Psych Exam #1 (NRS 330)

Content

what the clients says

Anal (Freud's stages of psychosexual development)

(18-36 months) - Anus, toilet training.

Phallic (Freud's stages of psychosexual development)

(3-5 yrs) - Genitals, penis envy in girls, Oedipal complex (girls attracted to dads and boys to moms)

Latency (Freud's stages of psychosexual development)

(5-11 years) - Resolution of oedipal complex, formation of superego, sexual drive channeled into socially appropriate activities such as homework, sports.

Gestalt therapy

(Frederick "Fritz" Perls) Emphasis on self-awareness. Identification of thoughts & feelings in the here and now. Journaling, writing letters to put past to rest.

Countertransference (Freud)

(Therapist transferring to the patient) Occurs when the therapist displaces onto the client attitudes or feelings from his/her past (i.e. a female nurse with teenage children who is frustrated with an adolescent client might respond in a parental manner). Nurses need to examine their own feelings, using self-awareness, and talking with colleagues.

Logotherapy

(Viktor Frankl): life with meaning; therapy as search for that meaning (logos). People that know their life has more meaning were able to cope better.

Reality therapy

(William Glasser) Focus on person's behavior and how that behavior keeps a person from achieving life goals. Those who are unsuccessful, often blamed their problems on other people, the system, or society. Challenges people to examine ways their own behavior impedes their ability to achieve goals.

Therapeutic results of group therapy

(Yalom,1995): New information or learning, inspiration or hope Interaction with others Feelings of acceptance, belonging Awareness of not being alone; others share same problems Insight into problems, behaviors, and effects on others Giving of oneself for the benefit of others (altruism)

Oral (Freud's stages of psychosexual development)

(birth - 18 months) - site of tension & gratification is mouth, lips - biting, sucking activities. Id is present, ego develops gradually.

Empirical (patterns of knowing)

(derived from nursing science) - panic attack, pulse increases.

Directive role

(direct yes/no questions; usually for clients with suicidal thoughts, in crisis, or who are out of touch with reality).

Aesthetic (patterns of knowing)

(from art of nursing) - sensing, intuition.

Personal (patterns of knowing)

(from life experiences) - client's face shows panic.

Ethical (patterns of knowing)

(from moral nursing knowledge) - shift over, nurse remains with client.

socioeconomic status

(income, education, occupation) - influences health, access to care, social class (can be factor).

Acceptance

(no judgments; set boundaries) - the behavior is inappropriate but the person is accepted, valued & worthy. Be firm, set limits on behavior.

Nondirective role

(nurse uses broad-opening, open-ended questions to collect information). Client identifies problem to discuss & goal. Nurse acts as guide & facilitates expression of feelings.

Hospital (inpatient) treatment

(often last mode of treatment) Indications: severe depression/suicidal; severe psychosis; alcohol or drug withdrawal; behaviors requiring close supervision in a safe, supportive environment

Transference (Freud)

(patient transferring to therapist) Occurs when the client unconsciously displaces onto the therapist attitudes & feelings the client originally experienced in other relationships (i.e. a female client working with a nurse the same age as her mother might react to the nurse like she reacts to her mother).

Positive regard

(unconditional nonjudgmental attitude) - respect Use presence or attending (verbal/nonverbal communication to convey nurse is listening). Lean forward, eye contact, arms at sides.

adult foster care (Residential Settings)

1 to 3 clients in family-like setting, meals, social activities with family.

Rational emotive therapy (Albert Ellis)

11 "irrational beliefs" leading to unhappiness. "Automatic thoughts" - use of ABC technique to identify these thoughts:

Group homes (Residential Settings)

6 to 10 residents, cook meals, household chores under supervision of staff.

Genital (Freud's stages of psychosexual development)

(11-13 years) - Puberty, involves capacity for true intimacy.

Sense of belonging

A feeling of connectedness or involvement in a social system/environment of which a person feels an integral part.

Active Listening & Observation

Active listening (concentrating exclusively on what patient says). Active observation (watching nonverbal actions as speaker communicates). Both help the nurse to: Recognize the most important issue. Know what questions to ask. Use of therapeutic communication techniques. Prevents jumping to conclusions. Objectively respond to message.

Avoidance of nontherapeutic techniques

Advising, belittling, challenging, probing, reassuring.

Assessment Content: History

Age Developmental stage Cultural considerations Spiritual beliefs Previous history

Possible assertive responses

Aggressive - "You are always late!" Passive-aggressive - "So nice of her to join us - aren't we lucky." Passive - makes statement to others but not to the specific nurse who is late. Assertive -" When you are late, shift report is disrupted, and I do not like having to repeat information that was already discussed.")

Complementary & Alternative Examples

Alternative medical systems (homeopathy, traditional Chinese medicine) Mind-body interventions (meditation, art, music therapy) Biologically based therapies (herbs, foods, vitamins) Manipulative and body-based therapies (therapeutic massage, chiropractic manipulation) Energy therapies (therapeutic touch, qi gong, pulsed fields, magnetic fields)

Displacement

Angry at boss but yells at spouse

Physiologic and self-care considerations

Eating habits. Sleep patterns. Health problems. Compliance with prescribed medications. Ability to perform activities of daily living

Appearance/motor behavior (Assessment Components)

Hygiene/grooming Appropriate dress Posture Eye contact Unusual movements/mannerisms Speech - quantity, quality, rate, abnormalities

Labile

Rapidly changing mood, unpredictable

Diagnostic and Statistical Manual of Mental Disorders (DSM)

The DSM classifies psychiatric disorders into categories. The DSM describes each disorder and provides the diagnostic criteria for each disorder.

Freud's Theory of Development

Theory based on belief that sexual energy (libido) was driving force of human behavior. Children progress through various stages with developmental tasks. Psychopathology results when person has difficulty transitioning from one stage to the next.

Erik Erikson Eight stages of psychosocial development

Trust vs. mistrust - hope Autonomy vs. shame/doubt - will Initiative vs. guilt - purpose Industry vs. inferiority - competence Identity vs. role confusion - fidelity Intimacy vs. isolation - love Generativity vs. stagnation - care Ego integrity vs. despair - wisdom

Interpersonal/relationship (influencing factors)

effective communication, ability to help others, intimacy, and balance of separateness and connectedness.

Alternative medicine

includes therapies used in place of conventional treatment.

Mental status exam

looks at patient's cognitive abilities Orientation to person, time, place, date, season, day of the week. Interpretation of proverbs. Math calculations. Memorization, short-term recall. Identification of common objects. Ability to follow multistep commands. Ability to write or copy a simple drawing.

Waxy flexibility (Unusual movements/mannerisms)

maintenance of a posture/position over time even when it is awkward or uncomfortable

Ego (Freud)

mediator between id and superego, mature/adaptive behavior, anxiety results from attempting to balance impulsive instincts (id) with stringent rules of superego. like a parent

withdrawal

others are taking thought away

Psychomotor retardation (Unusual movements/mannerisms)

overall slowed movements.

Conscious (Freud)

perceptions, thoughts, emotions that exist in person's awareness, i.e. feeling happy.

Denial

refusal to accept cancer diagnosis

Blunted affect

showing little or slow-to-respond facial expression

blocking

stopping abruptly

Affect

the outward expression of the emotional state.

Subconcious

thoughts, feelings in the preconscious or unconscious level.

American Nurses Association & Standards of Care

Authoritative statements that describe the responsibilities for which nurses are accountable.

Crisis intervention techniques (directive vs. supportive)

Balance of these strategies is most effective. Directive interventions: assess health status, promote problem solving - offer person new information, suggestions, feedback. Supportive interventions: deal with person's need for empathetic understanding, encourage discussion of feelings, affirm person's self-worth.

Abraham Maslow Hierarchy of needs

Basic physiologic, safety and security, love and belonging, esteem, self-actualization.

Termination Phase

Begins when client's problems are resolved. Ends when relationship is ended. Deals with feelings of anger or abandonment that may occur; client may feel termination as impending loss.

non verbal

Behavior that accompanies the verbal content; body language, eye contact, facial expression, tone of voice, speed, moans. May indicate speakers thoughts, feelings, & values unconsciously. Process: denotes all messages used to give meaning & context to message; listener interprets for agreement with verbal content. Congruent or incongruent message.

Existential Theories

Behavioral deviations occur when person is out of touch with self or environment. Person is self-alienated, lonely, sad, helpless Lack of self-awareness, harsh self-criticism Self imposed restrictions - not free to participate in meaningful relationships or choose from all possible alternatives Belief that person is avoiding responsibilities & giving into others Goal: to return person to authentic sense of self. Live in present & look to future.

Trust

Behaviors such as caring, interest, understanding, consistency, honesty, promise keeping, listening

Beliefs/Attitudes

Beliefs - ideas one holds true. Attitudes - feeling or frame of reference around which a person organizes knowledge about the world

Individual Psychotherapy

Bringing about change in a person by exploring his/her feelings, attitudes, thinking, behavior. One-to-one relationship between the therapist & the patient Progression through stages Relationship as key to success Therapist's theoretical beliefs strongly influence style of therapy.

Shorter impatient stays...

Can be as effective as longer hospitalizations, just as likely to attend follow-up programs, more likely to be employed, & show improved social functioning than those with longer stays.

How to Phrase Questions

Clarification to confirm nurse's understanding of what client is conveying. Identification of client's avoidance of anxiety-producing topic. Client may begin discussing topic of minimal importance because it is less threatening than issue that is increasing anxiety. Ask client which issue is most important at this time. Guidance in problem-solving, empowerment to change. Involve client as he/she is more likely to follow through on the solutions

Ivan Pavlov

Classical Conditioning - behavior can be changed through conditioning with environmental stimuli. Dog experiment - smell food (stimulus) = salivate (response) Ring bell (new stimulus) + food = dogs salivate After pairing, ring bell = dogs salivate

Jean Piaget's Theory of Cognitive Development

Cognitive, intellectual development progresses through a series of stages based on age, with demonstration of a higher level of functioning with each successive stage. Sensorimotor (birth-2 yrs) - self as separate, object permanence. Preoperational (2-6 yrs) - uses language to express self, symbolic gestures. Concrete operations (6-12 yrs) - applies rules, spatiality/reversibility; more social. Formal operations (12-15 yrs & beyond) - thinks/reasons in abstract terms. (critical thinking)

Conditions of touch

Comforting and supportive; also possible invasion of intimate & personal space. Evaluate client for cues that show whether touch is indicated. The nurse must evaluate use of touch based on the client's preferences, history, and needs. For example, clients with a history of abuse, hospital/unit policies.

Factors in cultural assessment

Communication Physical space or distance Social organization Time orientation Environmental control Biologic variations

Basic-level functions (of practice)

Counseling Milieu therapy Self-care activities Psychobiologic interventions Health teaching Case management Health promotion, maintenance

Roles/relationships

Current roles. Satisfaction with roles. Success at roles. Significant relationships. Support systems

Partial hospitalization programs (PHPs)

Day treatment programs - gradual transition to living independently

Community mental health movement

Deinstitutionalization (community mental health centers) Legislation for disability income - Supplement Security Income, Social Security Disability Income; increased independence; reduced costs in institutions. Changes in commitment laws (1970s) - more difficult to commit people against will.

Hildegard Peplau

Described the therapeutic nurse-client relationship with its phases and tasks Interpersonal dimension crucial to her beliefs is foundation for current practice.

Response to drugs - (individual factors)

Differences in ethnic groups related to metabolism, efficacy. Slower metabolism = need for lower doses Non-whites have higher serum levels + suffer more A.E.s

Mental health

Difficult to define No single, universal definition Many components influenced by factors Dynamic, ever-changing state A continuum a state of emotional, psychological, and social wellness evidenced by satisfying relationships, effective behavior and coping, positive self-concept, and emotional stability

General criteria for diagnosis with MH

Dissatisfaction with characteristics, abilities, accomplishments. Ineffective or unsatisfying relationships. Dissatisfaction with one's place in the world. Ineffective coping with life events. Lack of personal growth.

Crisis Intervention

Duration: self-limiting, usually 4 to 6 weeks Outcome: resolution to functioning at precrisis level, higher level, or lower level

Intimate (types of relationships)

Emotional commitment of two persons. Individual needs met; assistance with helping each other meet needs.

The Interview (environment/family input)

Environment: Comfortable, private, safe. Quiet with few distractions. Input from family, friends (patient's permission necessary). Information about their perceptions of patient.

Therapeutic communication can help nurses...

Establish a therapeutic relationship. Identify client's most important concerns; assess client's perceptions. Facilitate client's expression of emotions. Teach client, family necessary self-care skills. Recognize client's needs; implement interventions to address client's needs. Guide client toward more positive coping strategies & solutions.

The nurse uses therapeutic communication skills to achieve the following goals

Establish rapport by being empathetic, genuine, caring, unconditionally accepting of the person. Identify issues of concern. Gain an in-depth understanding of the client's perception. Explore client's thoughts, feelings. Guide client in developing problem-solving skills. Promote client's evaluation of solutions.

Self-Awareness Issues

Everyone has unique or different values, ideas, and beliefs. Possible conflict between personal values/beliefs & those of client. Need to accept differences; view each client as worthwhile regardless of opinions or lifestyle. Self-awareness through reflection. Keep diary, journal about experiences & related feelings. Seek alternative viewpoints - put yourself in the client's shoes. No one theory or treatment approach is effective for all patients. Using a variety of psychosocial approaches increases a nurse's effectiveness. Client's feelings & perceptions about his/her situation are the most influential factors in determining his or her response to therapeutic interventions - NOT what the nurses believes the client should do

3 prevention types

Examples include: Primary prevention: stress management education. Secondary prevention: early identification of mental health problems. Tertiary prevention: monitoring, coordinating psychiatric rehabilitation services.

Assertive Communication

Expression of positive and negative feelings/ideas in open, honest, direct way. Calm, specific factual statements. Focus on "I" statements.

Behaviorism

Focus on behaviors and behavior changes, not how mind works. Believe behavior can be changed through a system of rewards & punishment.

June Mellow

Focus on client's psychosocial needs & strengths (here and now).

Psychoanalysis

Focus on discovering causes of patient's unconscious, repressed thoughts, feelings, conflicts related to anxiety. Free association, dream analysis, behavior interpretation used to gain insight into and resolve these conflicts, anxieties. -Lengthy, expensive, practiced on limited basis today. -Freud's defense mechanisms still current.

Cognitive therapy

Focus on immediate thought processing - how person perceives or interprets experiences determines feelings & behaviors. Use by most existential therapists.

Therapeutic (types of relationships)

Focus on needs, experiences, feelings, ideas of client only. Use of communication skills, personal strengths, understanding of human behavior by nurse. Joint agreement on areas to work on; outcome evaluation.

Group leadership

Formal leader usually for therapy groups and education groups Identified based on education, credentials, qualifications. Informal leader usually for support groups and self-help groups All members seen as equal. Leader emerges as he/she is recognized as having knowledge, experience, etc., that others admire. Effective group leaders focus on group process as well as on group content.

Evolving Consumer Household (Residential Settings)

Group-living situation Residents make transition from group home to residence where they fulfill own responsibilities and function without onsite supervision.

WHO definition of disease

Health is defined as a state of complete physical, mental, and social wellness - NOT just absence of disease. Health is a positive state of wellbeing. Mental health is evidenced in people by satisfying interpersonal relationships, effective behavior and coping, positive self-concept, and emotional stability.

Physical health, health practices (exercise) - (individual factors)

Healthier = better coping with stress or illness. Poor nutrition, lack of sleep,& chronic illness impair one's ability to cope - modifiable factors.

Genetics, biologic factors (individual factors)

Heredity & biologic factors are not under voluntary control - cannot change these factors. Studies show many mental disorders appear more frequently in families. Biologic make up influences person's response to illness & treatment

DSM Axis

I - Clinical Disorders (Schizophrenia, Depression, etc.) II - Personality Disorders; Intellectual Disability III - Physical Disorders; Medical Conditions IV - Psychosocial/Environmental Factors (unemployment; homeless; divorce) V - GAF (global assessment of functioning - clients overall ability to function; 1-100 scoring; score of 50 is significantly impaired)

Dorothea Dix

In U.S., crusaded to reform treatment of mentally ill; 32 state hospitals opened; believed society obligated to provide adequate care.

Special Populations: Homeless Mentally Ill

In comparison to homeless, not mentally ill: Spend more time in jail Are homeless longer Spend more time in shelters Have less family contact Face greater barriers to employment Providing housing alone does not alter prognosis.

Behaviors Diminishing Therapeutic Relationships

Inappropriate boundaries (relationship becomes social or intimate). Feelings of sympathy, encouraging client dependency. Non-acceptance of client, avoidance Nursing Boundary Index Warning signals of abuse of the nurse-client relationship

Mental illness

Includes disorders that affect: Mood Behavior Thinking These often cause significant distress and/or impaired functioning. Individuals can experience dissatisfaction with self, relationships, and ineffective coping. Daily life may seem overwhelming & a sense of hopeless can ensue.

Healthy People 2020 objectives

Increase the number of people identified, diagnosed,& treated. Decrease rates of suicide & homelessness. Increase employment for those with serious mental illness. Provide more services for incarcerated persons with mental health problems.

Therapeutic Communication

Interpersonal interaction between nurse & client - focuses on the client's specific needs in order to promote an effective exchange of information. Skilled use of therapeutic communication techniques aids nurse in understanding & empathizing with client's experience. Needed to effectively meet the standards of client care. Establishing a therapeutic relationship is critical. Communication is the means by which the therapeutic relationship is initiated, maintained, & terminated.

Boundaries/Distance zones

Intimate (0 to 18 inches) - parents with young children. Personal (18 to 36 inches) - family & friends. Social (4 to 12 feet) - social, business setting. Public (12 to 25 feet) - speaker & audience. Therapeutic communication: most comfortable when nurse and patient are 3 to 6 feet apart. Hispanic, Middle Eastern, Asian are more comfortable with 4 to 12 feet distance. Ask permission if must invade intimate or personal zone

Judgment/insight

Judgment (interpretation of environment). Decision-making ability. Insight (understanding one's own part in current situation).

Self-Awareness

Know self - develop understanding of one's own thoughts, beliefs, values.

Cultural Patterns and Differences

Knowledge of expected cultural patterns as starting point when relating to people from different ethnic backgrounds. Wide variations among people from any culture. Provides basis for individual assessment in order to be culturally competent and implement care that meets client's need. Client is the best source of information.

Nurse's Role in Working with Patients from Various Cultures

Knowledge seeking about patient's cultural values, beliefs, health practices. Patient as best source of information. General cultural knowledge to guide nurse in initial meetings, decisions about what questions to ask. Preferences, health practices, beliefs. General knowledge not replacement for patient assessment Wide variations in individuals in culture.

DSM Classifications

Major psychiatric disorders (i.e. depression, anxiety). Medical conditions relevant to understanding/managing the person's mental disorder. Psychosocial and environmental problems (i.e. problems with primary support group, the social environment, education, occupation, housing, access to health care, and the legal system).

Categories of crises

Maturational (developmental) - predictable events in normal course of life, i.e. leaving home for 1st time, getting married, having baby. Situational - unanticipated/sudden events that threaten person's integrity, i.e. death of loved one, loss of job, physical illness. Adventitious (social) - natural disasters, war, violent crimes.

Understanding Meaning & Spirituality of Communication

Meaning: usually more meaning than just spoken word Need to accurately identify the meaning of the message (i.e. "I am going to kill you!" takes on two different messages depending on the context). Validation with client of verbal, nonverbal information Assessment of the context focuses on: Who was there. What happened. When it occurred. How event progressed. Why client believes it happened as it did.

Orientation Phase

Meeting nurse, client. Establishment of roles. Discussion of purposes, parameters of future meetings. Clarification of expectations. Identification of client's problems. Nurse-client contracts/confidentiality, duty to warn/self-disclosure.

Peplau Four levels of anxiety

Mild - heightened awareness, sharpened senses, alert, can solve problems, "butterflies" Moderate - selectively attentive, decreased perceptual field, muscle tension, increased automatisms (nervous mannerisms) Severe - feelings of dread, cannot complete solve problems, tachycardia, ritualistic (purposeless) behavior, go to ED thinking he/she is having heart attack. Panic - loss of rational thought, delusion/hallucinations, physically immobile, muteness

Verbal Communication Skills

Need for concrete (not abstract), clear, & easily understood messages for accurate information exchange. Therapeutic Communication Techniques Exploring, focusing, restating, reflecting promotes discussion of feelings or concerns in more depth. Other techniques useful in focusing or clarifying what is being said. Feedback via making an observation or presenting reality.

homeless mh outreach

Need psychosocial rehabilitation services, peer support, vocational training, daily living skills training to decrease homelessness & improve quality of life. Projects for Assistance in Transition from Homelessness (PATH program) - funds community-based outreach, mental health services ACCESS Demonstration Project - sites evidenced improved outcomes using outreach & intensive case management.

Overall assessment data

Not isolated bits of information Patterns or themes in data → nursing diagnoses Psychological tests - IQ & personality tests Psychiatric diagnoses - DSM-5 Mental status exam (MSE) - focuses on cognitive abilities

Unknowing (5th pattern of knowing)

Nurse admits lack of knowledge of client or understanding of client's subjective world. Authentic encounter devoid of any preconceptions. Nurse is open to hearing client's views without imposing his/her own values.

Psychosocial Interventions

Nursing activities that enhance patient's social & psychological functioning. They promote social skills, interpersonal relationships, & communication. Psychosocial interventions used by nurses to help meet client's needs & achieve outcomes in all practice settings - not just in mental health.

Assertive Community Treatment (ACT)

One of the most effective approaches Belief that skills training, support, & teaching should be done in the community where it is needed rather than hospital. Problem-solving orientation. No problem is too small. Direct provision of service rather than referral. Implement services in clients' homes or communities - not offices. Services intense - 3 or more face-to-face contacts to meet client's needs; no time constraints; team approach allows all staff to be familiar with all clients - no waiting for assigned contact.

Body language (non verbal) - open, closed

Open body position - sit facing client, legs uncrossed, hands at side. Demonstrates unconditional positive regard, trust, care, & acceptance. Nonthreatening eye contact, leaning forward indicates acceptance. Closed body position -crossed legs, folded arms, might threaten listener. Sitting behind desk creates barrier & decrease client's willingness to open up.

Interview Questions

Open-ended to initiate assessment. Focused if patient unable to organize thoughts or has difficulty answering open-ended questions.

B. F. Skinner

Operant Conditioning All behavior learned. Consequences result from behavior (reward or punishment). Recurrence of rewarded behavior.

Establishing a Therapeutic Relationship (peplau's model)

Orientation Working Termination Overlapping, interlocking of phases

Sensorium/intellectual Processes

Orientation/confusion - person, place, time, situation. Memory - recent/remote. Abnormal sensory experiences or misperceptions. Concentration - ask client to do tasks - spell word backwards. Abstract thinking abilities - interpret a common proverb - literal interpretations are evidence of concrete thinking.

Factors Influencing Assessment

Patient participation/feedback. Client's health status. Client's previous experiences/misconceptions about health care. Client's ability to understand. Nurse's attitude, approach.

Mentally ill

People who fail to fulfill roles and carry out responsibilities OR whose behavior is inappropriate viewed as ill.

therapeutic nurse-patient relationship: four phases

Peplau Orientation (directed by nurse, engage client in treatment, answer questions). Identification (client works interdependently with nurse, feels stronger). Exploitation (client makes full use of services offered). Resolution (no longer needs professional services; gives up dependent behavior (see Table 3.5)

Social networks, social support

Perception of support system (must feel support bolsters confidence, providing assistance with problem solving). Responsiveness of support system (actions consistent with client's desires). Family support, friends, coworkers, etc. Promotes health & wellbeing.

Self-concept

Personal view of self. Description of physical self. Personal qualities or attributes. Ask person to describe themselves

Psychosocial Assessment Purpose

Picture of patient's current emotional state, mental capacity, behavioral function. Basis for developing plan of care. Clinical baseline to evaluate effectiveness of treatment or measure patient's progress.

B.F. Skinner and Reinforcement

Positive reinforcement after behavior increases the frequency of the behavior. Removal of negative reinforcers after behavior increases the frequency of the behavior. Continuous reinforcement is the fastest way to increase behavior, but once reward ceases, the behavior stops. Random intermittent reinforcement increases behavior more slowly but with a longer-lasting effect. (randomly giving a reward)

Barriers to successful community reintegration

Poverty Homelessness Substance use Violence Victimization, rape, trauma Self-harm Persons with mental illness are more likely to be victims of violence, both in prisons & the community.

Stages of group development

Pregroup stage - members selected, purpose identified, group structure addressed (how often & where group will meet, leader selected, rules discussed). Beginning or initial stage - introductions, purpose, rules, & expectations reviewed, members "check out" others as they determine level of comfort in group setting. Working stage - focus on purpose, trust develops, cohesiveness, competition between members. Termination - work of group reviewed, focus is on accomplishments or growth

Community mental health treatment

Primary mode of treatment Clients continue to work and are able to stay connected with family, friends, and other support systems. Personality or behavior patterns gradually develop; unable to be changed in a relatively short inpatient course of treatment Peer counseling, advocacy, and mentoring are showing positive results.

Working Phase (sub categories) - exploitation

Problem identification: issues or concerns identified by client; examination of client's feelings and responses. Exploitation: examination of feelings and responses; development of better coping skills, more positive self-image, behavior change, independence. Possible transference/countertransference.

Communication

Process to exchange of information. Messages are simultaneously sent & received on two levels

Advanced-level functions (of practice)

Psychotherapy Prescriptive authority for drugs Consultation, liaison Evaluation

Social (types of relationships)

Purpose of friendship, socialization, companionship, or task accomplishment. Superficial communication; shifting roles; outcomes rarely assessed.

Empathy

Putting oneself in client's shoes. Client and nurse giving "gift of self" when empathy occurs - the client by feeling safe enough to share feelings & the nurse by listening and demonstrating understanding. Different from sympathy (feelings of concern or compassion; can shift the focus to the nurse's feelings).

inpatient hospital treatment

Rapid assessment & stabilization of symptoms. Discharge planning Client-centered multidisciplinary approach to brief stay is essential. Typically locked units - provide protection from outer world Safe/secure setting (advantage) Clients feel confined or dependent - emphasizes staff's power over them (disadvantage).

Sigmund Freud Theory

Repressed sexual impulses and desires as motivation for behavior.

Psychiatric Rehabilitation

Services to patients with persistent, severe mental illness in the community. Also known as community support services or programs. Focus on patient's strengths. Programs designed to help client manage illness & symptoms, gain access to needed services, & live successfully in the community. Activities involving medication management, transportation, shopping, food preparation, hygiene, finances, social support, vocational referral.

Psychosocial Rehabilitation

Services to promote recovery process Emphasis on recovery, going beyond symptom control and medication management; includes personal growth. Reintegration into community. Empowerment, increased independence. Improved quality of life. Characteristics of Later Stages Accepting illness Self-love Gaining control over symptoms

long stay clients

Severe, persistent mental illness requiring acute care services. Unsuccessful community placement. Client's with dual diagnosis - mental illness + substance abuse OR mental illness + developmental/intellectual diagnosis.

Ancient times mental illness theory

Sickness as displeasure of gods Punishment for sins; viewed as demonic (ostracized/burned at stake) or divine (worshipped/adored).

Sullivan's main work

Significance of interpersonal relationships - goal of treatment Therapeutic milieu or community (role of client-to-client interaction

Freudian slip

Slips are not accidental - indications of subconscious thoughts, feelings.

Students and Active listening & observation

Students often make mistake of constantly thinking ahead regarding the next question rather than actively listening to what client is saying. Results in a lack of understanding about the client's concern & conversation is vague, superficial, & frustrating to both parties.

DSM-5

Taxonomy published by the American Psychiatric Association It describes all mental disorders, outlining specific diagnostic criteria for each based on clinical experience/research.

Therapeutic Roles of the Nurse in a Relationship

Teacher (coping, problem solving, medication regimen, community resources). Caregiver (therapeutic relationship, physical care). Advocate (ensuring privacy and dignity, informed consent, access to services, safety from abuse and exploitation). Parent surrogate Methods to avoid inappropriate relationships between nurses and clients

Therapeutic Relationship

The ability to build therapeutic relationships is one of the most important skills a nurse can develop. Crucial to success of interventions with clients requiring psychiatric care. Therapeutic relationship + communication within it serve as underpinning for treatment & success.

Active Military & Veterans

The prevalence of PTSD and major depression is greater than their civilian counterparts. Increased rates of: Suicide Homicide Injury Physical illness Sleep disorders Substance abuse Marital and family dysfunction Prevalence of PTSD & major depression is greater among active duty military service members than civilians. Increased rate of suicide (2 times greater). Sleep disorders & substance abuse common. 3 or more deployments is risk factor for mental illness. Sexual traumas widespread for both males and females. Reluctance to seek treatment because: Treatment may not be readily available. Stigma of mental illness.

Prisoners

The rate of mental illness among the incarcerated is 5 times higher than the general population. Factors for placement in criminal justice system Deinstitutionalization More rigid criteria for civil commitment Lack of adequate community support Economization of treatment for mental illness Attitudes of police, society

Carl Rogers Client-centered therapy

Therapist takes a person centered approach & supportive role: Unconditional positive regard -demonstrate nonjudgmental caring to client. Genuineness - realness/congruence between what therapist believes and says. Empathetic understanding - therapist senses feelings/personal meaning from client & communicates it back to client.

Therapeutic Use of Self (and theorist)

Through self-awareness the nurse can use aspects of his/her personality, experiences, values, feelings, intelligence, needs, coping skills, perceptions to establish relationships beneficial to clients. Concept developed by H. Peplau Therapeutic use of self - nurses must understand themselves to promote growth& avoid limiting client's choices to those valued by the nurse.

DSM-5 three purposes

To provide a standardized nomenclature, language for mental health professionals. To present/identify defining characteristics or symptoms that differentiate specific diagnoses. To assist in identifying underlying causes of disorders.

Interpretation of signals or cues

To understand what a client means, the nurse watches & listens closely for cues - verbal or nonverbal messages that signal key words or issues for the client

Values/values clarification (choosing, prizing, acting)

Values (sense of right and wrong, code of conduct for living) Gain insight through clarification process: Values clarification Choosing - consider options & choose value that feels right. Prizing - cherishes value & attaches it to him/her self. Acting - put value into action.

Nonverbal Communication Skills cont.

Vocal cues - nonverbal sound signals transmitted alongwith content (i.e. voice volume, tone, pitch, intensity, pauses that augment sender's message). Eye contact - used to assess the other person, environment (increases during listening, decreases during speaking). Silence - long pauses in communication (may indicate person is thoughtfully considering question before responding).

Reaction formation

Woman who never wanted children becomes supermom.

Delusion (Thought process/content)

a fixed false belief not based in reality.

Crisis and 4 stages

a turning point in a person's life that produces an overwhelming emotional response - Experience of a life stressor which person cannot effectively manage through customary coping skills. Exposure to stressor Increased anxiety when usual coping ineffective Increased efforts to cope Disequilibrium, significant distress

Describe common student concerns about psychiatric nursing

a. Handling feeling unsafe b. Seeing someone known on the unit c. Dealing with similar problems or backgrounds d. Self-Disclosure e. Saying the wrong thing f. Knowing what to do g. Being rejected or not talking to the student h. Asking personal questions i. Handling bizarre, inappropriate, or sexually aggressive behavior

Hardiness (3 components)

ability to resist illness when under stress. 3 components: commitment, control, challenge.

Circumstantial thinking (Thought process/content)

answers question only after giving excessive unnecessary detail. the use of extraneous words and long, tedious descriptions

Culturally Competent

being sensitive to issues r/t culture, race, gender, sexual orientation, social class, economic situations, etc.

insertion

belief others are putting thoughts into client's head

Thought broadcasting

belief others know what the client is thinking

Self-efficacy

belief that personal abilities & efforts affect events in our lives. High efficacy - Set personal goals, self-motivated, cope. Low efficacy - low aspirations, self-doubt, anxious.

Group roles

can facilitate or inhibit the work of the group. Growth producing roles: information seeker, opinion seeker, information giver, energizer, coordinator, harmonizer, encourager, elaborator Growth inhibiting roles: monopolizer, aggressor, dominator, critic, recognition seeker, passive follower

Overt statements

clear, direct statements of intent

Mood

clients pervasive & enduring emotional state.

Facial expression (non verbal) - expressive, impassive, confusing

connects words to illustrate meaning. Expressive - portrays person's moment by moment thoughts, feelings, needs. Impassive - frozen into an emotionless expression similar to a mask. Confusing - one opposite of what the person wants to convey.

Beliefs about causes of illness (natural vs unnatural)

culture has the greatest influence on health beliefs & practices. Causes of illness in Non-Western cultures: Unnatural/Personal - d/t outside agent, spirit, or supernatural force. Natural - cause d/t natural conditions, cold, wind, or dampness.

Psychopharmacology and first meds

development of psychotropic drugs - first medications: -Chlorpromazine (Thorazine), antipsychotic -Lithium, antimanic agent Reduced agitation, psychotic thinking, and depression. Shorter hospital stays and less chaos/violence in hospital.

Loose associations (Thought process/content)

disorganized thinking that jumps from one idea to another with little relation between thoughts.

inappropriate affect

displaying a facial expression that is incongruent with mood or situation (silly, giddy).

Broad affect

displaying full range of expression

restricted affect

displaying one type of expression (serious, somber)

Dream analysis

dreams reflect a person's subconscious and have significant meaning (hidden or symbolic - woman chased by snakes fears intimacy with men).

revolving door theory and results

effect d/t deinstitutionalization. Patients often "boarded" in EDs while awaiting inpatient beds. Although people with severe and persistent mental illness have shorter hospital stays, they are admitted to hospitals more frequently. The continuous flow of clients being admitted and discharged quickly overwhelms general hospital psychiatric units Results in the following: Shorter hospital stays Decompensation Frequent rehospitalization Problems treating those with dual diagnoses (mental illness + substance abuse) in just 3 to 5 days.

Flight of ideas (Thought process/content)

excessive amount & rate of speech composed of fragmented or unrelated ideas.

Superficially right

fake positivity happens

Word salad

flow of unconnected words that convey no meaning

Mental Health Parity Act

forbids health plans from placing lifetime or annual limits on mental health coverage that are less generous than those placed on medical or surgical benefits

five types of touch

functional/professional - i.e. exams/procedures social-polite - i.e. handshake friendship-warmth -i.e. hug love-intimacy - i.e. kisses sexual-arousal -i.e. used by lovers

Resilience

having healthy responses to stressful circumstances. Positive outlook, flexibility, spirituality, supportive networks.

Supervised apartments (Residential Settings)

housed in apartment complexes, share apartments, staff available for crisis intervention, transportation, assistance with daily living tasks, etc.

Aristotle mental illness theory

imbalances of the four humors (amounts of blood, water, yellow and black bile in the body controlled emotions) Corresponded with happiness, calmness, anger, & sadness. Imbalance of humors caused mental illness. Balance restoration via bloodletting, starving, and purging.

Ideas of reference (Thought process/content)

inaccurate interpretation that general events are personally directed toward them.

Complementary medicine

includes therapies used with conventional medicine practices.

Sullivan life stages

infancy, childhood, juvenile, preadolescence, adolescence

ID (Freud)

innate desires, pleasure-seeking behavior, aggression, sexual impulses, instant gratification, no regard for rules.

Transitional Care Model

intensive services following long hospitalization to facilitate a client's transition to successful community living. Two essential components: Peer support - provided by a consumer now living successfully in community. Bridging staff - overlap between hospital staff & community care

Clubhouse model/Fountain House (and guaranteed rights)

intentional community based on belief clients with severe/persistent mental illness can & will achieve normal life goals when given opportunity, time, support, & fellowship. Four guaranteed rights of members A place to come to Meaningful work Meaningful relationships A place to return to (lifetime membership) Recognizes the physician-client relationship as key. Focus on health, not illness.

neologisms

invented words that have meaning only for the client.

Resourcefulness

involves using problem-solving abilities & believing one can cope with adverse/novel situations. Developed through interactions with others, coping with life.

Spirituality

involves using problem-solving abilities & believing one can cope with adverse/novel situations. Developed through interactions with others, coping with life. i.e. self-care behaviors, monitoring one's thoughts/feelings. a client's belief about life, health, illness, death, & one's relationship to universe. Differs from religion, which is an organized system of beliefs. Nurse's self-awareness of own spiritual beliefs. Need for objectivity and nonjudgmental attitude about client's beliefs. Cannot impose personal beliefs on clients. Respect client's religious & spiritual beliefs.

Culture

is all the socially learned behaviors, values, beliefs, & customs passed down to each generation. Each culture has rules governing verbal & nonverbal communication. Need for awareness of cultural differences: Speech patterns, habits Styles of speech, expression Eye contact Touch Concept of time Health, health care

Privacy

is desirable but not always possible in therapeutic communication (i.e. interview in conference room v. client's room)

Maslow humanistic theory (2 components)

it is a basic human psychosocial need that involves: Value - feeling needed/accepted. Fit - feeling that one meshes with environment. Thus, person feels valued, worthwhile.

case management

liaison between client & community resources. management of care on a case-by-case basis, representing an effort to provide necessary services while containing cost; in the community, case management services include accessing medical and psychiatric services and providing assistance with tasks of daily living such as financial management, transportation, and buying groceries

Three developmental cognitive modes (Sullivan)

of experience. Mental disorders are related to the persistence of one of the early modes: Prototaxic (infancy, childhood) - brief, unconnected experiences (schizophrenics) Parataxic (early childhood) -begin to connect experiences, reduce anxiety by repeating familiar experiences (paranoid ideas, slips) Syntaxic (school-aged children; more predominant in preadolescence) - can analyze experiences, maturity

Genuine interest

perceived as genuine person. Nurse demonstrates self-comfort, self-awareness of strengths and limitations, clear focus. Be open, honest, use active listening.

Individual/personal (influencing factors)

person's biologic make up, autonomy and independence, self-esteem, capacity for growth, emotional resilience or hardiness, sense of belonging, and coping/stress management abilities.

Criminalization of mental illness

practice of arresting & prosecuting mentally ill offenders at a rate 4 times that of general population in effort to contain them in some type of institution where they might receive treatment.

Behavior Modification (Skinner treatment modalities)

principles of reward or reinforcement used to change behavior.

Token Economy (Skinner treatment modalities)

provide reward for desired behaviors that can be redeemed for snacks, TV time, etc.

Board, care homes (Residential Settings)

provide room, bathroom, laundry facilities, one common meal per day.

Superego (Freud)

reflects moral and ethical concepts, values, parental and social expectations ( in direct opposition to id).

Automatisms (Unusual movements/mannerisms)

repeated purposeless behaviors often indicative of anxiety (drumming fingers, twisting hair, foot tapping).

Social/cultural/environmental (influencing factors)

sense of community, access to adequate resources, intolerance of violence, support of diversity among people, and a positive/realistic view of one's world.

Crisis resolution/respite care housing (Residential Settings)

short-term temporary shelter.

Flat affect

showing no facial expression

Nurse's role (peplau)

stranger (offer same acceptance as to any stranger) resource (answer questions) teacher (aid client in learning) leader (offer direction) surrogate (serve as substitute) counselor (promote expression of feelings)

Rationalization

student blames failure on teacher being mean.

milieu therapy

the concept involves clients' interactions with one another, that is, practicing interpersonal relationship skills, giving one another feedback about behavior, and working cooperatively as a group to solve day-to-day problems

duty to warn

the exception to the client's right to confidentiality; when health-care providers are legally obligated to warn another person who is the target of the threats or plan by the client, even if the threats were discussed during therapy sessions otherwise protected by confidentiality

Free association

therapist says word and client states 1st word that comes to mind to uncover subconscious or repressed thoughts, feelings.

Preconscious (Freud)

thoughts, emotions not currently in awareness but person can recall with effort - remembering what one felt as a child.

Unconscious (Freud)

thoughts, feelings that motivate a person even though he/she is totally unaware of them - includes defense mechanisms, instinctual drives. People repress into the unconscious the memory of traumatic events too painful to remember.

Factors that vary from cultures

time orientation, eye contact, touch, communication

Johari window (and steps)

tool to learn about oneself 4 quadrants: open/public self; blind/unaware self; hidden/private self; unknown 1st Step - nurse appraises own qualities (list values, attitudes, strengths, feelings, desires, etc.). 2nd step - Find out others perceptions by interviewing - ask people to identify your positive/negative qualities 3rd step - compare lists & assign qualities to quadrants. Goal: move qualities from quadrants 2, 3, 4 into quadrant 1 Indicates nurse is gaining self-knowledge & awareness.

Verbal (content vs context)

use of words. Content: literal words spoken. Context: Situation that clarifies the meaning of the content; environment, circumstances, situation in which communication occurs.

Systematic Desensitization (Skinner treatment modalities)

used to overcome fears or phobias; gradual exposure to anxiety-provoking situation until client can manage most anxiety-provoking situation.

Covert statements

vague, indirect messages that need interpretation & exploration

Tangential thinking (Thought process/content)

wandering off topic & never providing the information requested.

Process

what the client thinks

defense mechanisms

what the ego uses Methods of attempting to protect the self and cope with basic drives or emotionally painful thoughts, feelings. Operate at the unconscious level - people are not aware of what they are doing.

Congruence

words and actions match