WEEK 2 - Anxiety/Defense Mechanisms, Safety and security, Patient Assessment, Therapies, Psychotropic Medications

Moderate Anxiety

Able to stay still (sitting) Physical Sx's start Signing Fidgeting Wringing hands Incr. tone of voice Decr. concentration * Manageable pounding heart (NO pain)

ADULTHOOD Generativity vs. Stagnation (30 - 65)

Achieve life goals established for oneself while considering the welfare of future generations When prev. tasks are not achieved, the individual lacks the maturity to derive gratification from concern for welfare of others

SCHOOL AGE Industry vs Inferiority (6-12)

Achieve self-confidence by learning, competing, performing successfully, and receiving recognition from others. Harsh discipline, negative feedback, and setting unrealistic expectations will result in difficulty in interpersonal relationships, feelings of inadequacy, lack of ability to compromise and cooperate with others.

INFANCY Trust vs Mistrust (0 - 18 months)

Achieve trust in parent/caregiver and generalize this trust to others. Failure to respond to infant's distress promptly and consistently will result in difficulty with interpersonal relationships and suspiciousness

Therapeutic Communication - Safety

Address pt by name with respect Use a matter of fact tone of voice Keep wording simple Avoid rapid questioning No criticism Avoid unnecessary conflict Work to decr. pt's anxiety Seek clarification on what pt means Verbal Limit Setting: - Be sure pt knows unit rules - Clearly re-state the rules - ID undesirable bhvr - Suggest alter. bhvr - Clearly state/enforce consequences Verbal Contracting: - The RN and pt set up an agreement that if pt experiences (target Sx's), the pt will tell the nurse before doing anything unsafe

Least Restrictive Measures: Therapeutic Physical Limits

All limits req. MD order Seclusion and restraints also have legal time exp. that must be followed 1. Community limits: may go off hosp. grounds 2. Hospital Limits: may leave the locked unit but must remain on hosp. grounds. This is scheduled in advance, and usually lasts about 20 min 3. Unit Limits: Pt cannot leave unit 4. "Show of Force": when the pt looks to be loosing control, many staff will gradually gather around to escort pt to the seclusion room or/and apply restraints - when pt is already in seclusion room and the behvr worsens, many staff will enter the room together to place pt in restraints

Phase 3 crisis development

All possible resources, both internal and external, are called on to resolve the problem and relieve the discomfort. The individual may try to view the problem from a different perspective, or even to overlook certain aspects of it. New problem-solving techniques may be used, and, if effectual, resolution may occur at this phase, with the individual returning to a higher, a lower, or the previous level of premorbid functioning

1. Precipitating Event

Description of recent events in the pt's life that lead the pt to be hospitalized, recording pt's own words

CHILDHOOD Initiative vs Guilt (3 - 6)

Develop sense of purpose and assertiveness with ability to initiate /direct own activities Stifling creativity with an expected higher level of achievement than child can produce results in feelings of inadequacy, defeat, and guilt

Early Prevention - Safety

Anticipate and prevent situations that can cause harm Notice subtle changes in pt's bhvr Initiate a simple conversation with the pt about subtle changes that you noticed - First thing acknowledge the pt's anger/fear - Recognize that anger is a choice Be mindful that anger is a form of communication Active Listening to the pt is the process really attempting to hear, acknowledge , and understand what pt is saying. Listening means not only attending to the words but also underlying emotion and body language Comment on the emotion you are witnessing Anger is a bhvr that has benefit for the user Anger can get ppl: - attention they need - escape things the don't want to do - gain control - pump them up when they feel small and insignificant Address all escalating/acting out bhvrs EARLY before pt loses emotional control Move the pt to quiet area to promote calm setting

Nursing Diagnosis - Anxiety

Anxiety Ineffective Copying Post Trauma Syndrome Decisional Conflict

Somatic Symptom Disorder

Anxiety-Related disorder Characterized by physical symptoms suggesting medical disease but without demonstrable organic pathology or a known pathophysiological mechanism to account for them. Somatic symptom disorder (SSD) occurs when a person feels extreme anxiety about physical symptoms such as pain or fatigue. The person has intense thoughts, feelings, and behaviors related to the symptoms that interfere with daily life. A person with SSD is not faking his or her symptoms

Conversion Disorder

Anxiety-Related disorder Primary, Secondary, and Tertiary Gains. Mental condition in which a person has blindness, paralysis, or other nervous system (neurologic) symptoms that cannot be explained by medical evaluation

Obsessive-Compulsive Disorder (OCD)

Anxiety-Related disorder Recurrent obsessions or compulsions that are severe enough to be time-consuming or to cause marked distress or significant impairment

Panic Disorder

Anxiety-Related disorder Recurrent panic attacks which are unpredictable, assoc with feelings of doom and have intense physical symp. Symp: -DO NOT come on immediately (no cause/effect) At least four of the following: 1) palpitations, pounding, acc. heart, chest pain 2) sweating, chills, heat 3) trembling, shaking 4) SOB or smothering 5) nausea or ab. distress 6) dizziness etc 7) derealization/depersonalization 8) going crazy or fear of death Frequency: -lasts minutes -exacerbations and remissions

Post-Traumatic Stress Disorder (PTSD)

Anxiety-Related disorder Trauma that is outside the range of normal human experience (ie rape, war, physical attack) A: -reliving the event -sustained anxiety and arousal -numbing response -intrusive nightmares -amnesia -depression, guilt -substance abuses, anger, aggression, relationship problems. D: - symptoms present for more than 1 month, interfering with social life and occupation. - symptoms begin within 3 months after trauma or may be delayed SX: 1. Intrusion (ie memories being distressing) 2. Negative mood (being unhappy) 3. Dissociative (ie selective amnesia) 4. Avoidance 5. Arousal (ie sleep disturbance, extreme startle response)

Dissociative Disorders

Are defined by a disruption in the usually integrated functions of consciousness, memory, and identity

Lorazepam

Ativan Classification Therapeutic:anesthetic adjuncts, antianxiety agents, sedative/hypnotics Indications Anxiety disorder (oral). Preoperative sedation (injection). Decreases preoperative anxiety and provides amnesia. Unlabeled Use: IV: Antiemetic prior to chemotherapy. Insomnia, panic disorder, as an adjunct with acute mania or acute psychosis. Action Depresses the CNS, probably by potentiating GABA, an inhibitory neurotransmitter. Therapeutic Effects:Sedation. Decreased anxiety. Decreased seizures. Adverse Reactions/Side Effects CNS: dizziness, drowsiness, lethargy, hangover, headache, ataxia, slurred speech, forgetfulness, confusion, mental depression, rhythmic myoclonic jerking in pre-term infants, paradoxical excitation. EENT: blurred vision. Resp: respiratory depression. CV:rapid IV use only—APNEA, CARDIAC ARREST, bradycardia, hypotension.GI: constipation, diarrhea, nausea, vomiting, weight gain (unusual). Derm: rashes. Misc: physical dependence, psychological dependence, tolerance. NURSINGIMPLICATIONS Assessment ● Conduct regular assessment of continued need for treatment. ● Pedi: Assess neonates for prolonged CNS depression related to inability to metabolize lorazepam. ● Geri: Assess geriatric patients carefully for CNS reactions as they are more sensitive to these effects. Assess falls risk. ● Anxiety: Assess degree and manifestations of anxiety and mental status (orientation, mood, behavior) prior to and periodically throughout therapy. ● Prolonged high-dose therapy may lead to psychological or physical dependence. Restrict amount of drug available to patient. ● Status Epilepticus: Assess location, duration, characteristics, and frequency of seizures. Institute seizure precautions. ● Lab Test Considerations: Patients on high-dose therapy should receive routine evaluation of renal, hepatic, and hematologic function. ● Toxicity and Overdose: If overdose occurs, flumazenil (Romazicon) is the antidote. Do not use with patients with seizure disorder. May induce seizures.

Professional Behaviors - Safety

Being there Being aware Caring Connecting Balancing Deciding how to respond ID acting out bhvr early Have pt withing visual range at all time Avoiding hands in the pockets Mantn assertive, non-threatening stance Position yourself so you have easy access from the room Avoid touching the pt Stand at the angle to the pt Nurse must ID their own thoughts, feelings, and bhvrs If the nurse also experiences anger,then that person will not be very effective assisting pts with angry feelings

7. Spirituality/Religion

Belief in or relationship with some higher power, creative force, divine being, or infinitive source of energy/religious affiliation; whether or not pt is currently involved with a religion or spiritually practice

Severe Anxiety

Cannot stay still, getting up (eg. fixing papers) Incr. movements Pacing Doing more things Focus narrows to one thing chest pain, HA, focus on one thing

Impaired Mood Regulation

D: A mental state charact. by shifts in mood or affect and which compromises a constellation of effective, cognitive, somatic, and/or physiological manifestations varying from mild to severe CH: Changes in verbal behavior Dysphoria Excessive guilt Excessive self-blame and self-awareness withdrawal

HOPELESSNESS

D: A subjective state in which an individual sees limited or unavailable alternatives or personal choices and is unable to mobilize energy on own behalf Defining Characteristics: Passivity; decreased verbalization; decreased affect; verbal cues (e.g., saying "I can't," sighing); closing eyes; decreased appetite; decreased response to stimuli; increased/decreased sleep; lack of initiative; lack of involvement in care; passively allowing care; shrugging in response to speaker; turning away from speaker

Complicated Grieving Risk For

D: At risk for a disorder that occurs after the death of a significant other,in which the experience of distress accompanying bereavement fails to follow normative expectations and manifests in functional impairment, Inability to express these feelings may result in maladaptive behaviors RF: Death of a significant other Emotional instability Lack of social support

Risk For Other-Directed Violence

D: At risk for behaviors in which an individual demonstrates that he or she can be physically, emotionally, and/or sexually harmful to others RF: HISTORY OF VIOLENCE: Against others (e.g., hitting, kicking, scratching, biting or spitting, or throwing objects at someone; attempted rape, rape, sexual molestation; urinating/defecating on a person) Threats (e.g., verbal threats against property/person, social threats, cursing, threatening notes/letters or gestures, sexual threats) Antisocial behavior (e.g., stealing, insistent borrowing, insistent demands for privileges, insistent interruption of meetings; refusal to eat or to take medication, ignoring instructions)

Risk For Self-Directed Violence

D: At risk for behaviors in which an individual demonstrates that he/she can be physically, emotionally, and/or sexually harmful to self. Risk factors: Biochemical/neurologic imbalances. Impulsivity. Manic excitement. Psychotic symptomatology. Rage reaction. Restlessness.

Risk for Self-Mutilation

D: At risk for deliberate self-injurious behavior causing tissue damage with the intent of causing nonfatal injury to attain. Risk factors: Desperate need for attention. Emotionally disturbed or battered children. Feelings of depression, rejection, self-hatred, separation anxiety, guilt, and depersonalization. History of self-injury. History of physical, emotional, or sexual abuse. High-risk populations (BPD, psychotic states). Impulsive behavior. Inability to verbally express feelings. Ineffective coping skills. Mentally retarded and autistic children.

Risk for Loneliness

D: At risk for experiencing discomfort associated with a desire or need for more contact with others Risk Factors: Affectional deprivation Physical isolation Cathectic deprivation Social isolation

Risk For Suicide

D: At risk for self-inflicted, life-threatening injury. Risk Factors: Alcohol and substance abuse/use. Abuse in childhood. Family history of suicide. Fits demographic (children, adolescent, young adult male, elderly male, Native American, Caucasian). Grief, bereavement/loss of an important relationship. History of prior suicide attempt. Hopelessness/helplessness. Legal or disciplinary problems. Physical illness, chronic pain, terminal illness. Psychiatric illness (e.g., bipolar disorder, depression, schizophrenia). Poor support system, loneliness.

Ineffective Denial

D: Conscious or unconscious attempt to disavow the knowledge or meaning of an event to reduce anxiety and/or fear, leading to the detriment of health Defining Characteristics: Major* (Must Be Present) Delays seeking or refuses health care attention Does not perceive personal relevance of symptoms or danger Minor (May Be Present) Uses home remedies (self-treatment) to relieve symptoms Does not admit fear of death or invalidism* Minimizes symptoms* Displaces the source of symptoms to other areas of the body Cannot admit the effects of the disease on life pattern Makes dismissive gestures when speaking of distressing events* Displaces the fear of effects of the condition Displays inappropriate affect*

Impaired Verbal Communication

D: Decreased, reduced, delayed, or absent ability to receive, process, transmit, and use a system of symbols. CH: Difficulty vocalizing words Difficulty discerning and maintaining the usual communication pattern Disturbances in cognitive associations (e.g., perseveration, derailment, poverty of speech, tangentiality, illogicality, neologism, and thought blocking) Inability to find, recognize, or understand words Inability to recall familiar words, phrases, or names of known people, objects, and places Inappropriate verbalization Problems in receiving the type of sensory input being sent or sending the type of input necessary for understanding

Self-Mutilation

D: Deliberate self-injurious behvr. causing tissue damage with the intent of causing nonfatal injury to attain relief of tension CH: Biting Constricting body part Cuts of body Hitting Ingestion or inhalation of harmful substances Picking at wounds Scratches Burns

Complicated Grieving

D: Extended unsuccessful use of intellectual and emotional responses by which individuals, families, and communities attempt to work through the process of modifying self-concept based on the perception of loss CH: Repetitive use of ineffectual behaviors associated with attempts to reinvest in relationships; crying; sadness; reliving of past experiences with little or no reduction (diminishment) of intensity of the grief; labile affect; expression of unresolved issues; interference with life functioning; verbal expression of distress at loss; idealization of lost object (e.g., people, possessions, job, status, home, ideals, parts and processes of the body); difficulty in expressing loss; denial of loss; anger; alterations in eating habits, sleep patterns, dream patterns, activity level, libido, concentration and/or pursuit of tasks; developmental regression; expression of guilt; prolonged interference with life functioning; onset or exacerbation of somatic or psychosomatic responses

Ineffective Impulse Control

D: Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources CH: Change in communication patterns Decreased use of social support Destructive behavior toward self or others Difficulty asking for help Fatigue High illness rate Inability to meet basic needs and role expectations Statements indicating inability to cope

Ineffective Coping

D: Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources. CH: SUBJECTIVE Verbalization of inability to cope or inability to ask for help Sleep disturbance; fatigue Abuse of chemical agents [Reports of muscular/emotional tension, lack of appetite] OBJECTIVE Lack of goal-directed behavior/resolution of problem, including inability to attend to and difficulty with organizing information; [lack of assertive behavior] Use of forms of coping that impede adaptive behavior [including inappropriate use of defense mechanisms, verbal manipulation] Inadequate problem-solving Inability to meet role expectations/basic needs Decreased use of social supports Poor concentration Change in usual communication patterns High illness rate [including high blood pressure, ulcers, irritable bowel, frequent headaches/neckaches] Risk taking Destructive behavior toward self or others [including overeating, excessive smoking/drinking, overuse of prescribed/OTC medications, illicit drug use] [Behavioral changes (e.g., impatience, frustration, irritability, discouragement)]

Disturbed Personal Identity

D: Inability to maintain an integrated and complete perception of self CH: Alteration in body image Confusion about cultural values Delusional description of self Inability to distinguish b/w internal and external stimuli Ineffective relationships and role performance

Situational Low Self-Esteem

D: Inability to maintain an integrated and complete perception of self CH: Disturbed body image Contradictory personal traits Fluctuating feelings about self Ineffective role performance Gender confusion Ineffective coping Unable to distinguish between Uncertainty about ideological inner and outer stimuli and cultural values Delusional description of self Uncertainty about goals Feelings of emptiness Disturbed relationships Feelings of strangeness

Impaired Social Interaction

D: Insufficient or excessive quantity or ineffective quality of social exchange. CH: Alienating others through angry, clinging, demeaning, and/or manipulative behavior or ridicule toward others. Destructive behavior toward self or others. Dysfunctional interaction with peers, family, and/or others. Observed use of unsuccessful social interaction behaviors.

Chronic Sorrow

D: Irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by decreased ability to interpret environmental stimuli; decreased capacity for intellectual thought processes; and manifested by disturbances of memory, orientation,and behavior, Inability to express these feelings may result in maladaptive behaviors. CH: Altered interpretation, response to stimuli, and/or personality No change in LOC Clinical evidence of organic impairment Short- and long-term memory loss Progressive or long-standing impaired cognition or socialization

Social Isolation

D: Loneliness experienced by an individual and perceived as imposed by others and as a negative state or threat CH: - Lack of family support. - Emotional sad or off. - Withdrawal, no communication, no eye contact. - Concern for one's own thoughts. - Verbal and behavioral hostility. - Presence of a physical and / or psychological. - Expresses feelings of loneliness or rejection. - Present feelings of indifference. - Lack of meaningful goals in life and inability to meet the expectations of others.

Chronic Low Self-Esteem

D: Long standing negative self-evaluation/feelings about self or self-capabilities. CH: Evaluates self as unable to deal with events. Excessively seeks reassurance. Expresses longstanding shame/guilt. Hesitant to try new things/situations. Longstanding or chronic self-negting verbalizations; expressions of shame and guilt. Overly conforming, dependent on others' opinions, indecisive. Rationalizes away/ rejects positive feedback and exaggerates negative feedback about self.

Noncompliance

D: Patient's failure to comply with the prescribed treatment regimen for his/her full recovery from such illness or disease. CH: Verbalization of lack of financial support Lack of support groups Poor knowledge on the importance of completing treatment Contradicting health, cultural and religious beliefs Lack of motivation

Defensive Coping

D: Repeated projection of falsely positive selfevaluation based on a self-protective pattern that defends against underlying perceived threats to positive self-regard CH: SUBJECTIVE Denial of obvious problems/weaknesses Projection of blame/responsibility Hypersensitive to slight/criticism Grandiosity Rationalizes failures [Refuses or rejects assistance] OBJECTIVE Superior attitude toward others Difficulty establishing/maintaining relationships, [avoidance of intimacy] Hostile laughter or ridicule of others, [aggressive behavior] Difficulty in reality testing perceptions Lack of follow-through or participation in treatment or therapy [Attention-seeking behavior]

Post Trauma Syndrome

D: Sustained maladaptive response to a traumatic, overwhelming event CH: Aggression Alienation Alteration in concentration and mood Anger Anxiety Denial Depression Grieving Guilt Horror Panic attacks Repression Substance abuse Shame

Ineffective Health Management

D: The inability to identify, manage, or seek out help to maintain health Defining Characteristics: History of lack of health-seeking behavior; reported or observed lack of equipment, financial, and/or other resources; reported or observed impairment of personal support systems; expressed interest in improving health behaviors; demonstrated lack of knowledge regarding basic health practices; demonstrated lack of adaptive behaviors to internal and external environmental changes; reported or observed inability to take responsibility for meeting basic health practices in any or all functional pattern areas

Powerlessness

D: The lived experience of lack of control over a situation, including a perception that one's actions do not significantly affect an outcome CH: Alienation Dependency Depression Doubt about role performance Shame Lack of control

Decisional Conflict (specify)

D: Uncertainty about course of action to be taken when choice among competing actions involves risk, loss, or challenge to personal life values CH: SUBJECTIVE Verbalized uncertainty about choices or of undesired consequences of alternative actions being considered Verbalized feeling of distress or questioning personal values and beliefs while attempting a decision OBJECTIVE Vacillation between alternative choices; delayed decision making Self-focusing Physical signs of distress or tension (increased heart rate; increased muscle tension; restlessness; etc.)

Labile Emotional Control

D: Uncontrollable outbursts of exaggerated and involuntary emotional expression CH: Absence of eye contact Difficulty in use facial expressions Embarrassment r/t emotional expression Excessive crying without feeling sad Excessive laughing without feeling happiness Withdrawal from occupational or social situation

Anxiety

D: Vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with the threat. CH: Affective Apprehensive Feelings of inadequacy Focus on self Irritability Painful or persistent increased helplessness Behavioral Diminished productivity Expressed concerns about changes in life events Insomnia Restlessness Cognitive Confusion Difficulty concentrating Diminished ability to learn or solve problems Fear of unspecified consequences Physiological, sympathetic: Anorexia Diarrhea Dry mouth Facial flushing Increased BP, pulse, respirations Twitching, increased reflexes Physiological, parasympathetic Abdominal pain Faintness Fatigue Nausea Urinary frequency, urgency

Disturbed Personal Identity Risk For

D: Vulnerable to ability to maintain an integrated and complete perception of self, which may compromise health RF: Alteration in social role Developmental transition Discrimination Dysfunctional family Exposure to toxic chemicals Low self-esteem

Risk For Powerlessness

D: Vulnerable to the lived experience of lack of control over a situation , incl. a perception that one's actions do not signif. affect the outcome, which may compromise health CH: Anxiety Caregiver role Economically disadvantaged Ineffective coping strategies Insufficient support Low self-esteem Pain Illness

Disturbed Body Image

D: Confusion in mental picture of one's physical self. CH: Actual change in structure or function Alteration in social function (e.g, withdrawal, isolation, flamboyance) Focusing behavior on changed body part/function Intentional hiding of body part Refusal to discuss or acknowledge change Refusal to look at, touch, or care for altered body part Verbal preoccupation with changed body part or function Verbalization about altered structure or function of a body part.

Group Therapy

D: A form of psychosocial Tx in which a number of pts meet together with therapist for purpose of sharing , gaining personal insight, and improving interpersonal coping strategies

Risk Factors - Anxiety

Hereditary Physiological (brain diff.-frontal and prefrontal lobe cortex, temporal lobe and amygdala). - too emotional Environmental - First child, test, job interview, traffic, being late, etc. Lifestyle Choices - too much caffeine, drugs, alcohol, changes in life, physiological.

8. Recreational/Leisure Interests

Hobbies, interests and what the pt did during free time prior to the hospitalization.

Several strategies have been developed to counter negative, regressive effects of institutionalization of Milieu Therapy

Distribution of power Open communication Structured interactions Work- related activities. Community and family involvement in the treatment process Adaptation of the environment to meet developmental needs.

Patient Outcomes

Does not harm self Does not harm others Uses words when angry, not hands Does not act on delusions Does not cut self * time frame * expected bhvr * action verb * observable/measurable/realistic

Conscious Copying Mechanisms

Eating Drinking Smoking Exercising Deep breathing Talk to support person Bath Reading Writing Meditation, Yoga, etc.

10. Education

Education that was completed

Phase 4 crisis development

If resolution does not occur in previous phases, "the tension mounts beyond a further threshold or its burden increases over time to a breaking point. Major disorganization of the individual with drastic results often occurs." Anxiety may reach panic levels. Cognitive functions are disordered, emotions are labile, and behavior may reflect the presence of psychotic thinking

Anxiety

Emotional-subjective experience depending on a person: can be exhibited as irritation, anger, depression, or apathy Social product of interpersonal relationships and easily :passed to others" (respons to simple statements) Physiological-physical Sx's: - chest pain - palpitations - diaphoresis - incr. VS - SOB - Flushed - N/V/D - constipation - Lack of appetite - abd. pain

* Defense Mechanisms *

Employed by the ego in the face of threat to biological or psych integrity.

Evaluation - Anxiety

Evaluate and reassess each pt outcome Determine if outcomes are achieved based on pt statements and actions Patient describes own anxiety and coping patterns. Patient demonstrates improved concentration and accuracy of thoughts. patient demonstrates ability to reassure self. Patient maintains a desired level of role function and problem solving. Patient monitors signs and intensity of anxiety. Patient identifies strategies to reduce anxiety. Patient identifies and verbalizes anxiety precipitants, conflicts, and threats. Patient demonstrates return of basic problem-solving skills. Patient demonstrates increased external focus. Patient has vital signs that reflect baseline or decreased sympathetic stimulation. Patient has posture, facial expressions, gestures, and activity levels that reflect decreased distress.

Psychodynamic Theory

Inability of ego to intervene when conflict occurs b/w id and superego, producing anxiety

Panic Attack

Inability to communicate/move/function C/O dizziness Hyperventilation Heart palpitations NI: simple, nice, clear, and direct statements delusional statements, loss of reality, disorganized

ERIKSON'S DEVELOPMENTAL TASKS

Indicate whether the pt is meeting the developmental tasks for age group or not

Mood

Individual's sustained emotional tone, which signif. influences bhvr, personality, perception

3. Current Family Relationships

Info about pt's current family members, their roles, and relationships

PSYCHOSOCIAL DATA

Info about various aspects of pt's life and ability to function effectively in society

Phases of Crisis Intervention: The Role of the Nurse Phase 1. Assessment

Information is gathered regarding the precipitating stressor and the resulting crisis that prompted the individual to seek professional help (what brought you here today)

ADOLESCENCE Identity vs. Role Confusion (12 - 20)

Integrate tasks mastered in prev. stages to secure a sense of self separate from parent figures. Independence is discouraged and adolescent is nurtured in dependent role, discipline harsh, inconsistent, or absent, shifting parents/caregivers or parent/caregiver rejection results in self-doubt, confusion about life role, limited personal goals

Therapeutic Milieu - Safety

Locked unit No glass or sharps Danger areas locked Shower curtain rods are "break-away" type Craft items secured when not in use Uncluttered hallways Good lighting Personal search policies Noise level low Unit repairs made immediately No smoking on unit minimal changes in routine Minimal crowding of ppl Visitor bag search policy If police are on unit, no guns

Mild Anxiety

Normal. Awareness and being alert (ready) heightens concentration

Keeping the Unit Safe - Mapping Psych Nursing Skills

Nurse maint-ed focus outward on the unit Maintn-ed on-going process of being aware Kept track of emotional tone of entire milieu Attended to pt movement on the unit Noticed pt's subtle bhvr changes Compared pt's current level of worsening with the pt's usual presentation Demonstrated an awareness when the unit was getting out of hand Common RN activities: - Going back to pt periodically and talking and calming - Providing reassurance of their presence - Particularly watched pts who knew each other from the streets - Avoided over-controlling the pt

Compulsions

Repetitive behaviors or thoughts that a person engages in to neutralize, counteract, or make their obsessions go away. People with OCD realize this is only a temporary solution, but without a better way to cope, they rely on the compulsion as a temporary escape. Compulsions can also include avoiding situations that trigger obsessions. Compulsions are time consuming and get in the way of important activities the person values. Examples: - washing to remove germs, - praying to counter blasphemous or sacrilegious thoughts that could result in going to hell, - checking for assurances that doors are locked or people are OK, - putting things in order (arranging), - repeating other behaviors to get rid of a thought (turning a light off and on until a bad thought goes away) - mental rituals that take place purely in the person's mind. Compulsive rituals are all about trying to get reassurance and certainty.

Crisis Intervention

Requires problem-solving skills that are often diminished by the level of anxiety accompanying disequilibrium

OLDER ADULTHOOD Ego Integrity vs. Despair (65 - death)

Review one's life to derive meaning from positive and negative events while achieving a positive sense of self-worth When earlier tasks are not fulfilled, the individual feels self-contempt, disgust, and worthlessness with anger, depression, and loneliness evident

Nursing Diagnosis

Risk for Self-Directed Violence Risk for Other Directed Violence Disturbed Sensory Perception Ineffective Impulse Control Ineffective Coping Impaired Social Interaction

S = subjective O = objective A = assessment/analysis

S I'm not going to take those medications. S Stated that the food is poisoned. O Talked with another patient for 15 minutes. O,A Neatly groomed and dressed. S The voice is telling me to kill my mother. O,A Labile affect. A Willing to express concerns. O Wearing soiled, mismatched clothing, hair uncombed. O Spends free time in room. S Talked about being worried about her husband. A Showing increased insight. O Attending all groups. A Adequate pain relief from Tylenol. O Speaks rapidly in a loud tone of voice. A Decrease in withdrawn behavior. O,A Speech is pressured

Nursing Evaluation

Safety Evaluation of the Pt: - Was my pt safe today - Is my pt on the appropr. precautions - Did my pts achieve their safety outcomes - Do I need to make modifications in care plan Safety Evaluation of the Therapeutic Milieu - Was the environment safe today - Was the overall safety maintained on the unit today

Tertiary Gain

Shift in family focus from conflict to concern for "sick" f-ly member The receipt of positive reinforcement for somaticizing by causing focus of the family to switch to the individual and away from conflict that may be occurring withing family.

Nurse Self-Assessment

Since anxiety is contagious, how would it feel to work with the pt with anxiety Anxious Afraid Drained Not easy

6. Cultural Factors

Specific ethnic group pt identifies with, if any , and if so, how this might affect their care

Planning - Outcomes - Anxiety

State decr. anxiety (feel better) Exhibits decr. anxiety: decr. pacing, no wringing hands, sitting still. Eg. Sitting still for 5 miutes VS within certain range (specify) States ways to cope with anxiety (relaxation, discussing feelings (instead of acting out on them), using meds)

Precautions - Safety

Suicide: q 15 min with doc-on 1:1 sup. when using harmful objects Violence: 2 staff members obs. q 15 min with doc-on 1:1 sup. when using harmful objects Escape: No lingering in doorways Check unfamiliar faces Know which pts are on escape precautions Use specific staff entrance

12. Participation in program/Milieu Activities

Participation in groups and interactions with other during the current hospi-zation

Important Pt Safety Risk Factors

Past Hx Presenting Problem Current Behvrs

Secondary Gain

Perceived benefits and advantages of being "sick" The receipt of positive reinforcement for somaticizing through added attention, sympathy, and nurturing

Generalized Anxiety Disorder

Persistent, unrealistic, excessive anxiety which have occurred more days than not for 6 months. Symp: -muscle tension, restlessness, keyed up -spends time preparing for stressors -avoids activities with possible negative outcomes -procrastinates decision-making

4. Current Significant Other Relationships

Ppl outside pt's family who are important

Restraints

Pt is restrained in bed by leather straps 4 point restraints used Intensive 1:1 sup. by staff Q 15 min RN checks with doc. Monitor pt's resp. closely Must attend to pt's basic needs

Seclusion

Pt must remain in a locked room with little furniture or belongings Pt usually puts on a hosp. gown Includes camera AT least 2 staff need to be present to open the door Q 15 min check with doc. No conversations with Pt in seclusion

Supervision - Safety

Pt rounds every 15 min 1:1 supervision: cont. "eye on pt" observation. Must be within 6 feet at all times

The Nurse-Pt Relationship - Safety

Pt trusts you Positive interactions with pt Help pt express their feelings Allow pt to make some decisions Attend/conduct/participate in group meetings Affirm pt's individuality

Assessment - Pt with Anxiety

Pt's ability to meet basic needs (+ or _ eating, sleeping; withdrawal, activity level, safety and security (excess energy))

MENTAL STATUS EXAMINATION

Questions and Observation 1. Appearance 2. Behavior and Attitude (body movements, activity, eye contact, body language) 3. Mood and Affect (angry, sad; appropriate, not, flat, blunted). 4. Characteristics of speech (volume, pressure, rate, rhythm, pattern, tone) 5. Thought Content (predominant themes, delusions, hallucinations, obsessions) 6. Thought Process (flow of thought or the way pt thinks; logical? relevant? towards goal? Concentration, attention, clarity, ability to abstract - asking meaning or proverbs) 7. Pt Insight (ability to acknowledge and understand his/her illness and the need for Tx) 8. Pt Judgment (ability to assess social situations, understand consequences, realistic goals, use examples form pt's life or the day) * May also include an assessment of memory and intellectual function

Most Restrictive Measures: Seclusion/Restraints

Rationale: to assist pt maintain or achieve behavioral control over their intense emotional experience Duration: for only as long as needed * Be sure to follow all agency policies regarding spec. limits and precautions. * Know what you are allowed to do as an RN in the agency in which practice. * Always use least restrictive limit that is necessary

Insight

Recognition of one‟s own condition. (mental illness) It refers to:- the conscious awareness and understanding of one‟s own psychodynamics and symptoms of maladaptive behavior; highly important in effecting changes in the personality and behavior of a person

Primary Gain

Relief of unconscious conflict and anxiety The receipt of positive reinforcement for somaticizing by being able to avoid diff. situations b/c of physical complaint.

* Psychotropics *

Term is used to describe the classifications of medications used to treat mental illness Med that affects psychic function, bhvr, or experience

Phases of Crisis Intervention: The Role of the Nurse Phase 3. Intervention

The actions identified in the planning phase are implemented * A reality-oriented approach is used *****A rapid working relationship is established by showing unconditional acceptance, by active listening, and by attending to immediate needs (no judgment) * A problem-solving model becomes the basis for change

Affect

The bhvral expression of emotion; may be apprpr (congruent with the situation), inapproprt (incongruent with the situation) or blunted (diminished range and intensity), or flat (absence of emotional expression)

Why does a patient diagnosed with a mental illness need to go through a grief process?

The illness may be life long, alteration or loss of function may occur, medications may be required

Phase 1 crisis development

The individual is exposed to a precipitating stressor. Anxiety increases; previous problem-solving techniques are employed

NI - Key Concepts

The nurse-pt relationship Early prevention Therapeutic communication Professional Bhvrs Therapeutic Milieu Supervision/Precautions Least restrictive measures; seclusion/restrains

Goal of Crisis Intervention

The resolution of an immediate crisis and restoration to at least the level of functioning that existed before the crisis period. Promote a sense of safety first. *** Depend on nature of crisis and client's reaction but include: 1) relieve current symptoms; 2) help identify, gain understanding of factors that led to crisis; 3) use remedial measures/resources to restore pre-crisis level of functioning; 4) help develop adaptive coping strategies for current and future situation; 5) help client connect stresses with past experience. First three goals for all crises, last two if feasible or necessary.

* Obsessions *

Thoughts, images, or impulses that occur over and over again and feel out of the person's control. The person does not want to have these ideas. He or she finds them disturbing and unwanted, and usually knows that they don't make sense. They come with uncomfortable feelings, such as fear, disgust, doubt, or a feeling that things have to be done in a way that is "just right." They take a lot of time and get in the way of important activities the person values. Example: - fears of contamination/germs, - causing harm (perhaps by hitting someone with a car that you don't mean to), - making mistakes (leaving the door unlocked), disasters (causing a fire), - certain numbers (such as 13 and 666), - unwanted violent thoughts (thought of harming a loved one), - blasphemous thoughts (cursing God), - sexual thought (what if I'm a child molester, gay, or want to have sex with my mother?), - need for symmetry and exactness, - thoughts that something is terribly wrong with your body (what if I have cancer?). A general theme is that obsessions concern situations where there is some degree of uncertainty (what if "X" happens and I didn't do enough to prevent it?)

Other Early Prevention NI - Safety

Time away from stressful situation Walking Talking to someone who will listen Lying down Peaceful music Time alone Reading Drawing Wrapping in a blanket Pacing Coloring Shower/Bath Breathing for relaxation Exercising Warm or cold face cloth Running cold water on your hands Apply ice to the skin Relaxation exercising Gym Spiritual practices/meditation Being read to Crossword puzzle Playing a game Drinking something pleasant Writing Eating something pleasant

Behavior Therapy

To assist pt to change maladaptive or undesirable behavior by manipulating the environment and behavior. Based on the assumption that behavior learned and can be changed or relearned. Goal: Identify maladaptive or undesirable behavior in order to bring about behavioral change. When pt demonstrates desired behvr, positive reinforcement used to reward and strengthen new bhvr.

Cognitive Therapy

To assist pt to control thought distortions that are considered to be a factor in the development and cont. of emotional disorder. Goals: - to obtain symptom ASAP - To assist a pt to identify dysfunctional pattern of thinking - to guide pt to evidence and logic that effectively test the validity dysfunctional thinking Therapist helps the pt identify distorted thoughts evaluate the thoughts as nonproductive, and replace them with rational thoughts. Change is thoughts will lead to change in behvr.

* Psychotherapy *

To assist the pt to more effectively deal with emotional and social problems. Therapist might be: - Nurse - Social worker - Psychologist - Psychiatrist Goals: - reduce pt discomfort or pain (emotional, psych-social, or physical) - improve social functioning - Improve ability to perform or act appropr-ly Features: 1. The therapeutic relationship - b/w pt and therapist based on respect, confidence, and trust 2. Communication - ability of pt to talk openly about thoughts, feelings, and conflicts in an effort to relieve pain and suffering 3. Education and reeducation - incr. pt understanding and to help pt make changes 4. Change or transformation - when pt is free to make conscious choices, acts on the choices, and accepts responsibility for the consequences.

Family Therapy

To improve functioning of the family by modifying relat-ships of family members. Dysfunctional family fails to meet physical, emotional, intellectual, social, and spiritual needs of its members. Pt is a f-ly member with bhvral disturbances. But the focus of the therapy is on all f-ly members. Dysfunction within fmly: - scapegoating (one member is blamed for all problems) - ineffective patterns of communication Double blind communication - when a person receives simultaneous and contradictory messages. No matter how a person responds, it is wrong. Eg.: Go ahead and go skiing but don't blame me if you break your leg.

Dialectical Behavior Therapy

To treat chronic self-injurious and suicidal bhvrs. Type of bhvr-cognitive therapy incorporating Eastern mindfulness. Goals: - to teach pt skills and bhvrs to cope with stress - to regulate emotions - to improve relationships with others

Dissociative Identity Disorder

Type of Dissociative Disorder Characterized by the existence of two or more personalities within a single individual Transition from one personality to another usually sudden, often dramatic, and usually precipitated by stress

Dissociative amnesia

Type of Dissociative Disorder Defined as an inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness, and which is not due to the direct effects of substance use or a neurological or other medical condition. Onset usually follows severe psychosocial stress.

Depersonalization/Derealization Disorder

Type of Dissociative Disorder Feelings of unreality Changes in body image Feelings of detachment from the environment A sense of observing oneself from outside the body

Minor Tranquilizer

Used to reduce anxiety, fear, tension, agitation, and related states of mental disturbance. Minor tranquilizers, which are also known as antianxiety agents, or anxiolytics, are used to treat milder states of anxiety and tension in healthy individuals or people with less serious mental disorders. Benzodiazepines, among which are diazepam (Valium), chlordiazepoxide (Librium), and alprazolam (Xanax). These drugs have a calming effect and eliminate both the physical and psychological effects of anxiety or fear. Besides the treatment of anxiety disorders, they are widely used to relieve the strain and worry arising from stressful circumstances in daily life.

EBP - Safety

Violent incidents are more likely to occur when there are no scheduled activities More leisure/treatment activities are assoc. with greater improvements in pt Sx's and functioning The amount of positive staff interaction given to a pt during hospi-zation is the most important predictor of how well pt will do after D/C Violence decr. when staff remain outside of nursing station having positive interactions with the pts

2. Early Family Relationships

What pt remembers about family members and relationships while growing up.

Phase 2 crisis development

When previous problem-solving techniques do not relieve the stressor, anxiety increases further. The individual begins to feel a great deal of discomfort at the point. Coping techniques that have worked in the past are attempted, only to create feelings of helplessness when they are not successful. Feelings of confusion and disorganization prevail.

9. Current Living Arrangements

Where pt lives and with whom, where will pt go after discharge

rationalization

attempting to make excuses or formulate logical reasons to justify unacceptable feelings or behaviors. ex: john tells the rehab nurse, "I drink because it's the only way I can deal with my bad marriage and my worse job."

projection

attributing feelings or impulses unacceptable to one's self to another person. ex: sue feels a strong sexual attraction to her track coach and tells her friend, "he's coming on to me!"

dispositional crisis (class 1)

an acute response to an external situational stressor (married, having baby, going to college, empty nest, death of spouse)

intellectualization

an attempt to avoid expressing actual emotions associated with a stressful situation by using the intellectual processes of logic, reasoning, and analysis. ex: a client's husband is being transferred with his job to a city far away from her parents. she hides anxiety by explaining to her parents the advantages associated with the move.

identification

an attempt to increase self-worth by acquiring certain attributes and characteristics of an individual one admires. ex: a teenager who required lengthy rehabilitation after an accident decides to become a physical therapist as a result of his experiences.

* Crisis *

defined as a sudden event in ones life that disturbs homeostasis during which usual coping mechanisms cannot resolve the problem

Depersonalization

feelings of being detached Characterized by a temporary change in the quality of self-awareness

Derealization

feelings of unreality Described as an alteration in the perception of the external environment.

introjection

integrating the beliefs and values of another individual into one's own ego structure. ex: children integrate their parents' value system into the process of conscience formation. a child says to a friend, "don't cheat. it's wrong."

repression

involuntarily blocking unpleasant feelings and experiences from one's awareness. ex: an accident victim can remember nothing about his accident

isolation

separating a thought or memory from the feeling, tone, or emotion associated with it. ex: a young woman describes being attacked and raped, without showing any emotion.

undoing

symbolically negating or canceling out an experience that one finds intolerable. ex: joe is nervous about his new job and yells at his wife. on his way home he stops and buys her some flowers.

displacement

the transfer of feelings from one target to another that is considered less threatening or that is neutral. ex: a client is angry with his physician, does not express it, but becomes verbally abusive with the nurse.

suppression

the voluntary blocking of unpleasant feelings and experiences from one's awareness. ex: scarlett says, "I don't want to think about that now. I'll think about that tomorrow."

Phases of Group Development Final or Termination Phase

this marks the end of the group sessions responsibilities: >group members discuss termination issues >the leader summarizes work of the group and individual contributions

Milieu Therapy

"A scientific structuring of the environment to effect behavioral changes and to improve the psychological health and functioning of the individual." The community environment itself serves as the primary tool of therapy Goal of Milieu Therapy: to manipulate the environment so that all aspects of the client's hospital experience are considered therapeutic. Within the therapeutic community setting, the client is expected to learn adaptive coping, interaction relationship skills that can be generalized to other aspects of his or her life

Thought Content

(Inquired/Observed) - Possible questions for patient: • "What do you think about when you are sad/angry?" • "What's been on your mind lately?" • "Do you find yourself ruminating about things?" • "Are there thoughts or images that you have a really difficult time getting out of your head?" • "Are you worried/scared/frightened about something or other?" • "Do you have personal beliefs that are not shared by others?" (Delusions are fixed, false, unshared beliefs.) • "Do you ever feel detached/removed/changed/different from others around you?" • "Do things seem unnatural/unreal to you?" • "What do you think about the reports in papers such as The National Enquirer?" • "Do you think someone or some group intend to harm you in some way?" • [In response to something the patient says] "What do you think they meant by that?" • "Does it ever seem like people are stealing your thoughts, or perhaps inserting thoughts into your head? Does it ever seem like your own thoughts are broadcast out loud?" • "Do you ever see (visual), hear (auditory), smell (olfactory), taste (gustatory), and feel (tactile) things that are not really there, such as voices or visions?" (Hallucinations are false perceptions) • "Do you sometimes misinterpret real things that are around you, such as muffled noises or shadows?" (Illusions are misinterpreted perceptions)

Thought Processes

(Inquired/Observed): logic, relevance, organization, flow and coherence of thought in response to general questioning during the interview. - Possible descriptors: • Linear, goal-directed, circumstantial, tangential, loose associations, incoherent, evasive, racing, blocking, perseveration, neologisms.

Etiology of Anxiety

* Chronic OVERUSE of some defense mechanisms - Phobias (Unconsciously put anxiety on a thing) - OCD - Somatic Symptom (conversion is main def. mech) - Dissociative Disorders (similar to repression, loss of memory) * Inadequacy of and inability to use some defence mech-sms - GED - Panic - PTSD

* Nursing Diagnosis *

* Mental Health *

Implementation of NI - Anxiety

* Mild-Moderate Anxiety: - Make observations ("Your hands are not wringing") - Use destruction ("Let's talk about...") - Encourage thoughts, feelings, discussion of stressors and alternate responses when pt is ready (this anxiety is manageable) * Severe to Panic Anxiety: - Calm manner - Simple, direct, firm, concrete approach - Offer self (stay or walk with the pt) _________________________________________ * Perform ongoing assessments of mental status and level of anxiety * Minimize environment stimuli (going to the room, lower lights) * Re-assure and support pt (offer self) * Medicate as needed with antianxiety or anxiolytic , minor tranquilizers, sedatives, hypnotics. * Lorazepam and Clorazepam *Encourage discussion of feelings regarding issues instead of focusing on anxiety/physical Sx's or Pain. * Structure and refocus obsessive thinking * Structure day to accommodate compulsive rituals (20/shift to wash hands) * Avoid challenges and logic regarding strange rituals and obsessions * Assist with decision making/problem solving (discuss pros and cons of choices) when anxiety level is manageable

Levels of Prevention - Anxiety

* Primary Prevention: - Stress management and relaxation/yoga/meditation/exercise classes * Secondary Prevention: - Early identification and Tx (screenings, initial Tx and use of meds) * Tertiary Prevention: - Long term Tx and rehabilitation

* Nursing Assessment *

* Safety and Security * After Hx conduct a full mental status exam as part of your assessment

UNConscious Copying Mechanisms

- All defense mechanisms (except suppression) - Defense mechanisms defend against internal anxiety and conflicting emotions Two main emotions: 1. Anger 2. Sexual impulses

* Guidelines for conducting Mental Health Assessment *

- Allows RN to establish a base line of pt info, determine the pt's perceptions of his or her situation, gather info about pt's overall functioning, plan appropriate care, to develop therap. relationship and establish written record of pt's info. - Data is collected by using the skills of observation and interviewing. - Primary source: pt, pt's family or significant other or chart. During Mental Health Assessment, RN will be collecting data classified in the following categories: - Psychosocial - Medical and psych. Hx - Mental Status Examination (MSE)

Anxiolytic

- Long-term use of benzodiazepines can result in physical dependence or psychological addiction - Nonbenzodiazapines: Useful antianxiety drugs • Anxiolytic drugs: Block neurotransmitter receptor sites Uses • Anxiety disorders, panic attacks • Preanesthetic sedatives, muscle relaxants • Convulsions or seizures • Alcohol withdrawal Adverse Reactions • Early reactions: Mild drowsiness or sedation, lightheadedness or dizziness, headache • Other adverse body system reactions - Lethargy, apathy, fatigue - Disorientation, anger, restlessness - Nausea, constipation or diarrhea, dry mouth - Visual disturbances Dependence • Long-term use results in physical drug dependence and tolerance • Withdrawal symptoms may occur with as few as 4-6 weeks of therapy with benzodiazapine • Nursing alert - Symptoms of benzodiazepine withdrawal: Increased anxiety, concentration difficulties, tremor and sensory disturbances

In addition to interviewing and observing the patient, how are the effects of psychotropic medications monitored?

- blood tests - CBC, blood level of medications, - liver enzymes - kidney function - electrolyte levels - vital signs - especially BP, may need to monitor for orthostatic changes

Therapeutic communications skills were demonstrated by the nurses as they worked with patients

- empathetic listening - open-ended questions - focusing

Phases of Group Development Initial or Orientation Phase

- primary focus: >define the purpose and goals of the group - responsibilities: >the group leader sets a tone of respect, trust, and confidentiality among members. >members get to know each other and the leader. >there's a discussion about termination.

NI to Max Med Compliance

1. Develop theraputic alliance with pt and f-ly - avoid being judgmental 2. Attempt to determine reasons for not following med regime 3. Assess pt's/family's knowledge about meds 4. Teach pt/family about meds (SE, benefits, management of SE, etc.) 5. Admin. longer lasting meds to decr. dosage frequency 6. Make med regime as simple as possible 7. Arrange for med admin. supervision by f-ly member, friend, or agency staff 8. Arrange meds in Mediset (a plastic box - for each day, can be filled by staff or f-ly) 9. Arrange for support to obtain meds (eg. financial, transport, etc.)

Professional Responsibilities of the Pt in Restraints

1. Doc. q 15 min 2. 1:1 sup. of pt 3. On-going review and training

PATIENTS WITH ANXIETY - COMMUNICATION

1. For patients with mild to moderate anxiety: State observations regarding patient's behavior. Use distraction to refocus patient. 2. For patients with severe to panic anxiety: Use simple, concrete, firm statements Stay with patient. 3. Structure and refocus obsessive thinking and conversation. 4. Avoid challenging or using logic concerning strange behaviors and thinking. 5. Encourage direct expression and identification of thoughts and feelings, stressors, and alternative responses when appropriate.

MEDICAL AND PSYCH HISTORY

1. Hx of Med Surg Illnesses/Hosp-ns 2. Hx of Psych/chemical dependency Tx/Hosp-ns 3. Allergies 4. Meds 5. Review of Systems (info about each body system)

ASSETS, STRENGTHS, AREAS OF WELLNESS

1. Motivation 2. Education 3. Employment or potential for employment 4. Economic status 5. Physical health 6. Supports (family, friends)

Information Pt Needs while Teaching the Pt or Family

1. Nature of the illness: - What is Anxiety - To what might it be related - What is OCD - Sx's of anxiety disorders 2. Management of the Illness: a. Med managmnt (SE, length of time till effect, what to expect from med). - Meds for all disorders b. Stress Management: - Relaxation techniques 3. Support Services - Crisis hotline - Support groups - Individual Psychotherapy _________________________________________________ * S/S of anxiety * Causes of anxiety * Management - connect s/s of anxiety with stress - Avoid anxiety producing situations - Learn stress management * Utilize bhvr modific. and cogn.-bhvral approaches * Use of meds a sordered * Use of available resources and support services: health care provider, clinics, groups, internet * Evidence based research indicates that meditation, mindfulness, and yoga can help

Crisis Balancing Factors

1. Perception of event: Indv. percieves event Realistically vs Unrealistic Realistically= indv. finds adequate resources to solve and restore equalibrium Unrealistic= perception of event is distorted, ineffective problem solving, resolution not met. 2. Availability of Situational Support: Who is support system. Thnigs in environment that can be counted on to help resolve problem Ie: Family, resources 3. Availability of Adequate Coping Mechanisms: Things that provide comfort or stress relase Positive vs negative coping skills + = deep breathing, meditation - = denial, yelling, or acting out.

Nursing Interventions of the Pt in Restraints

1. Preserve pt's dignity at all times utilizing uncondit. positive regard and valuing of the pt as a fellow humman being. Practice a caring presence. Reassure pt that there is a person with them at all times to alleviate feelings of helplessness. 2. Remind the pt of the purpose of the restrnts. Teach that violence is an unacceptable response to anger and that you want to help the pt find more constructive ways to express anger. 3. Listen to the pt and use other therap. communic. techniques 4. Address basic needs - raise the pt's HOB to minim. feelings of vulnerability and risk for aspiration. Address hydration, nutrition, and elimination often. 5. Tx of Sx's 6. Reorient PRN 7. Meds PRN

Assessment of Past Hx

1. Psych Hx: informs about severity of illness 2. Med. Hx: Causing Sx's 3. Violence Hx: can indicate potential, esp. if recent 4. Past living environment: - abuse - doesn't trust - neglect - doesn't expect needs - chaos - no healthy boundaries

Current Behaviors

1. Self-care abilities: physical/cognitive 2. Anxiety level: creates negative internal energy 3. "Acting out": yelling, aggression, scratching, laughing, crying (responding in behavior instead of talking bout problem) 4. Destructive Bhvr pattern: intimidation, manipulation, refusal to discuss an issue, vengeance, self-mutilation, etc. 5. Ability to control emotions: yes/no 6. Impulsivity: Y/N 7. Insight: Y/N 8. Use of PRN Meds: Y/N; helpful/not

Assessment of Presenting Problem

1. The current admitting safety issue: reason for admission 2. Activity level: incr. or decr. 3. Mood: depressed? Manic? 4. Disorganized thinking: poor attention, scattered thoughts, confusion, forgetfulness 5. Psychosis: hallucinations/delusions 6. Med. Compl: yes/no 7. Current Living Envirnmt: what is their situation

Milieu Therapy - Skinner (1979) outlined seven basic assumptions on which a therapeutic community is based:

1. The health in each individual is to be realized and encouraged to grow. 2. Every interaction is an opportunity for therapeutic intervention. 3. The client owns his or her own environment. 4. Each client is responsible for his or her own behavior. 5. Peer pressure is a useful and powerful tool. 6. Inappropriate behaviors are dealt with as they occur. 7. Restrictions and punishment are to be avoided.

5 major classifications of psychotropics and their use(s)

1. antipsychotics (neuroleptics) - treat psychotic symptoms such as delusions, paranoia, hallucinations 2. antiparkinson (anticholinergic) agents - treat uncomfortable side effects of antipsychotics 3. antidepressants - treat acute and chronic depression, treat some anxiety disorders such as panic disorder and obsessive-compulsive behavior 4. antimanics (mood stabilizers) - treat bipolar disorders 5. anxiolytics - treat anxiety

3 general mechanisms of action of medications used to treat mental illness

1. block excesses of certain brain chemicals 2. make existing chemicals more affective 3. mimic and improve action of deficient levels of chemicals

Techniques and tools used by the nurse when assessing a patient with a mental illness

1. interviewing patient about symptoms, medication side effects, etc. 2. observing patient for symptoms, medication side effects, physical appearance, tec. 3. documenting data 4. using assessment tools such as the Mini-Mental Status Exam, depression rating scale

Mental Status

A comprehensive description or statement of a patient's intellectual capacity, emotional state, and general mental health based on examiner's observations and directed interview; includes assessment of mood, behavior, orientation, judgment, memory, problem-solving ability, and contact with reality.

Phobia

A phobia is classified as a type of anxiety disorder, since anxiety is the chief symptom experienced by the sufferer An extreme or irrational fear of or aversion to something or some situations.

Phases of Crisis Intervention: The Role of the Nurse Phase 4. Evaluation of crisis resolution and anticipatory planning

A reassessment is conducted to determine whether the stated objectives were achieved * A plan of action is developed for the individual to deal with the stressor should it reoccur

Role of nurse - Milieu Therapy

ADPIE Treatments plans Pt's physiological needs are met Reality orientation Written activities schedules Meds Therapeutic communication and relationship Major focus is 1:1 relationship. Ability to trust. In the treatment setting all the group members can be motivated to work toward the common goal of improved mental health.

Crisis intervention

problem solving skills that are diminished due to anxiety

denial

refusing to acknowledge the existence of a real situation or the feelings associated with it. ex: a woman drinks alcohol every day and cannot stop, failing to acknowledge that she has a problem.

regression

retreating in response to stress to an earlier level of development and the comfort measures associated with that level of functioning. ex: when 2-year-old jay is hospitalized for tonsillitis he will drink only from a bottle, even though his mom states he has been drinking from a cup for 6 months.

YOUNG ADULTHOOD Intimacy vs. Isolation (20 - 30)

Form intense and lasting relationship/commitment to another person, cause, career, or creative effort. Failure to achieve the ability to give self d/t not have been a recipient of love during earlier development years and results in withdrawal and social isolation

5. Other Community Supports

Friends, community agencies, groups orin some situations group homes.

Phases of Crisis Intervention: The Role of the Nurse Phase 2. Planning of therapeutic intervention

From the assessment data, the nurse selects appropriate nursing diagnoses that reflect the immediacy of the crisis situation ****Desired outcome criteria are established ****Appropriate nursing actions are selected, taking into consideration the type of crisis as well as the individual's strengths and available resources for support

TODDLER Autonomy vs Shame and Doubt (18 months - 3 years)

Gain self-control and independence within environment Restriction of independent behaviors or setting unrealistic expectations will result in a sense of being controlled by others, lack of self-confidence and lack of pride.

How can MI interfere with pt's ability to feel and act safely?

1. Anxiety: - can't concentrate or think things through 2. Disorganized Thinking: - perceives reality incorrectly and acts on it 3. Mood: - sense of hopelessness/suicidal thoughts 4. Substance Abuse: - poor judgment

Milieu Therapy - Conditions that Promote a Therapeutic Community

1. Basic physiological needs are fulfilled. 2. The physical facilities are conductive to achievement of the goals of therapy. 3. A democratic form of self-government exists. 4. Responsibilities are assigned according to client capabilities. 5. A structured program of social and work-related activities is scheduled as part of the treatment program. 6. Community and family are included in the program of therapy in an effort to facilitate discharge from treatment

Face-to-Face Assessment of the PT in Restraints

1. Assess for physical risks of loss of life - deaths of pt's in restraints asphyxia, acute delirium or cardiac complications - Surveillance of pt's immediate situation - Resp. - skin color, O2 sat - Cardiac - Stress - Meds 2. Assess for additional dangers and discomfort - size of the pt (obesity) - Positioning of the pt/extremities - location of restraints on the body - Pt's clothing - Bedding - Bed itself - Aspiration pneumonia - Meds (clozapine/clozaril) - General med conditions/med Hx/ lab data 3. Assess pt's psych and mental status - compare to prev. exam. - acute excited states - psych conditions/current Sx's/PTSD-re-traumatizing - Situation that led to restsrt. -Evaluation of pt's reaction to restrnt. application 4. Assess with legal and ethical consid. in mind - As a general rule, practitioners must adhere to he highest standard set forth by the reg-tory bodies that cover the facility where RN works - Appropr. use of restrnts and seclusion - Actual technique of application of restraints - Know state laws, Joint Commission rules and hosp. policies - Determine need to cont./terminate restraints 5. Assess environment - temp. in room - ventilation - lighting - noise level/ amount of talking

Reasons for Noncompliance with Meds

1. Denial of illness r/t: - Sx of MI that alter thought process and affect insight - Difficulty learning from life experiences and cognitive diff-ties - Stigma assoc. with MI - Perception that Sx make the pt special and unique 2. SE, fear of addiction 3. Lack of energy and motivation, forgetfulness 4. Alcohol or street drug use that impairs pt's judgment 5. Family or therapist opposition to meds 6. Changes in social network, supervision, Tx system or living situation 7. Lack of money or transport to purchase meds 8. Relief of symptoms may be interpreted as a "cure" leading pts to believe meds are no longer needed 9. Prolonged length of time b/w stopping meds and the occurrence of a relapse

Phases of Group Development Middle or Working Phase

>promote problem solving skills to facilitate behavioral changes. >power and control issues can dominate in this phase. responsibilities: >the group leader uses therapeutic communication to encourage group work toward meeting goals >members take informal roles within the group, which can interfere with, or favor, group progress toward goals.

Yalom's 11 "curative Factors" in Group Therapy

Altruism: when group members help each other Catharsis: relief from emotional distress through uninhibited expression/emotions that were not shown/experienced before Existential factors: the process of learning that one has to take responsibility for one's life & the consequences of one's decisions Cohesiveness: members feel a sense of belonging, acceptance & validation Imparting information: learning factual information from others in the group Imitative behavior: developing social skills through modeling, observation, & imitating the therapist & other members Instillation of hope: when members are inspired & encouraged by others Interpersonal learning: members achieve greater self-awareness through interaction & receiving feedback Development of socializing techniques: the group setting provides a safe & supportive environment where members can take risks Corrective recapitulation of the primary family experience: members unconsciously identify the group therapist & other members with their own parents & siblings. The therapist's interpretations can help members gain understanding of the impact of childhood experiences on their personality & they can learn to avoid repeating unhelpful past interactive patterns in present day relationships Universality: recognizing shared experiences & feelings among group members & the problems are universal concerns

Clonazepam

Clonapam, KlonoPIN, Rivotril Classification Therapeutic:anticonvulsants Indications Prophylaxis of: Petit mal, Lennox-Gastaut, Akinetic, Myoclonic seizures. Panic disorder with or without agoraphobia. Unlabeled Use: Uncontrolled leg movements during sleep. Neuralgias. Infantile spasms. Sedation. Adjunct management of acute mania, acute psychosis, or insomnia. Action Anticonvulsant effects may be due to presynaptic inhibition. Produces sedative effects in the CNS, probably by stimulating inhibitory GABA receptors. Therapeutic Effects: Prevention of seizures. Decreased manifestations of panic disorder. Adverse Reactions/Side Effects CNS: SUICIDAL THOUGHTS, behavioral changes, drowsiness, fatigue, slurred speech, ataxia, sedation, abnormal eye movements, diplopia, nystagmus. Resp:qsecretions. CV: palpitations. Derm: rash. GI: constipation, diarrhea, hepatitis, weight gain.GU: dysuria, nocturia, urinary retention.Hemat:anemia, eosinophilia, leukopenia, thrombocytopenia. Neuro: ataxia, hypotonia. Misc: fever, physical dependence, psychological dependence, tolerance. NURSINGIMPLICATIONS Assessment ● Observe and record intensity, duration, and location of seizure activity. ● Assess degree and manifestations of anxiety and mental status (orientation, mood, behavior) prior to and periodically during therapy ● Assess need for continued treatment regularly. ● Assess patient for drowsiness, unsteadiness, and clumsiness. These symptoms are dose related and most severe during initial therapy; may decrease in severity or disappear with continued or long-term therapy. ● Monitor closely for notable changes in behavior that could indicate the emergence or worsening of suicidal thoughts or behavior or depression. ● Lab Test Considerations: Patients on prolonged therapy should have CBC and liver function test results evaluated periodically. May cause anqin serum bilirubin, AST, and ALT. ● May causepthyroidal uptake of sodium iodide, 123I, and 131I. ● Toxicity and Overdose: Therapeutic serum concentrations are 20- 80 mg/ mL. Flumazenil antagonizes clonazepam toxicity or overdose (may induce seizures in patients with history of seizure disorder or who are on tricyclic antidepressants).

What major factor affects the successful outcome of using psychotropics?

Compliance

Med Compliance In Pts with MI

Compliance with med can be a problem in all pts with chronic health issues, not only MI. When pts are noncomp. with their meds, the nurse should determine the reasons and implement interventions

11. Occupation

Current position if employed, Hx of other jobs, with dates and length

compensation

covering up a real or perceived weakness by emphasizing a trait one considers more desirable. ex: a physically handicapped boy is unable to participate in football, so he compensates by becoming a great scholar.

maturational/developmental crisis (class 4)

crisis that occurs in response to a situation that triggers emotions related to unresolved conflicts in ones life (dependency, value conflicts, sexual identity, control, emotional intimacy, failing at work, divorce)

reaction formation

preventing unacceptable or undesirable thoughts or behaviors from being expressed by exaggerating opposite thoughts or types of behaviors. ex: jane hates nursing. she attended nursing school to please her parents. during career day, she speaks to prospective students about the excellence of nursing as a career.