types of Communication

VERBAL • Spoken • Underlying emotion is conveyed NON-VERBAL • Gestures, expression, body language • Usually communicated first • Priority over contradictions *If there is a discrepancy between what is being said and what is be conveyed non-verbally, we tend to go with the non-verbal communications *If there is a discrepancy between what is being said and what is be conveyed non-verbally, we tend to go with the non-verbal communications

Native Americans

Varying views of mental illness • Language limitations Limited access to professional care • Historical distrust of outsiders • Systemic barriers Substance use disorders common

Useful mental health cultural assessment tool is the classic set of questions proposed by Kleinman and colleagues (1978)

What do you call this illness (diagnosis) When did it start? (onset) What do you think caused it? (etiology) How does the illness work? What does it do to you? (course) How long will it last? Is it serious? (prognosis) How have you treated the illness? How do you think it should be treated? (treatment) Allows patient to be heard and understood.

Spiritual Assessment

What gives your life meaning? What brings you joy & peace? Is your faith helpful to you in stressful situations? Do you participate in any religious activities? Do you believe in God or a higher power?

Involuntary commitment

When the patient is severely mentally ill, a danger to themselves or others, or is unable to care for themselves in the basic capabilities because of mental illness, they can be committed without their consent. **Patients can still make decisions about their healthcare when they are admitted. **With involuntary commitment, you have to have reasonable cause and treatment has to be reasonably helpful to the patient

Intentional tort

Willful or intentional acts that violate another person's rights or property (person or reputation)

Writ of habeas corpus

Written order to free the patient

SAFE-T: Documentation

You have to document the risk factors, protective factors, results of the inquiry, interventions taken, etc. Be descriptive.

Which technique would be least effective in promoting therapeutic communication? a. Reflection b. Confrontation c. Reassurance d. Restatement

c. Reassurance

When documenting a patient's appearance, which of the following descriptions would be appropriate? a. The patient is casually dressed and well groomed. b. The patient is wearing jeans and a t-shirt. Grooming intact. c. The patient is wearing jeans with hole in the knee, clean t-shirt. Hair is combed and clean. No visible scars or tattoos.

c. The patient is wearing jeans with hole in the knee, clean t-shirt. Hair is combed and clean. No visible scars or tattoos. Rationale This is nonjudgmental, but specific. a. might as well just checked the box. What defines casual? b. is ambiguous and judgmental (what does intact mean?). When describing general appearance, it is important to be objective and nonjudgmental as possible. Be descriptive.

Invasion of privacy

i.e. Taking someone's pictures without permission

DOCUMENTATION OF CARE

• A record's usefulness is determined by evaluating— when the record is read later—how accurately and completely it portrays the patient's behavioral status at the time it was written. *Undocumented care did not happen in the eyes of the law.

FORENSIC NURSING

• Application of nursing principles in a court of law to assist a decision • Nurse often educates the Court on the science of nursing • May provide opinions using appropriate nursing standards • Issues at stake may include -Patient competency -Individual's fitness to stand trial -Involuntary commitment -Responsibility for a crime • Other tasks -Support of victims or perpetrators of crime and violence -Collection of evidence -Provision of health care in prison settings

FIVE PRINCIPLES OF BIOETHICS

• Beneficence: The duty to promote good • Autonomy: Respecting the rights of others to make their own decisions • Justice: Distribute resources or care equally • Fidelity (nonmaleficence): Maintaining loyalty and commitment; doing no wrong to a patient • Veracity: One's duty to always communicate truthfully

Suicide: Intermediate/Long-Term Risk

• Biological Domain - Medications - Electroconvulsive therapy - Physical care • Psychological Domain - Challenging suicidal mindset - Adaptive coping strategies - Commitment to treatment • Social Domain (Social networks (Family, friends, care givers) - Social skills training - Support networks-How does the patient reach care givers? • Family • Professional caregivers • Crisis phone numbers - Stigma reduction

Suicide: Care for Caregivers

• Can be highly stressful • Verbalizing feelings can be helpful • Allow time for grieving - Anniversary dates especially difficult (Birthdays, anniversaries, date of death, back-to-school, many events can provoke grief of the lost of the loved one) • Nurses have opportunity for role modeling *Interacting with individuals who have attempted suicide can be very stressful. Verbalizing these feelings can be very helpful.

Basic Level and Advanced Practice Psychiatric-Mental Health Nursing Interventions

• Coordination of care • Health teaching and health maintenance • Milieu therapy • Pharmacological, biological, and integrative therapies • Advanced Practice Intervention ALL OF THE ABOVE PLUS: • Medication prescription and treatment • Psychotherapy • Consultation

FIVE ELEMENTS TO PROVE NEGLIGENCE

• Duty: what is expected of the nurse • Breach of duty: the nurse doesn't meet the requirements expected of the duty • Cause in fact: If it were not for what this nurse did or didn't do, would the injury have occurred? • Proximate cause: intervening actions or whatever happened cause the harm • Damages: what damage was done?

INVOLUNTARY COMMITMENT

• Emergency commitment (temporary admission) • Person confused or demented; emergency admission • Used for observation, diagnosis and treatment • Generally for 24 to 96 hours (here is ~72 hours) • Court hearing before discharge or next admission (Court-ordered outpatient treatment is a thing too.) • Assisted outpatient treatment • Court-ordered

VIOLENCE IN THE PSYCHIATRIC SETTING

• Employers are not typically responsible for employee injuries from violent patients. • Nurses must participate in setting policies that create and maintain a safe environment • Always document patient's potential for violence • Communicate observations to colleagues

ETHICAL CONCEPTS

• Ethics: The study of philosophical beliefs about what is considered right or wrong in a society •Bioethics: Used in relation to ethical dilemmas surrounding health care • Ethical dilemma: Conflict between two or more courses of action, each with favorable and unfavorable consequences

PATIENT CONFIDENTIALITY EXCEPTIONS

• Exceptions to the rule: • Duty to warn and protect third parties (potential victims) • Child and elder abuse reporting statutes -*All 50 states have child abuse laws. Need to omit drug or alcohol use w/o court order -*It's a misdemeanor if you don't report abuse

Therapeutic Relationships

• Facilitate communication of distressing thoughts and feelings • Assist with problem solving related to ADLs • Help examine and decrease self-defeating behaviors • Promote self-care/independence • Provide education • Promote recovery

External Protective Factors

• Family/community support • Positive therapeutic relationships • Responsibility for children, pets (When others are dependent on you, it is harder for you to commit suicide.) • Access to effective, timely healthcare (The more health care that you have, the less likely you are to become seriously ill. You get the help that you need.)

Mental Status Exam (MSE): Perceptual Disturbances

• Hallucinations (e.g., auditory, visual) • Illusions

SAFE-T: Identify risk factors

• Health conditions - Acuity level - Current and past • Psychological • Environmental • Cultural - Gender - Sexual orientation - Religion - Acuity level - Current and past • Cultural - Gender - Sexual orientation - Religion • Demographic - Age - Race - Occupation - Race - Marital status

Suicide Risk Factors

• Health conditions (What is the health condition? Is it terminal? The health condition may not outright increase suicidal ideations, but may contribute.) - Acuity level - Current and past • Psychological (To what extent do we handle stress negatively?) • Environmental (Are we in an environment with many suicides? What is the media saying about suicide? The more suicides that are present, the more likely those with suicidal ideations are to die by suicide. This is especially true of celebrity suicide.) • Cultural (Gender should be more of a demographic RF. Gender differences are not just social but biological. However, sexual orientation is a big RF in most places. Suicide is condoned in some religious practices.) - Gender - Sexual orientation - Religion • Demographic (Certain occupations (military and first responders) increase the risk of suicide. Unmarried individuals are at higher risk than married couples.) - Age - Race - Occupation - Race - Marital status

Suicide: Documentation

• History, assessment, interventions • Presence/absence suicidal thoughts • Use of drugs, alcohol, medications • Patient judgment • Medication supply • Ongoing treatment plan - Include parent/guardian as needed

Warning Signs: Is Path Warm?

• Ideation • Substance use • Purposelessness • Anxiety • Trapped • Hopelessness • Withdrawal • Anger • Recklessness • Mood Changes

Western Tradition

• Identity found in individuality • Values Ø Autonomy Ø Independence Ø Self-reliance • Mind and body separate entities • Disease has a cause, and treatment is aimed at the cause • Time is linear • Success is obtained in preparing for the future

ADMISSION PROCEDURES

• Informal admission—sought by patient • Voluntary admission—sought by patient or guardian • Involuntary commitment—without patient's consent -Mentally ill -Danger to self or others -Unable to acquire basic necessities

Suicide inquiry: Assessing Suicidal Episode

• Intent to die - Include assessment of prior attempts: HX of attempts (what, when, why didn't they die?) • Severity of ideation - How often, how long - Level of distress increasing: Scale of 1-10, how depressed/suicidal do you feel/suicidal do you feel? - Ability to dismiss/not act • Degree of planning: Vague or detailed? - Access to materials needed for plan - Ability/willingness to stop self: Is there a time or place set to prevent people from stopping them?

PATIENT CONFIDENTIALITY

• Legal considerations • Health Insurance Portability and Accountability Act (HIPAA) • Confidentiality after death • Confidentiality of professional communications • Confidentiality and human immunodeficiency virus (HIV) status

Suicide Safety Plan

• Multiple step written statement by patient agreeing to voluntarily engage in treatment • Includes early warning signs and emergency care planning • Assumes patient is willing and able to be open and honest • Efficacy is unknown

GUIDELINES FOR ENSURING ADHERENCE TO STANDARDS OF CARE

• Negligence, irresponsibility, or impairment • Duty to intervene and duty to report • Incompetence, impairment, or criminal activity • Bodies to whom the nurse must report vary from state to state *State laws vary as to who you need to report to.

Internal Protective Factors

• Non-violent problem solving skills • Coping mechanisms (Especially adaptive coping mechanisms.) • Frustration tolerance • Cultural/religious beliefs (Suicide is against certain religions. Catholicism believes suicide prevents entrance to heaven.)

Mental Status Exam (MSE): Cognition

• Orientation: time, place, person • Level of consciousness (e.g., alert, confused, clouded, stuporous, unconscious, comatose) • Memory: remote, recent, immediate (long/short-term) • Fund of knowledge: (general intelligence) • Attention: performance on serial sevens, digit span tests (test for immediate recall) • Abstraction: performance on tests involving similarities, proverbs • Insight: understanding of nature of illness (Do you think you need to be in the hospital? What do you think is causing your problems?) • Judgment : ability to make decisions (Do you act before thinking? Do your decisions involve hurting yourself or others? Do you put yourself in harm's way?) • Concentration/calculation

Suicide: High/Imminent Risk

• Reconnecting to others/instilling hope - Active listening: reverse of hopelessness can help - Nonjudgmental approach: establish rapport - Cognitive interventions: Rassurance • Emotional stability • Ensuring safety: Complete control over any objects that could hurt the patient. - Inpatient care

PATIENTS' RIGHTS UNDER THE LAW

• Right to treatment • Right to refuse treatment • Right to informed consent -Indicates that the patient has been provided with basic understanding of risks, benefits, and alternatives -Person must voluntarily accept treatment -To be effective legally, it must be informed and in general a physician or advanced practice provider must obtain the consent. •Rights regarding involuntary commitment and psychiatric advance directives •Rights regarding restraint and seclusion •Right to confidentiality

Who establishes the standards of nursing care?

• State Boards of Nursing • Professional Organizations • Institutional Policies and Procedures • Custom as a Standard of Care

Mental Status Exam (MSE): Ideas of Harming Self or Others

• Suicidal or homicidal history and current thoughts • Presence of a plan • Means to carry out the plan • Opportunity to carry out the plan

Mental Status Exam (MSE): Disorders of the Form of Thought

• Thought process [e.g., disorganized, coherent, flight of ideas (jumping rapidly between ideas and thoughts), neologisms (making up words), thought blocking, circumstantiality] • Thought content (e.g., delusions, obsessions)

TORT LAW: Intentional Tort

• Tort—a civil wrong for which money damages may be collected by the injured party (plaintiff) from the responsible party (the defendant) • Intentional tort—willful or intentional acts that violate another person's rights or property • Assault • Battery • False imprisonment • Invasion of privacy • Defamation of character (slander or libel)

MEDICAL RECORDS

• Used for quality improvement • Used as evidence • Growing use of electronic documentation

Suicide No-Suicide Contract

• Verbal or written "agreement" between nurse and patient that patient will not commit suicide during a specified timeframe • No longer considered an effective suicide prevention intervention

DISCHARGE PROCEDURES

•Conditional release (May require outpatient TX) •Unconditional release (no strings attached) •Release against medical advice (AMA) (Doctors don't agree that the PT should leave)

VOLUNTARY ADMISSIONS INFORMAL ADMISSION

•Informal admission •Voluntary admission •Voluntary patients have the right to request and obtain release. Before release, reevaluation may be needed

Patient Protection & Affordable Care Act

"Obama Care" • Coverage for most uninsured Americans through Medicaid expansion -Common for people to receive Medicaid benefits for mental health (state dependent-Georgia is not extensive with its coverage)

Why shouldn't you ask "why" questions?

"Why" questions imply that we are criticizing the patient for making the choices that they are making. It can lead the patient to feel defensive. Asking "Why" •Demands an explanation •Implies wrongdoing/criticism •Increases defensiveness

What is the leading cause of disability in the U.S.?

-Mental illness is both common and expensive. About 10% of people with mental illness have a high level of impact on their lives (i.e. it impacts jobs, relationships, etc.) -Mental illness is both common and expensive. About 10% of people with mental illness have a high level of impact on their lives (i.e. it impacts jobs, relationships, etc.) • High prevalence • 1:4 Americans = 61.5 million • $317 Billion in associated costs • Healthcare, lost wages, disability

Blocks to Communication

• Non-verbal communication: Eye-rolling, gestures, texting on your phone, etc. • Giving advice • Agreement: Agreeing suggest judgment • Challenges: Judgmental • Reassurance: Similar to giving advice, challenging, agreeing • Disapproval: Similar to giving advice, challenging, agreeing

Mental Health

...the emotional and psychological well-being of an individual who has the capacity to interact with others, deal with ordinary stress, and perceive one's surroundings realistically. ANA, APNA, ISPN, 2014

Therapeutic Communication Techniques: Giving information

Description: Makes facts the person needs available. Supplies knowledge from which decisions can be made or conclusions drawn. For example, the patient needs to know the role of the nurse, the purpose of the nurse-patient relationship, and the time, place, and duration of the meetings. Example: "My purpose for being here is..."... "This medication is for..."... "The test will determine..."...

Therapeutic Communication Techniques: Offering self

Description: Offers presence, interest, and a desire to understand. Is not offered to get the person to talk or behave in a specific way. Example: "I would like to spend time with you." "I'll stay here and sit with you awhile."

Types of stigmas

1. Public Stigma 2. Self-Stigma 3. Label Avoidance * Stigmas lead to discrimination. * Embarrassment or cultural influences play a huge role in how an individual responds to mental health stigmas.

Therapeutic Communication Techniques: Verbalizing the implied

Description: Puts into concrete terms what the patient implies, making the patient's communication more explicit. Example: Patient: "I can't talk to you or anyone else. It's a waste of time." Nurse: "Do you feel that no one understands?"

Therapeutic Communication Techniques: Restating

Description: Repeats the main idea expressed. Gives the patient an idea of what has been communicated. If the message has been misunderstood, the patient can clarify it. Example: Patient: "I can't sleep. I stay awake all night." Nurse: "You have difficulty sleeping?" or Patient: "I don't know... he always has some excuse for not coming over or keeping our appointments." Nurse: "You think he no longer wants to see you?"

Therapeutic Communication Techniques: Attempting to translate into feelings

Description: Responds to the feelings expressed, not just the content. Often termed decoding. Example: Patient: "I am dead inside." Nurse: "Are you saying that you feel lifeless? Does life seem meaningless to you?"

The deinstitutionalization movement of the 1960s

In the 1960s and 1970s, there was a big move to push mental health facilities to release their patients. The idea behind this was that mentally ill patients should be treated in the least extreme ways possible. However, the closure of institutions led to many patients without places to go. Many of them did not have the family support that they needed to undergo and psychosocial and biological rehabilitation.

What are the reasons for involuntary admission?

3 Reasons: -suicidal, -homicidal, or -unable to care for yourself due to mental health condition. (form 1013 is Georgia's form if due to mental health, 2013 is the form for these conditions due to substance abuse).

Surgeon General's Report on Mental Health 1999

• Documents that mental illnesses are diagnosable and new effective treatments offer more options than ever before. • Highlights need to reduce stigma and dispel myths about mental health. • Seeks to improve public awareness about mental illness. • Documents the need for mental health services and providers and delivery of state-of-the-art treatments.

How can mental health stigmas be addressed?

• Education/PSA (Public Service Announcements) • Media Responses • Policy Initiatives

Adverse Childhood Experiences (ACEs)

Abuse Physical Emotional Sexual Neglect Physical Emotional Household Dysfunction Divorce Caregiver Mental Illness Maternal Violence Incarcerated caregiver Caregiver Substance Abuse *4 or more ACES suggest a higher risk of adverse reactions

Human Genome Project (HGP)

An international collaborative effort to map and sequence the DNA of the entire human genome.

Therapeutic Communication Techniques: Seeking consensual validation

Description: Clarifies that both the nurse and patient share mutual understanding of communications. Helps the patient to clarify thoughts. Example: "Tell me whether my understanding agrees with yours."

Nursing Process

Assessment Diagnosis Outcomes Identification Planning Implementation Evaluation

Therapeutic Communication Techniques: Giving broad openings

Description: Clarifies that the lead is to be taken by the patient. However, the nurse discourages pleasantries and small talk. Example: "Where would you like to begin?" "What are you thinking about?" "What would you like to discuss?"

Therapeutic Communication Techniques: Focusing

Description: Concentrates attention on a single point. It is especially useful when the patient jumps from topic to topic. If a person is experiencing a severe or panic level of anxiety, the nurse should not persist until the anxiety lessens. Example: "This point you are making about leaving school seems worth looking at more closely." "You've mentioned many things. Let's go back to your thinking of 'ending it all.'"

Therapeutic Communication Techniques: Reflecting

Description: Directs questions, feelings, and ideas back to the patient. Encourages the patient to accept personal ideas and feelings. Acknowledges the patient's right to have opinions and make decisions and encourages the patient to think of oneself as a capable person. Example: Patient: "What should I do about my husband's affair?" Nurse: "What do you think you should do?" or Patient: "My brother spends all of my money and then has the nerve to ask for more." Nurse: "You feel angry when this happens?"

Therapeutic Communication Techniques: Suggesting collaboration

Description: Emphasizes working with the patient, not doing things for the patient. Encourages the view that change is possible through collaboration. Example: "Perhaps you and I can discover what produces your anxiety." "Perhaps by working together, we can come up with some ideas that might improve your communication with your spouse."

Therapeutic Communication Techniques: Exploring

Description: Examines certain ideas, experiences, or relationships more fully. If the patient chooses not to elaborate by answering no, the nurse does not probe or pry. In such a case, the nurse respects the patient's wishes. Example: "Tell me more about that." "Would you describe it more fully?" "Could you talk about how it was that you learned your mom was dying of cancer?"

Therapeutic Communication Techniques: Voicing doubt

Description: Expressing uncertainty regarding the reality of the patient's perceptions or conclusions, especially in hallucinations and delusions. Example: "Isn't that unusual?" "Really?" "That's hard to believe."

Therapeutic Communication Techniques: Silence

Description: Gives the person time to collect thoughts or think through a point. Example: Encouraging a person to talk by waiting for the answers.

Therapeutic Communication Techniques: Seeking clarification

Description: Helps patients clarify their own thoughts and maximize mutual understanding between nurse and patient. Example: "I am not sure I follow you." "What would you say is the main point of what you just said?" "Give an example of a time you thought everyone hated you."

Mental Status Exam (MSE): Behavior

• Excessive or reduced body movements • Peculiar body movements (e.g., scanning of the environment, odd or repetitive gestures, level of consciousness, balance, and gait) • Abnormal movements (e.g., tardive dyskinesia, tremors) • Level of eye contact (keep cultural differences in mind)

Certified peer specialists

Certified peer specialists are those with mental illness that are stable enough in their mental health to work with others with mental health issues. They are specially trained to work with peers.

Characteristics of Resilience

Characteristics • Optimism • Sense of mastery • Competence *Resilience is essential to recovery

Who defines mental illness in a society?

Culture defines what mental illness is. For example, there was a time that homosexuality was considered a mental illness. The most dominant culture is a society is usually the one that is most influential in setting the definition of what mental illness is.

Therapeutic Communication Techniques: Encouraging description of perception

Description: Increases the nurse's understanding of the patient's perceptions. Talking about feelings and difficulties can lessen the need to act them out inappropriately. Example: "What do these voices seem to be saying?" "What is happening now?" "Tell me when you feel anxious."

Therapeutic Communication Techniques: Giving recognition

Description: Indicates awareness of change and personal efforts. Does not imply good or bad, right or wrong. Example: "Good morning, Mr. James." "You've combed your hair today." "I see you've eaten your whole lunch."

Therapeutic Communication Techniques: Accepting

Description: Indicates that the person has been understood. An accepting statement does not necessarily indicate agreement but is nonjudgmental. Example: "Yes." "Uh-huh." "I follow what you say."

Therapeutic Communication Techniques: Presenting reality

Description: Indicates what is real. The nurse does not argue or try to convince the patient, just describes personal perceptions or facts in the situation. Example: "That was Dr. Todd, not a man from the Mafia." "That was the sound of a car backfiring." "Your mother is not here; I am a nurse."

Mental Status Exam (MSE): Appearance

• Grooming and dress • Level of hygiene • Pupil dilation or constriction • Facial expression • Height, weight, nutritional status • Presence of body piercing or tattoos, scars, etc. • Relationship between appearance and age

Diagnostic & Statistical Manual of Mental Disorders-5 (DSM-5)

DSM-5 Diagnostic and Statistical manual of mental disorders (fifth ed.) • American Psychiatric Association (2013) • Provides a common language of specific criteria for diagnosing individuals with mental disorders

Psychiatric Mental Health (PMH) Nursing Assessment: Demographic info

Demographic Info ◦ Maintain confidentiality: i.e. initials only; be vague about occupation (a student at AU is really just an undergrad. ◦ Legal status: Voluntary or involuntary admission status (two legal statuses in the state of Georgia

Therapeutic Communication Techniques: Encouraging evaluation

Description: Aids the patient in considering other persons and events from the perspective of the patient's own set of values. Example: "How do you feel about...?" "What did it mean to you when he said he couldn't stay?"

Therapeutic Communication Techniques: Offering general leads

Description: Allows the other person to take direction in the discussion. Indicates that the nurse is interested in what comes next. Example: "Go on." "And then?" "Tell me about it."

Therapeutic Communication Techniques: Encouraging formulation of a plan of action

Description: Allows the patient to identify alternative actions for interpersonal situations the patient finds disturbing (e.g., when anger or anxiety is provoked). Example: "What could you do to let anger out harmlessly?" "The next time this comes up, what might you do to handle it?" "What are some other ways you can approach your boss?"

Therapeutic Communication Techniques: Encouraging comparison

Description: Brings out recurring themes in experiences or interpersonal relationships. Helps the person clarify similarities and differences. Example: "Has this ever happened before?" "Is this how you felt ...?"... "Was it something like...?"...

Therapeutic Communication Techniques: Summarizing

Description: Brings together important points of discussion to enhance understanding. Also allows the opportunity to clarify communications so that both nurse and patient leave the interview with the same ideas in mind. Example: "Have I got this straight?" "You said that..." "During the past hour, you and I have discussed..."

Therapeutic Communication Techniques: Making observations

Description: Calls attention to the person's behavior (e.g., trembling, nail-biting, restless mannerisms). Encourages patient to notice the behavior and describe thoughts and feelings for mutual understanding. Helpful with mute and withdrawn people. Example: "You appear tense." "I notice you're biting your lips." "You seem nervous whenever John enters the room."

Termination begins in the resolution phase of the nurse-patient relationship. True False

False

The federal law requiring hospitals to inform patients of their right to refuse treatment is based on the Tarasoff v. California decision. True False

False

Helpful guidelines for communication

First: When in doubt, FOCUS ON FEELINGS Use: Use silence therapeutically Keep: Keep the focus on the patient Avoid: See Page 150 "Tactics to Avoid"

The HEADSSS Psychosocial Interview Technique

H Home environment (e.g., relations with parents and siblings) E Education and employment (e.g., school performance) A Activities (e.g., sports participation, after-school activities, peer relations) D Drug, alcohol, or tobacco use S Sexuality (e.g., whether the patient is sexually active, practices safe sex, or uses contraception) S Suicide risk or symptoms of depression or other mental disorder S Safety (e.g., how safe does the patient feel at home and school, wear a safety belt, or engage in dangerous or risky activities)

New Freedom Commission on Mental Health (2001)

In February 2001, President George W. Bush announced his New Freedom Initiative to promote increased access to educational and employment opportunities for people with disabilities. The Initiative also promotes increased access to assistive and universally designed technologies and full access to community life.

Psychiatric Mental Health (PMH) Nursing Assessment: Past Psychiatric History, Family History, and Substance Use History

Past Psychiatric History Out-patient therapy/Hospitalizations Medications Other treatments Adherence: *Not compliance. Compliance means following orders, adherence suggests that they have a role in the planning of their treatment. Abuse history: Abuse history is difficult to get directly from the patient. May need to get it from the chart. Clinically relevant abuse will likely be on the chart. Family psychiatric history: Is there a family history of mental illness? Substance use history: ETOH, cigarettes, recreational, medications, etc. Use does not necessarily equal abuse. Patients are not always forthcoming with this info.

Physical Assessment

Physical Health Status ◦ Common co-morbid PH conditions ◦ PH conditions that mimic MH conditions Physical Exam ◦ Review of Systems ◦ Neurologic Status ◦ Lab Results: what is relevant to the patient Physical Functions *All of these are influenced by mental health and can influence mental health: ◦ Elimination ◦ Activity & Exercise ◦ Sleep ◦ Appetite & Nutrition/Hydration ◦ Sexuality ◦ Self-Care

Psychiatric Mental Health (PMH) Nursing Assessment: Presenting problem

Presenting problem: Explain what makes the DX an acute illness (SS=suicidal tendencies, not depression, which is a DX) ◦ Patient v. other reporters ◦ Focus on acute symptoms/precipitants

QSEN

Quality and Safety Education in Nursing -Institute of Medicine (IOM) in the late 1990s

The Wellstone-Domenici Parity Act of 2008

The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is a federal law that generally prevents group health plans and health insurance issuers that provide mental health or substance use disorder (MH/SUD) benefits from imposing less favorable benefit limitations on those benefits than on medical/surgical benefits.

Diathesis-Stress Model

The theory that mental and physical disorders develop from a genetic or biological predisposition for that illness (diathesis) combined with stressful conditions that play a precipitating or facilitating role (environmental stress or trauma. -Also called diathesis-stress hypothesis (or paradigm or theory). -Assertion: Most psychiatric disorders result from a combination of genetic vulnerability and negative environmental stressors

Mental Status Exam (MSE): Mood

• Affect: flat, bland, animated, angry, withdrawn, appropriate to context • Mood: sad, labile (mood changes quickly), euphoric

Risk and Protective Factors

• Individual attributes and behaviors: -Make us vulnerable (genetically) or more resilient • Social and economic circumstances: -Some groups are exposed to higher levels of economic or social stressors than other groups. • Environmental factors: -Environmental exposure can offer vulnerability or protection from stressors

Patients who are involuntarily hospitalized have the right to refuse medication. True False

True

Self-awareness is achieved primarily by obtaining feedback from others True False

True

Cultural considerations for therapeutic communication

• Communication Style -Can be dependent on cultural or geographical norms. Example: Asking for tea (it could be hot or iced) • Eye Contact -Eye contact is preferred in some cultures and frowned upon in others. • Perception of Touch -What touch is appropriate/inappropriate? • Cultural Filters -What is acceptable in the culture? Cultures develop biases through which we interpret things.

Match the concept with the statement that best reflects that concept. a. "The patient in room 405 reminds me of my mother who always beat me' [Nurse avoids this room] b. "It is so sad that your mom died' [Nurse becomes tearful] c. "I can see you are sad about your mom dying." [Silence] d. "I would really like to get to know you better" [Nurse sits down next to patient] 1. Countertransference 2. Empathy 3. Rapport 4. Sympathy

a. "The patient in room 405 reminds me of my mother who always beat me' [Nurse avoids this room] = 1. Countertransference b. "It is so sad that your mom died' [Nurse becomes tearful] = 4. Sympathy c. "I can see you are sad about your mom dying." [Silence] = 2. Empathy d. "I would really like to get to know you better" [Nurse sits down next to patient] = 3. Rapport

Which patient is displaying symptoms consistent with a mental health illness? a. A 19-year old student who hears voices that peers do not hear during lectures in a college math course b. A 32-year old parent living in a busy city who holds 8-year-old child's hand every time they cross the street c. A 67-year-old patient who has had at least one daily episode of crying since the loss of a spouse 1 month ago d. A 15-year-old who spends free time alone room on the computer, including reluctance to come out of the room for meals

a. A 19-year old student who hears voices that peers do not hear during lectures in a college math course Hallucinations are false perceptions that have no relationship to reality. Crying is a normal response of mourning the loss of a loved one. The 15-year-old child's behavior is typical. The 32-year-old parent is exhibiting a typical response regarding child safety.

Resilience is most closely related to which concept? a. Adaptation b. Spirituality c. Self-confidence d. Self-actualization

a. Adaptation Resilience is associated closely with the process of adapting and helps people facing tragedies, loss, trauma, and severe stress. Resilience refers to an ability and capacity to secure resources needed to support one's well-being. Spirituality relates to one's search for the meaning of life, a relationship with a higher being, and adherence to transcendent values. Self-confidence is the result of intact self-image and self-esteem. Self-actualization is part of Maslow's hierarchy of needs.

Which intervention is considered within the scope of practice for a basic psychiatric mental health nurse? Select all that apply. One, some, or all responses may be correct. a. Coordinate the care of a patient diagnosed with acute depression. b. Establish rules for an acute care unit that treats depressed patients. c. Provide information materials concerning depression to the patient's family members. d. Report to the patient's interdisciplinary team behaviors that suggest the depression is worsening. e. Make changes in the patient's medication therapy based on their reported state of mind.

a. Coordinate the care of a patient diagnosed with acute depression. b. Establish rules for an acute care unit that treats depressed patients. c. Provide information materials concerning depression to the patient's family members. d. Report to the patient's interdisciplinary team behaviors that suggest the depression is worsening. Psychiatric mental health nurses are registered nurses educated in nursing and licensed to practice in their individual states. Psychiatric nurses are qualified to practice at two levels, basic and advanced, depending on educational preparation. Coordination of care, health teaching and health maintenance, milieu management, and pharmacological, biological, and integrative therapies are all considered basic level interventions. The advanced practice mental health nursing professional has gained diagnostic privileges, prescriptive authority, and permission to engage in psychotherapy.

Which federal legislative act helps ensure equality in benefits for both medical/surgical and mental health needs to all insured Americans? Select all that apply. One, some, or all responses may be correct. a. Mental Health Parity Act of 1996 b. The Wellstone-Domenici Parity Act of 2008 c. Patient Protection and Affordable Care Act of 2010 d. Health Care and Education Reconciliation Act of 2010 e. The Health Insurance Portability and Accountability Act of 1996

a. Mental Health Parity Act of 1996 b. The Wellstone-Domenici Parity Act of 2008 c. Patient Protection and Affordable Care Act of 2010 Parity simply refers to equivalence, and there are legislative acts (Mental Health Parity Act, The Wellstone-Domenici Parity Act, and the Patient Protection and Affordable Care Act) that help require insurers (including Medicare and Medicaid) to provide mental health coverage (both annual and lifetime benefits) at the same level provided for medical/surgical coverage. The Health Insurance Portability and Accountability Act and the Health Care and Education Reconciliation Act are not related to assuring parity regarding mental health and medical/surgical benefits.

Which intervention relates directly to the phenomena of concern that is central to the practice of psychiatric mental health nursing? Select all that apply. One, some, or all responses may be correct. a. Preventing mental and behavioral distress and illness b. Promoting optimal mental and physical health and well-being c. Promoting social inclusion d. Developing a friendship-based nurse-patient relationship with a patient who has no involved family e. Monitoring the patient for self-harm or self-destructive behaviors

a. Preventing mental and behavioral distress and illness b. Promoting optimal mental and physical health and well-being c. Promoting social inclusion Phenomena of concern for psychiatric mental health nurses include promotion of optimal mental and physical health and well-being, prevention of mental illness, and promotion of social inclusion of mentally and behaviorally fragile individuals. The phenomena of concern also includes monitoring the patient for signs of self-harm and destructive behaviors. The nurse-patient relationship should never be friendshipbased but rather strictly professional. Therapeutic outcomes are not achievable when the relationship is based on a personal rather than a professional framework.

Which activity occurs during the orientation phase of the nurse-patient relationship? a. Testing the relationship b. Resolving the relationship c. Engaging in problem solving d. Identifying problems

a. Testing the relationship

Mental Illness

• Disorders of definable diagnosis • Significant mental dysfunction/disturbance • Developmental • Biological • Physiological • Culturally defined

Which question would the nurse include when asking a patient to identify contributing factors that may affect their mental health? Select all that apply. One, some, or all responses may be correct. a. "How many hours a night do you sleep?" b. "What types of activities do you do for fun?" c. "Do you have access to public transportation?" d. "Can you tell me how you feel about yourself?" e. "Do you take any over-the-counter medications?"

b. "What types of activities do you do for fun?" c. "Do you have access to public transportation?" d. "Can you tell me how you feel about yourself?" Contributing factors to mental health and wellness include individual attributes, social and economic circumstances, and environmental factors. The question, "Can you tell me how you feel about yourself?" is a question about an attribute. How a person views themselves is important in evaluating a patient's perceived attribute. Asking about access to public transportation is a question for an environmental assessment. Inadequate transportation can interfere with the patient obtaining necessary basic needs such as food and medical care. Asking about what types of activities a patient enjoys is an assessment of their social circumstances. Asking how many hours a night a patient sleeps or if they take any over-the-counter medications does not specifically relate to an individual attribute, social and economic circumstance, or environmental factor.

An adolescent patient tells the nurse, "My mom scolded me yesterday, and I was crying for 3 hours. I have never cried like this before. Does this mean I have a psychiatric illness?" Which response from the nurse is most appropriate? a. "You should consult a psychologist." b. "You just had an emotional outburst." c. "You should have responded in a firm manner." d. "You should try to stay away from any stressors."

b. "You just had an emotional outburst." Crying after a feud with a loved one is a normal emotional response to a negative situation. The nurse cannot say that the patient shows abnormal behavior. The nurse should reassure the patient, saying that the patient's behavior was a normal emotional outburst. The patient does not need to consult a psychologist. Telling the patient that they should have responded in a firm manner indicates that the nurse believes that the patient showed an inappropriate behavior. Asking the patient to try to stay away from stressors is not an appropriate response because one has to learn to cope with stressors. Getting upset for being scolded by parents is normal, and the nurse should not advise the patient to stay away from parents for this.

Which action can a nurse who is active in state and national legislation take to effect change in the climate for mental health treatment? a. By becoming active in politics leading to a potential political career. b. By reducing the stigma of mental illness and advocating for equality in treatment. c. By advocating for reduced mental health insurance benefits to discourage abuse of the system by inappropriate psychiatric admissions. d. By encouraging laws that would make the involuntary long-term commitment process easier and faster for caregivers of mentally ill persons.

b. By reducing the stigma of mental illness and advocating for equality in treatment. Nurses who are aware of legislative concerns and who are active in organizations that promote mental health awareness and appropriate and equal treatment for mental illness help achieve thee goal of parity, or equality of treatment for mentally ill individuals. Becoming active in politics may be a personal goal but does not directly or necessarily reduce stigma or encourage treatment equality. Encouraging laws regarding the involuntary long-term commitment process and advocating for reduced mental health insurance benefits are undesirable outcomes.

Which statement about diagnosis of a mental disorder is true? a. The symptoms of each disorder are common among all cultures. b. Culture may cause variations in symptoms for each clinical disorder. c. Psychiatric diagnoses are listed separately from other physical disorders in a five-axis system. d. All mental disorders listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition ( DSM-5) are seen in all cultures.

b. Culture may cause variations in symptoms for each clinical disorder. Every society has its own view of health and illness and the types of behavior categorized as mental illness. Culture also influences the symptoms of a particular disorder. Thus the symptoms of each disorder are not common among all cultures. For example, individuals of certain cultures are more likely to express depression through somatic symptoms than through affect and feeling tone. The five-axis system was abandoned in the DSM-5. It is too absolute to claim that all mental disorders in the DSM-5 are seen in all cultures because any given culture influences what is acceptable or unacceptable with regard its social norms.

The nurse is explaining the principles of recovery to the caregivers of a patient with a mental illness. The nurse tells them, "Your child will slowly recover over a period of time. There may be occasional setbacks, and the right behavior will only be learned through experience." Which principle of recovery is the nurse referencing? a. Hope b. Nonlinear c. Self-directed d. Empowering

b. Nonlinear The nurse is explaining to the caregivers that the mental illness recovery process is nonlinear. This means that recovery is a continuous process, occasional setbacks will take place, and a patient learns from experience. The recovery principle of hope suggests that the process of recovery motivates the individual with mental illness. The recovery process is self-directed, which means that the patient has the right to lead, control, and determine their own path of recovery. The recovery process is empowering, meaning that the patient has the authority to choose from a range of options and to participate in all healthcare decisions.

A patient says to the nurse, "Once in a while I have some anxiety about my job, but otherwise, life is good." On which part of the mental health mental illness continuum is this patient? a. Resilience b. Well-being c. Mental illness d. Emotional concerns

b. Well-being Well-being is characterized by adequate to high-level functioning in response to routine stress and resultant anxiety or distress. Job stress and anxiety are part of everyday life. Resilience is not a part of the mental health mental illness continuum but rather refers to an ability and capacity to secure resources needed to support one's well-being. Mental illness refers to all mental disorders manifested in significant dysfunction that may be related to developmental, biological, or psychological disturbances in mental functioning. Emotional concerns apply to temporary distress or impairments.

Which statement best describes the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition ( DSM-5)? a. It is a compendium of treatment modalities. b. It offers a complete list of nursing diagnoses. c. It is a medical psychiatric assessment system. d. It suggests common interventions for mental disorders.

c. It is a medical psychiatric assessment system. The DSM-5 is a classification of mental disorders that includes descriptions and criteria of diagnoses. The manual is not a compendium of treatment modalities, nor does it offer a complete list of nursing diagnoses or common interventions for mental disorders.

Which statement is an accurate depiction of mental illness? a. Mental illness is the result of the moral deterioration of our society. b. People are not as tough as they once were, which has led to an epidemic of mental illness. c. Mental illness is difficult to define because different cultures vary regarding what is considered healthy. d. The main reason for so much mental illness is that families no longer spend enough time together.

c. Mental illness is difficult to define because different cultures vary regarding what is considered healthy. There is no standard measure for mental health, in part because it is culturally defined and is based on interpretations of effective functioning according to societal norms. Stating that mental illness is caused by the moral deterioration of society, that people are not as tough as they once were, and that families do not spend enough time together demonstrate stigma and overgeneralization.

A nurse working in a psychiatric unit plans to apply milieu therapy on a patient. Which intervention would the nurse include in the therapy? a. Coordinate the implementation of the nursing care plan and documents. b. Apply current knowledge to assess the patient's response to medication. c. Provide and maintain a safe and therapeutic environment in collaboration with others. d. Give anticipatory guidance to prevent or reduce mental illness and enhance mental health.

c. Provide and maintain a safe and therapeutic environment in collaboration with others. Milieu therapy means providing and maintaining a safe and therapeutic environment in collaboration with patients, families, and other healthcare clinicians. Applying current knowledge to assess the patient's response to medication pertains to pharmacological, biological, and integrative therapies. Coordinating the implementation of the nursing care plan and documents refers to coordination of care. Giving anticipatory guidance to prevent or reduce mental illness and enhance mental health is related to health teaching and health maintenance.

Which patient behavior indicates the need for involuntary admission to a psychiatric unit? a. Saying, "I don't want to eat." b. Urine drug screen is positive for methamphetamine c. Taking an overdose of digoxin d. Hearing voices of deceased family members

c. Taking an overdose of digoxin

The nurse assesses a 64-year-old patient who recently attempted suicide. During the assessment, the patient explains to the nurse that the attempt was not an act of mental illness but rather done out of honor for family. The patient asks why a mental health assessment is necessary. Which response by the nurse is best? a. "There is no honor in committing suicide." b. "Your culture must take life and death very seriously." c. "Attempting suicide is a sign of mental illness no matter how you look at it." d. "Please tell me more about how your concern for family honor has affected you."

d. "Please tell me more about how your concern for family honor has affected you." Nurses have an obligation to provide patient-centered care, which involves respecting the cultural and religious differences and preferences of patients. The patient is explaining a cultural practice, so the nurse's best response is to first gather more information about that practice. It is inappropriate to tell the patient that there is no honor in committing suicide, because certain cultures honor those who commit suicide. Commenting that the patient's culture takes life and death very seriously does not address the patient's question. It is inappropriate to tell the patient that suicide is a sign of mental illness because other cultures do not see it this way.

The nurse assesses a patient who reports insomnia and weight loss related to an inability to cope with ending a 3-year relationship. The patient tells the nurse, "I'm barely able to concentrate at work, and I'm afraid my performance is going downhill." Which assessment does the nurse infer about this patient? a. The patient has a mental illness. b. The patient is reporting normal symptoms. c. The patient has good mental health and well-being. d. The patient is showing signs of mild to moderate distress.

d. The patient is showing signs of mild to moderate distress. According to the mental health continuum, patients who demonstrate problems such as insomnia, loss of appetite, and inability to concentrate are considered to be experiencing mild to moderate discomfort and distress. Mild symptoms indicate that a mental illness is not yet in full effect but that there are emotional problems or concerns that should be addressed. The patient does not necessarily have a mental illness yet. The patient is not reporting normal symptoms. The patient does not have good mental health and well-being, as health and well-being are marked by occasional stress to mild distress and no impairment.

Therapeutic Communication

• "Ongoing process of interaction through which meaning emerges" • Role of self-disclosure -Not the same as in social relationships -Not a first-line intervention *Words need to be well-chosen. They should be causative/productive to help the patient. Part of this is determining how much you should tell the patient about yourself versus how much they should tell you about themselves. Self-disclosure should be minimal and only used in a way that is therapeutic for the patient.

Principles of Therapeutic Communication

• Patient as focus of interaction • Cautious use of self-disclosure • Non-judgmental, professional tone • Avoid communication blocks -Advice giving: What if they disagree? Did you just close the therapeutic conversation and become less credible? They don't get the chance to solve the problem themselves. -Changing the subjects: May make the patient feel like what they are saying is not important or you are ignoring them. • Clarifying statements: Repeating back, paraphrasing, making sure that you understand what the patient is saying.

Factors in Communication: Relationships

• Power structure: What kind of relationship exists between the two people having a conversation? Authoritarian? Peer? What kind of relationship exists between the two people having a conversation? Authoritarian? Peer?

Recovery from Mental Illness

• Process of change through which individuals improve their health and wellness, live a self-directed life, & strive to reach their full potential • Related to increased role of consumer advocates -Certified peer support specialists • Replaces medical model with more collaborative approach -Nihil de nobis sine nobis ("Nothing about us without us")

Mental Status Exam (MSE): Speech

• Rate: slow, rapid, normal • Volume: loud, soft, normal • Disturbances (e.g., articulation problems, slurring, stuttering, mumbling) *You can have different combinations of the speech descriptors. This is more your perception. Pressured speech means that the person is speaking so rapidly that they seem forced to speak. Excessive speech may be a person in a manic episode or psychotic episode.

Mental Health Parity Act of 1996

• Required insurance coverage for MH conditions to be equivalent to PH conditions -Prior to the Mental Health Parity Act of 1996, it was permissible for healthcare insurance companies to limit the number of mental health conditions. Now, the insurance must cover physical ailments and mental health problems equally. (There are still exceptions, but for the most part this applies to all insurance companies)

SOLER

• S - Sit squarely facing the client •O - Observe an open posture. • L - Lean forward toward the client. • E - Establish eye contact • (unless ethnic/cultural background of client discourages direct eye contact) •R - Relax

Verbal Communication

• Silence and Listening: intentional silence • Therapeutic use of silence • Active vs. passive listening • SOLER mnemonic: Sitting, Observing, Lean in, Eye-contact, Relax • Validation • Explicitly checking nurse's own thoughts or feelings • "I" statements: "I think you said,....Is that correct?"

Trauma-Informed Care

• Strengths-based approach -What are the patient's positive resources? What tools from their childhood do they have? • Prevent re-traumatization -Avoiding triggers or situations that remind the patient of a trauma • Integral to recovery-oriented PMH nursing care • Incorporates a basic realization and understanding of the impact of trauma in order to recognize and respond therapeutically -Trauma impacts the brain at a physiologic/biologic level, not just psychological. (i.e. it changed their biologic response to inflammation, etc.) • Appreciates many problem behaviors began as understandable attempts to cope • Priorities patient choice and control over the healing process • Seeks to be culturally competent • context of life experiences • cultural background

Factors in Communication: Personal

•Health status: Stroke, ventilator, schizophrenia? • Language skills: What is their language skill? English primary language? How old are they? • Socio-demographics: -Age: Age, slang, etc. change the complexity of the language spoken/understood -Gender/Sex: Traditional socialism (stereotype) of women

Factors in Communication: Environmental

•Privacy: Are there distractions? Is the person comfortable to answer the question in the present environment? •Noise