STUDY GUIDE EXAM 1 (SLIGHTLY LESS incomp)

seclusion (definition)

"the involuntary confinement of a patient alone in a room, or area from which the patient is physically prevented from leaving"

anosognosia

(ah-no-sag-NO-zsuh) is the inability to realize one is ill—an inability caused by the illness itself. It is common in severe mental illness. Anosognosia may lead the patient to resist or stop treatment, making care more challenging and frustrating to others. Anosognosia can interfere with requesting or accepting help.

Chapter 3-Psychobiology and Psychopharmacology

**This is not an all-inclusive list of medications; only examples are provided in the guide**

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

A. Physician Explanation: Has to be physician; Nurse can sign as witness, though

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

B. No Explanation: pt has confidentiality after death

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

B.False

Audience Response Question: Which of these mental health problems has the highest annual prevalence in the United States? A. Schizophrenia B. Panic disorder C. Major depressive disorder D. Generalized anxiety disorder

C. Major depressive disorder Leading cause of disability in U.S. at 6.7% prevalence over 12 months

Audience Response Questions: Edgar is diagnosed with major depression and post-traumatic stress disorder (PTSD). At the team meeting, Edgar describes some of the struggles with this disorder since returning home from the war. He agrees with his wife Annie and his team that while they will work on treating his current symptoms, they will also collaborate on preventing its progression to a more severe level so that it doesn't become disabling or lead to suicidal ideation. Which type of prevention is Edgar's team most focused on? A. Primary prevention B. Secondary prevention C. Tertiary prevention D. It's too late for prevention; Edgar already has a depressive disorder.

C. Tertiary prevention

Outcomes Identification

Clearly defined outcome criteria are important for identifying the behaviors that staff can encourage if their interventions have been successful.

Delusions (textbook)

Delusions are false beliefs that are held despite a lack of evidence to support them. The most common delusions involve persecutory, grandiose, or religious ideas. For example, a person with poor self-esteem may believe that he is Beethoven or God, possibly driven by a need to feel important or powerful. Just because someone has a mental illness does not mean that every improbable belief is delusional. One patient repeatedly told staff that criminals were out to kill him. Staff later learned that he had been selling drugs, had not paid his suppliers, and that drug dealers were trying to harm him.

Serious side effects of antipsychotic medications

Nurses need to know about some rare but serious and potentially fatal effects of antipsychotics, including anticholinergic toxicity, neuroleptic malignant syndrome, and severe neutropenia. Nurses in psychiatry, primary care, and emergency services in particular need to be familiar with and to monitor for the early signs of these side effects. Patients and families should be taught to recognize and respond immediately to dangerous side effects.

Disorders co-occurring with schizophrenia

Disorders co-occurring with schizophrenia should be actively treated. Major depressive disorder is common in schizophrenia and is typically treated with antidepressants and other interventions. Antidepressants and mood-stabilizing agents may be needed for mood symptoms in schizoaffective disorder. Benzodiazepines such as lorazepam (Ativan) can reduce agitation and anxiety (which can worsen other symptoms and is quite common in schizophrenia) and can help lessen both positive and negative symptoms.

Nonmaleficence

Doing no harm to the patient (e.g., protecting confidential information about a patient).

Theory behind causative factors (ppt)

Dopamine theory--when D2 receptors are blocked reduces symptoms of schizophrenia (1st generation antipsychotics) Other neurochemicals-- serotonin and dopamine blocked by 2nd generation antipsychotics NMDA receptors and glutamate Acetylcholine --- Dopamine plays a role in schizophrenia (too high).

T o F: It is always useful to prove that the patient's delusion is incorrect

False; Until the patient's testing of reality improves, it is never useful to try to prove that the delusion is incorrect. This can instead intensify the delusion and cause the patient to view staff as people who cannot be trusted. However, it is helpful to clarify misinterpretations of the environment and gently suggest, as tolerated, a more reality-based perspective. For example: Patient: I see the doctor is here. He wants to kill me. Nurse: It is true the doctor wants to see you, as he talks with all patients about their treatment. Would you feel more comfortable if I stayed with you during your meeting? Focusing on reality-based activities and events occurring in the present keeps the focus on reality and provides opportunities to distinguish what is real. The nurse works with the patient to find and promote helpful coping strategies.

What is psychiatric mental health nursing? (ppt)

Psychiatric Mental Health Nursing: Thoughts about working with individuals with mental disorders? What skills will you use? What are your concerns? This is a specialty area working across the lifespan, with a variety of diagnoses and manifestations, in a range of settings Psychiatric-Mental Health Nursing: Scope and Standards Practice (2014- ANA, APNA- and ISPN)--promote mental health using the nursing process. Updated 2022.

Relapse Prevention

Relapse prevention efforts are vital. Each relapse may increase residual dysfunction and deterioration and can contribute to despair, hopelessness, and suicide risk. Recognizing early warning signs of relapse—such as reduced sleep, social withdrawal, and worsening concentration—followed by close monitoring and intensification of treatment as needed is essential to minimize the duration and severity of psychotic episodes and resulting disruption of the patient's life.

Duty to Warn Potential Victim: Tarasoff case

Report any safety concerns and threats to treatment team and your instructor Report child and elder abuse (mandated reporter) Other legal issues --- If you know that the pt is going to hurt someone, you need to warn that person. You also cannot release that pt. ^Usually get an order of protection

Autonomy

Respecting the rights of others to make their own decisions (e.g., acknowledging the patient's right to refuse medication supports autonomy).

Restraints (ppt)

Restraints are a last resort; Used only in cases where pt safety and/or staff safety is at risk Every 15 minutes got to monitor for: V/S Fluids Must be a face-to-face assessment Research has shown it's traumatic for the patient and is EQUALLY traumatic for the staff --- Pt's appreciate access to things, when possible Less violence happens when pt's have a little bit of freedom (e.g., cell phones at certain times)

Patient Rights (treatment, refuse treatment, informed consent, Advanced directives, restraint/seclusion, confidentiality)

Right to Treatment Right to Refuse Treatment except if emergency or court ordered Right to Informed Consent Rights related to restraint and seclusion Right to Confidentiality (HIPAA)

Theory behind causative factors (textbook)

Schizophrenia is believed to occur when multiple inherited genetic abnormalities combine with other factors. Such other factors include viral infections, birth injuries, environmental stressors, prenatal malnutrition, trauma, and abnormal neural pruning that alters brain development or function and/or injures the brain directly. --- For the record, between the ppt and the textbook answers for theory behind causative factors, I think the dopamine theory is what she'd ask about. Honestly, for the whole schizophrenia chapter, I would recommend the ppt cards over the textbook ones if you are really pressed for time and want to cram.

Second-generation antipsychotics

Second-generation antipsychotics include drugs such as clozapine (Clozaril), risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), and ziprasidone (Geodon). They are D2 receptor antagonists, as are first-generation antipsychotics, but they bind to serotonin receptors as well. Second-generation antipsychotics are often chosen as first-line antipsychotics because they are equally effective for positive symptoms and may also help negative symptoms.

Historical Perspective

See Historical Perspectives Flashcard Set in this folder

State Boards of Nursing

Nursing boards are state governmental agencies that regulate nursing practice and whose primary goal is to protect the health of the public by overseeing the safe practice of nursing. They have the authority to license nurses who meet a minimum competency score on board examinations, and also have the power to revoke licenses. Each state has its own Nurse Practice Act that identifies the qualifications for registered nurses, identifies the titles that registered nurses will use, defines what nurses are legally allowed to do (scope of practice), and describes the actions that are followed if nurses do not follow the nursing law.

Nursing Diagnosis vs DSM V

Nursing care, as opposed to medical care, is care based on responses to illness. Registered nurses do not diagnose, prescribe, and treat major depressive disorder. They treat the problems associated with depression, such as insomnia or hopelessness. Nurses provide effective care using the nursing process as a guide to holistic care. While the DSM-5 is used to diagnose a psychiatric disorder, a well-defined nursing diagnosis provides the framework for identifying appropriate nursing interventions for dealing with the patient's reaction to the disorder. The International Classification for Nursing Practice (ICNP) , developed by the International Council of Nurses (ICN, n.d.), provides standardized nursing diagnoses that are used to guide care in this textbook.

Pharmacological Interventions (ppt)

Offer prn Antianxiety and antipsychotics, can be given separate or together Oral if appropriate Educate patient

Levels of nursing practice- Advanced Level

One of the first APN roles in the US was the psychiatric clinical nurse specialist (CNS) in the 1950s. They were originally trained to provide individual therapy and group therapy in state psychiatric hospitals and to provide training for other staff. Eventually they, along with psychiatric nurse practitioners (NPs) who were introduced in the mid-1960s, gained diagnostic privileges, prescriptive authority, and the ability to provide psychotherapy. Currently, the psychiatric-mental health advanced practice registered nurse (PMH-APRN) is a licensed registered nurse with a Master of Science in Nursing (MSN) or Doctor of Nursing Practice (DNP) in psychiatric nursing. ^DNP= practice, PhD= research The PMH-APRN functions with various levels of autonomy depending on the state and is eligible for specialty privileges.

Right to Treatment (text)

One of the most fundamental rights of a patient admitted for psychiatric care is the right to quality care. We refer to this as the right to treatment. Particularly in the case of involuntary commitment, how can we deny a person's liberty and then not provide treatment? Based on the decisions of a number of early court cases, patients have specific rights to treatment. They include: • The right to be free from excessive or unnecessary medication • The right to privacy and dignity • The right to the least restrictive environment • The right to an attorney, clergy, and private care providers • The right to not be subjected to lobotomies, electroconvulsive treatments, and other treatments without fully informed consent

Health teaching and promotion

One of the most important roles a nurse plays in a patient's recovery is that of role model and educator. You can model appropriate responses and ways to cope with anger, teach patients a variety of methods to appropriately express anger, and educate patients regarding coping mechanisms, de-escalation techniques, and self-soothing skills to manage behavior. It is also helpful to assist the patient in identifying triggers for angry or aggressive behavior. One method that can be used if the patient is not out of control is a "do over." The patient who responds inappropriately can try again to respond in a more appropriate way while being coached by the nurse. Interest in using alternative interventions such as mindful living in healthy patients has been gaining interest. Nurses may introduce these concepts and educate the patient on how to incorporate them into their lives.

Insurance regulation changes have occurred since the 2016 presidential election

One of the most significant changes has been expanded access to short-term health insurance plans. These plans are not subject to parity rules for mental health coverage. Individuals may not be aware of this until they are faced with treatment for psychiatric conditions or substance use.

Application of the nursing process (assessment, diagnosis, outcome identification, planning, implementation, and evaluation)

See notes below, but review PSYCHOTHERAPEUTIC MANAGEMENT ppt/cards for these, as well.

psychiatric-mental health advanced practice registered nurse (PMH-APRN)

a licensed registered nurse with a Master of Science in Nursing (MSN) or Doctor of Nursing Practice (DNP) in psychiatric nursing.

mental health continuum

a method of conceptualizing mental health and mental illness as a spectrum

psychiatric-mental health registered nurse (PMH-RN)

a nursing graduate who possesses a diploma, an associate degree, or a baccalaureate degree and chooses to work in the specialty of psychiatric-mental health nursing.

command hallucination

a particularly concerning symptom wherein the person is directed to take an action. Command hallucinations may be dangerous and must be evaluated carefully. For example, they may be telling a patient to "jump out the window" or to "hit that nurse." Command hallucinations are often frightening and may be a flag warning of a psychiatric emergency. It is essential to assess what the patient hears, the source to which it is attributed, the patient's ability to recognize the hallucination as "not real" and resist commands.

Predictors of violence

Substance use Increasing hyperactivity Voice: verbal abuse, loud voice, silence Possession of weaponIntense eye contact Environment: increase stimulation, poor boundaries and structures Cognitive deficits -.-.- - SUD (not getting enough substance, getting too much) - incarcerated pop - ER, critical care (step-down unit), behavioral floors - Anxious pts - Schizophrenia - Hx of violence (whether it be them committing it or experiencing it)

Comorbidity and Risk Factors (textbook)

Substance use disorders, particularly alcohol and marijuana, occur in nearly half of affected individuals. Substance use may be a form of self-treatment for certain symptoms (e.g., social discomfort) or side effects (e.g., sedation). It is associated with poorer treatment adherence and prognosis and with increased relapse, incarceration, homelessness, violence, and suicide. About 60% of individuals with schizophrenia use nicotine, possibly owing to genetic factors or as a form of coping with cognitive impairment or anxiety. Smoking doubles the risk of cancer and contributes to cardiovascular and respiratory disorders. Anxiety, depression, and suicide co-occur frequently in schizophrenia. At least 20% of people with schizophrenia attempt suicide, whereas 5% to 10% die by suicide, a rate five times that of the general population. Suicide attempts are more common within 3 years of diagnosis and especially upon discharge after the first episode of schizophrenia. Physical illnesses are more common among people with schizophrenia. They face a risk of premature death that is 3.5 times greater than the risk in the general population; on average, moreover, patients with schizophrenia die more than 20 years prematurely with cardiovascular disease and metabolic syndrome. Individuals with psychotic disorders are at greater risk for poor health maintenance behaviors (e.g., reduced physical activity), poor nutrition, substance use, poverty, limited access to healthcare, victimization, trauma, and reduced ability to recognize or respond to signs of illness. They may also receive poorer-quality healthcare owing to poverty, stigma, impaired ability to express their needs, or stereotyping (e.g., emergency department staff assuming that chest pain complaints are imaginary or not serious). Polydipsia is compulsive drinking of fluids; it occurs in about 20% of individuals with schizophrenia. The excess fluid reduces sodium levels, which results in hyponatremia (also known as water intoxication) in up to 5% of those affected. Symptoms of hyponatremia include confusion, delirium, hallucinations, worsening of psychotic symptoms, dilute urine, polyuria, and ultimately coma. Contributing factors include antipsychotic medications th

Comorbidity and Risk Factors (ppt)

Substance use disorders--50% occurrence nicotine dependence up to 60% Anxiety Depression Suicidality (up to 5-10% suicide) 20% attempt Physical illnesses- premature death 3.5x higher Polydipsia --- If family is depressed, we worry about suicidal ideation Sedentary lifestyle and smoking= we worry about cardiovascular disease 20% of schizophrenia pts may also suffer from polydipsia, which can lead to hyponatremia. You could have episodes where you may mimic someone who has a UTI and has delirium. Some medications also make them want to drink more water.

Cognitive symptoms (cont.)

Subtle or obvious impairment in memory, attention, thinking (e.g., disorganized or irrational thoughts); impaired executive functioning (e.g., impaired judgment, impulse control, prioritization, and problem solving). Cognitive symptoms represent the third symptom group and are evident in most patients with schizophrenia. These impairments can lead to poor judgment and leave the person less able to cope, learn, manage health, or succeed in school or work. Medication is of limited value, but other treatments such as cognitive remediation (discussed later) can be helpful.

affective symptoms

Symptoms involving emotions and their expression.

Interventions-First-generation antipsychotics--TD:

Tardive dyskinesia (TD) Varies in intensity Can tx. with valbenazine (Ingrezza) & deutetrabenazine (Austedo) Reduces the severity of symptoms AIMS test (Abnormal Involuntary Movement Scale) (p. 214 text), and video in Canvas Module, important to assess

tardive dyskinesia

Tardive dyskinesia is a persistent EPS involving involuntary rhythmic movements. It develops in about 25% of patients on antipsychotics. Tardive dyskinesia is more common with first-generation antipsychotics, usually after prolonged treatment, and usually persists even after the medication has been discontinued. Smoking, alcohol, and stimulant use may increase the risk of this form of EPS. It usually begins in oral and facial muscles and progresses to include the fingers, toes, neck, trunk, or pelvis. More common in women, tardive dyskinesia varies from mild to severe, and can be disfiguring or incapacitating

Tardive dyskinesia (cont.)

Tardive dyskinesia is a persistent EPS involving involuntary rhythmic movements. It develops in about 25% of patients on antipsychotics. Tardive dyskinesia is more common with first-generation antipsychotics, usually after prolonged treatment, and usually persists even after the medication has been discontinued. Smoking, alcohol, and stimulant use may increase the risk of this form of EPS. It usually begins in oral and facial muscles and progresses to include the fingers, toes, neck, trunk, or pelvis. More common in women, tardive dyskinesia varies from mild to severe, and can be disfiguring or incapacitating. Tardive dyskinesia in adults can be treated with two drugs: valbenazine (Ingrezza) and deutetrabenazine (Austedo). These drugs are selective vesicular monoamine transporter inhibitors and reduce the severity of abnormal movements in tardive dyskinesia. Adverse effects include sleepiness and QT prolongation. They are contraindicated with congenital or acquired long-QT syndrome or related dysrhythmias. They should be used with caution in people who drive or operate heavy machinery or do other dangerous activities until how the drug affects them is known. Switching to a second-generation antipsychotic or reducing or (paradoxically) increasing the first-generation antipsychotic dosage can be helpful.

Psychotherapeutic Management

model of care that clarifies the nature of psychiatric nursing and differentiates psychiatric nursing practice from other disciplines. Components include therapeutic nurse-patient relationship, psychopharmacology, and milieu management. ^ Review quizlet set in this folder on this topic

right to privacy

nurse has a duty to preserve confidentiality

cultural competence

nurses adjust their practices to meet their patients' cultural beliefs, practices, needs, and preferences.

executive functioning

reasoning, setting priorities, comparing options, placing things in logical order or groups, anticipating and planning, and inhibiting undesirable impulses or actions, problem-solving; impaired executive functioning is a cognitive symptom of schizophrenia

mental illness

refers to all psychiatric disorders that have definable diagnoses. These disorders are manifested in significant dysfunctions that may be related to developmental, biological, or psychological disturbances in mental functioning. The ability to think may be impaired—as in Alzheimer's disease. Emotions may be affected—as in major depressive disorders. Behavioral alterations may be apparent—as in schizophrenia. People may experience some combination of the three alterations.

psychosis

altered cognition, altered perception, and/or an impaired ability to determine what is or is not real

violence

always an objectionable act that involves intentional use of force that results in, or has the potential to result in, injury to another person

aggression

an action or behavior that results in a verbal or physical attack

severe neutropenia

an acute condition involving a dangerously low white blood cell count (neutropenia), which increases the risk of a serious infection. Neutropenia is defined by an ANC of less than 500/μL. Left untreated, this life-threatening condition leads to death, most commonly through bacterial infection of the blood, or septicemia. Monitoring for neutropenia is done as part of the complete blood count through an ANC. Symptoms of severe neutropenia include signs of infection (e.g., fever, chills, and sore throat) or increased susceptibility to infection.

anger

an emotional response to frustration of desires, a threat to one's needs (emotional or physical), or a challenge. It is a normal emotion that can even be positive when it is expressed in a healthy way. Once anger is acknowledged, channeling anger into productive pursuits such as exercise, art, or cleaning out a closet is healthy. Anger can also be a motivator to try harder or an aid in survival when fighting is the last and only resort.

concrete thinking

an impaired ability to think abstractly, resulting in interpreting or perceiving things in a literal manner. For example, a nurse might ask what brought the patient to the hospital, and the patient answers "a cab" rather than "a suicide attempt." The meanings of proverbs can be used to assess abstract thought. An abstract interpretation of "The grass is always greener on the other side of the fence" is that we feel that we might be happier given other circumstances. A concrete interpretation could be "That side gets more sun, so it's greener there." Concreteness reduces one's ability to understand and respond to concepts requiring abstract reasoning, such as love or humor. Nurses can assist by communicating in more concrete terms that do not require abstract reasoning.

assertive community treatment (ACT)

an intensive type of case management developed in the 1970s; teams work intensively with patients in their homes or in agencies, hospitals, and clinics—whatever settings patients find themselves in.

duty to protect

an obligation to warn third parties when they may be in danger from a patient

trauma-informed care

an older concept of providing care that has recently been reintroduced. It is based on the notion that disruptive patients often have histories that include violence and victimization. These traumatic histories can impede patients' ability to self-soothe, result in negative coping responses, and create a vulnerability to coercive interventions (e.g., restraint) by staff. Trauma-informed care focuses on the patient's past experiences of violence or trauma and on the role these experiences currently play in their lives.

prevention

any action taken to keep people healthy and/or avoid further injury

tort

any wrongful act, intentional or accidental, that results in an injury to another

psychiatric case management

assist patients in finding housing or obtaining entitlements

Cultural norms

attitudes and behaviors that are culturally defined and considered normal, typical, or average within a given group. Because cultural norms prescribe what is normal and abnormal, culture helps to develop concepts of mental health and illness.

Treatment Over Objection

based on the capacity to give informed consent --- Upon a patient's objection to the proposed treatment, the treating physician shall formally evaluate whether the treatment is in the patient's best interests, in light of all relevant circumstances including the risks, benefits and alternatives to the patient of the treatment, and the nature of the patient's objection

The first-generation and some second-generation antipsychotics cause anticholinergic side effects by ___

blocking muscarinic cholinergic receptors.

Therapeutic communication techniques for patients with schizophrenia (textbook)

build trust and reduce anxiety. Staff should remember that people with schizophrenia may have memory and attentional impairment and that repetition and visual and verbal reminders promote learning and task completion. People who think concretely also benefit from concrete examples during education (e.g., counting out the equivalent number of sugar cubes found in a bottle of cola to show its sugar content). Shorter (less than 30 minutes) but more frequent interactions may be less stimulating and better tolerated than fewer, longer interactions. When a patient is hallucinating, the nurse focuses on understanding the patient's experiences and responses. Suicidal or homicidal themes or commands require safety measures. For example, if voices tell a patient that a peer plans to assault him, the patient may act aggressively against that person. In this case, close monitoring, helping the patient to feel safe, and maintaining separation of the patient and potential victim would be indicated. Impaired reality testing prevents self-correction of irrational thoughts that normally would be disregarded. When the nurse attempts to see the world through the patient's eyes, it becomes easier to understand the patient's delusion. For example: Patient: You people are all alike ... all part of the FBI plot to destroy me. Nurse: It seems to you that people want to hurt you. That must be very frightening. I will not hurt you, and we can work together to help you feel safer. Here, the nurse acknowledges and accepts the patient's experience and feelings, conveys empathy about the patient's fearfulness, provides reassurance about her intentions, avoids questioning the delusion itself, and focuses on helping the patient feel safer (addressing the underlying theme of fear). Focusing on the delusion itself, the beliefs about the FBI, would not be helpful. Focusing on fear, its causes, and what can help the patient to feel more secure is therapeutic.

incidence

conveys information about the risk of contracting a disease. It refers to the number of new cases of mental disorders in a healthy population within a given period of time, usually annually. Example: The incidence of neonatal abstinence syndrome was 32,000 in 2014, a fivefold increase over the course of a decade. These numbers help to reveal a disturbing public health trend that should be addressed by healthcare providers and policy makers

Signs of Mental Health (ppt)

cope with life stressors, be productive, contribute to society, aware of own strengths and limitations

delusions

false beliefs that are held despite a lack of evidence to support them. The most common delusions involve persecutory, grandiose, or religious ideas

validation therapy

focuses on helping the person work through the emotions behind challenging behaviors

long-acting injectable

formulations that need to be administered only every 2 to 4 weeks or even months

electronic healthcare

health services delivered via an electronic medium

phenomena of concern

human experiences and responses

diathesis-stress model

in which diathesis represents biological predisposition and stress represents environmental stress or trauma—is the most accepted explanation for mental illness. This nature-plus-nurture argument asserts that most psychiatric disorders result from a combination of genetic vulnerability and negative environmental stressors.

Anticholinergic side effects

include urinary retention, dilated pupils, constipation, reduced visual accommodation (blurred near vision), tachycardia, dry mucous membranes, reduced peristalsis (rarely leading to paralytic ileus and risk of bowel obstruction), and cognitive impairment. Taking multiple medications with anticholinergic side effects increases the risk of anticholinergic toxicity. In general, first-generation antipsychotics have either a strong EPS potential or strong anticholinergic potential; that is, when one side effect is prominent, the other is not.

metabolic syndrome

includes weight gain (especially in the abdominal area), dyslipidemia, increased blood glucose, and insulin resistance. Metabolic syndrome is a significant concern and increases the risk of diabetes, certain cancers, hypertension, and cardiovascular disease, making its prevention an important role for nurses. Metformin (Glucophage), an anti-diabetic medication, has shown promise in reducing antipsychotic weight gain in children, adolescents, and adults

Seclusion

is confining patients alone in an area or a room and preventing them from leaving. Seclusion is limited to patients who are demonstrating violent or self-destructive behavior that jeopardizes the safety of others or themselves. Even if the door is not locked, making threats if the patient tries to leave the room is still considered secluding. However, a person who is physically restrained in an open room is not considered to be in seclusion. Seclusion should be distinguished from timeout. Timeout is when a patient chooses to or accepts a suggestion to spend time alone in a specific area for a certain amount of time. The patient can leave the timeout area at any point.

elopement

leaving before being discharged (also referred to as being away without leave or AWOL)

competency

legal term related to the degree of mental soundness a person has to make decisions or to carry out specific acts. Like the phrase "innocent until proven guilty," patients are considered competent until they have been declared incompetent.

least restrictive alternative doctrine

mandates that care providers take the least drastic action to achieve a specific purpose. For example, if you can treat someone safely for depression on an outpatient basis, hospitalization would be too restrictive and unnecessarily disruptive.

Reslience (textbook)

the ability and capacity for people to secure the resources they need to support their well-being. It is a quality found in some children of poverty and abuse who seek out trusted adults. These adults provide them with the psychological and physical resources that allow them to excel. Being resilient does not mean being unaffected by stressors. People who are resilient are effective at regulating their emotions and not focusing on negative, self-defeating thoughts. You can get an idea of how good you are at regulating your emotions and coping with difficult situations by using the Brief Resilient Coping Scale

resilience

the ability and capacity for people to secure the resources they need to support their well-being. It is a quality found in some children of poverty and abuse who seek out trusted adults. These adults provide them with the psychological and physical resources that allow them to excel.

battery

the actual harmful or offensive touching of another person --- the actual harmful or offensive touching of another person. Shoving a patient from behind to hurry the patient up is an example of battery. Often, assault and battery occur together when a threat is made and then carried out.

reality testing

the automatic and unconscious process by which we determine what is and is not real. We all experience thoughts that are irrational or distorted, yet we usually catch and correct them via reality testing. You might think you hear a voice, but you see that no one is present, so you conclude you are mistaken—it wasn't real. With impaired reality testing, the person experiences hallucinations or delusions as real.

stigma

the belief that the overall person is flawed

ethics

the branch of knowledge and philosophical beliefs about what is right or wrong in a society

negligence

the most common unintentional tort. It is defined as the failure to use ordinary care in any professional or personal situation when there is a duty to do so. Failure to question a physician's order, failure to protect a patient from self-harm, and failure to provide patient teaching are all examples of negligence.

Echolalia

the pathological repetition of another's words, occurring perhaps because the patient's thought processes are so impaired that she is unable to generate speech of her own.

informed consent

the patient has been provided with basic information regarding risks and benefits, and alternatives to treatment. The person must be voluntarily accepting the treatments. While registered nurses routinely provide education about treatment, typically it is the prescriber who is legally responsible for securing informed consent. The principle of informed consent is based on a person's right to self-determination as described in the landmark case of Canterbury v. Spence.

positive symptoms

the presence of symptoms that should not be present. Positive symptoms include hallucinations, delusions, paranoia, or disorganized or bizarre thoughts, behavior, or speech.

epidemiology

the quantitative study of the distribution of mental disorders in human populations. Understanding this distribution helps to identify high-risk groups and risk factors associated with illness onset, duration, and recurrence

stabilization

the resolution of the immediate crisis

least restrictive environment

the setting that provides the necessary care while allowing the greatest personal freedom.

false imprisonment

when a person is confined in a limited area or within an institution. A charge of false imprisonment may be made after a person is placed in restraints or seclusion. Medications that result in chemical restraint may also fit in this category of tort.

hallucinations

when a person perceives a sensory experience for which no external source exists (e.g., hearing a voice when no one is speaking)

voluntary admission

when patients apply in writing for admission to the facility. The person should understand the need for treatment and be willing to be admitted. If the individual is under 16, the parent, legal guardian, custodian, or next of kin may have authority to apply on the person's behalf. Adolescents between 16 and 18 may seek admission independently or on the application by an authorized individual or agency. Voluntarily admitted patients have the right to request and obtain release. Before being released, reevaluation may be necessary. Reevaluation can result in a decision on the part of the care provider to initiate an involuntary commitment according to criteria established by state law.

intentional torts

willful or intentional acts that violate another person's rights or property. Ex: assault, battery, and false imprisonment.

neologism

words that have meaning for the patient but a different or nonexistent meaning for others. A patient may use a known word differently than others or create a completely new word that others do not understand (e.g., "His mannerologies are poor").

right to treatment

rights to quality care, which include: • The right to be free from excessive or unnecessary medication • The right to privacy and dignity • The right to the least restrictive environment • The right to an attorney, clergy, and private care providers • The right to not be subjected to lobotomies, electroconvulsive treatments, and other treatments without fully informed consent

Legal considerations (ppt)

○Health Insurance Portability and Accountability Act (HIPAA) ○Confidentiality after death ○Confidentiality of professional communications --- There IS confidentiality after death

restraint (definition)

"any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely"

writ of habeas corpus

"formal written order" to "free the person." The writ of habeas corpus is the procedural mechanism used to challenge unlawful detention by the government. The hospital must immediately submit the document to the court. The court will then decide if the patient has been denied due process of law.

Duty to protect patient

-never leave a suicidal patient with means to harm self alone! Call someone or bring the patient with you to someone

Outpatient settings (ex. Primary care providers, specialized, ACT, Intensive and partial outpatient treatment, emergency care) (ppt)

-Primary Care Providers -Specialty Psychiatric Providers -Patient-Centered Medical Homes ^ Big trend in Boston; where pts can make an appointment and go to a home (like a hotel with individual apartments) and people take care of you. One stop shop. Short-term, like going to a doctor. -Community Mental Health Centers -Psychiatric Home Care/Personal Recovery Programs (PROS) ^ For pt's that are not as "high-functioning." -Assertive Community Treatment (ACT) -Intensive Outpatient Programs/Partial Hospitalization -Programs ^ For "higher functioning" pts -Telepsychiatry -Mobile Mental Health

Restraints (cont.)

-SIGNS OF INJURY ASSOCIATED WITH APPLICATION OF RESTRAINT - NUTRITION & HYDRATION - CIRCULATION & ROM IN THE EXTREMITIES - VITAL SIGNS - ELIMINATION & HYGIENE NEEDS - PHYSICAL & PSYCHOLOGICAL STATUS & COMFORT Reapplying restraint needs new order F2F one time order. Cannot be PRN, cannot be standing Nursing cannot create an order. Dr or 3 year independent provider --- Can be traumatizing for pt and nurses don't take both arms out at the same time (take one arm out, then take out opposite leg, wait two minutes then do the same for the other side) ^taking one arm out strengthens the upper body

There are six basic considerations for ensuring safety

1. Avoid wearing dangling earrings, necklaces, and scarves in acute care environments. The patient may become focused on these and grab at them, causing serious injury. 2. Ensure that there is enough staff for backup. Only one person should talk to the patient, but staff need to maintain an unobtrusive presence in case the situation escalates. 3. Always know the layout of the area. Correct placement of furniture and elimination of obstacles or hazards are important to prevent injury if the patient requires physical interventions. 4. Do not stand directly in front of the patient or in front of the doorway. The patient may consider this position as confrontational. It is better to stand off to the side and encourage the patient to have a seat. 5. If a patient's behavior begins to escalate, provide feedback: "You seem to be very upset." Such an observation allows exploration of the patient's feelings and may lead to de-escalation of the situation. 6. Avoid confrontation with the patient, either through verbal means or through a "show of support" with security guards. Verbal confrontation and discussion of the incident must occur when the patient is calm. A show of force by security guards may serve to escalate the patient's behavior. Security personnel are better kept in the background until they are needed to assist.

Medical records help to determine:

1. The extent of the patient's damages and pain and suffering in personal injury cases, such as when a psychiatric patient attempts suicide while under the protective care of a hospital. 2. The nature and extent of injuries in child abuse or older adult abuse cases. 3. The nature and extent of physical or mental disability in disability cases. 4. The nature and extent of injury and rehabilitative potential in workers' compensation cases. Medical records may also be used in police investigations, civil conservatorship proceedings, competency hearings, and involuntary commitment procedures. In states that mandate mental health legal services or a patients' rights advocacy program, audits may be performed to determine the facility's compliance with state laws or violation of patients' rights. Finally, medical records may be used in professional and hospital negligence cases.

In an emergency situation where a person may cause serious and imminent harm to self or others, institutions can medicate a person without a court hearing. Beyond emergency situations, after a court hearing, a person can be medicated if all of the following criteria are met:

1. The person has a serious mental illness 2. The person's functioning is deteriorating and if the person is suffering or exhibiting threatening behavior 3. The benefits of treatment outweigh the harm 4. The person lacks the capacity to make a reasoned decision about the treatment 5. Less-restrictive services have been found inadequate

Assessment guidelines - areas to assess (ppt)

1.Prodromal-Before acute symptoms 2.Acute--onset or exacerbation of symptoms with loss of function 3.Stabilization--decreasing symptoms 4.Maintenance--near baseline. Symptoms absent or decreased What settings will individuals be treated in for each of these phases?

Interventions-Second-generation antipsychotics (ppt)

1990s-Clozaril-Serotonin (5-HT2A receptor) & Dopamine (D2 receptor) antagonists, risk of agranulocytosis necessitates WBC monitoring Often first-line treatment, less EPS, or tardive dyskinesia Significant weight gain except ziprasidone (Geodon) Disadvantage—tendency to cause significant weight gain; risk of *metabolic syndrome* A major concern for increased cardiovascular disease and diabetes (insulin resistance) --- Clozaril-serotonin is not a first-line treatment anymore Have to know how you are doing. Interventions-Antipsychotics and serious effects: Anticholinergic Toxicity-potentially life-threatening medical emergency Symptoms-ANS instability, hyperpyrexia without diaphoresis, delirium, and hallucinations. Neuroleptic malignant syndrome (NMS)—Acute, life threatening emergency-can be fatal, altered consciousness, muscle rigidity, hyperpyrexia with diaphoresis, hypertension, tachycardia, tachypnea, drooling Agranulocytosis--monitor for decreased WBC or neutropenia, signs infection Liver impairment—1st generation more-monitor liver function How would you manage each of these serious side effects? (text p. 216)

Confidentiality of Professional Communications

A legal privilege exists as a result of specific laws to protect the confidentiality of certain professional communications (e.g., physician-patient, attorney-patient). The theory behind providing a privilege is to ensure that patients will speak frankly and be willing to disclose personal information because they know that care providers will not repeat or distribute confidential conversations. In 12 states, the legal privilege of confidentiality has been extended to advanced practice registered nurses (Pierce, 2014). In nine states, privileged communication is also provided for registered nurses who work in mental health. In the remaining states, nurses must answer a court's questions regarding the patient, even if this information implicates the patient in a crime. In these states, the confidentiality of communications cannot be guaranteed.

akathisia

A motor restlessness that causes pacing and/or an inability to stay still or remain in one place. It can be severe and distressing to patients and can be mistaken for anxiety or agitation. These symptoms may lead to mistakenly administering more of the drug that originally caused the akathisia, making it worse. A tardive form can persist despite treatment.

Safety (textbook)

A multidisciplinary approach, have a plan of care, discuss intervention strategies at team meetings. The plan for discharge should include appropriate follow-up, possibly with an anger-management course, must be put into place. The consistency of intervention among all team members is key. A thorough consideration of the environment is important when considering anger and aggression on the unit. It is important to be proactive and not reactive. It is hard to imagine how the stimulation of a psychiatric unit might be experienced by someone whose anxiety is extremely high or who is delusional or confused. If the patient has enough control, sometimes simply taking a timeout to the patient's room is sufficient. A multisensory room, aka a Snoezelen, is another form of timeout. This quiet room is partially lit, has relaxing music available, and has comfortable furniture and soft pillows. It promotes feelings of security and safety. Behavior rarely occurs in a vacuum. Examine the milieu as a whole and identify the stressors patients have to deal with, especially patients who have an antisocial personality disorder. These individuals tend to create havoc and make it appear that another patient is at fault, either for their own pleasure or for their own purposes (e.g., escaping the unit or getting into the medication room). So even while dealing with an incident, staff must be aware of what could be happening in the surrounding environment.

Caring for patients in any setting who are feeling overwhelmed

A patient loses autonomy and control when hospitalized, which can cause a great deal of related distress. When this stress is combined with the uncertainty of illness, a patient may respond in ways that are not usual for him or her. A careful nursing assessment, with history and information from family members, helps to evaluate whether a patient's anger is a usual or an unusual way of managing stress. Interventions for patients whose usual coping strategies are healthy involve finding ways to reestablish or substitute similar means of dealing with the hospitalization. This problem solving occurs in collaboration with the patient in interactions that demonstrate the nurse acknowledges the patient's distress, validates it as understandable under the circumstances, and indicates a willingness to search for solutions. Validation includes making an apology to the patient when appropriate, such as when a promised intervention (e.g., changing a dressing by a certain time) has not been delivered, or sympathizing with the patient about the "horrible food" by assisting with menu selections.

Confidentiality After Death

A person's reputation can be damaged even after death. It is important that you do not divulge information after a person's death that you could not legally share before the death. In the courtroom setting, the Dead Man's Statute protects confidential information about individuals when they are not alive to speak for themselves. About half the states have such a law; again, these laws vary from state to state.

Signs of Mental Health (textbook)

A sense of well-being describes the general state of people in this category. Well-being= adequate to high-level functioning. Although individuals at this end of the continuum may experience stress and discomfort resulting from problems of everyday life, they experience no serious impairments in daily functioning. Ex: you may feel dismay over a failed exam, trivial concerns, or the death of a loved one, but during those low times, you are fully or vaguely aware that you are not functioning well. - However, time, exercise, a balanced diet, rest, interaction with others, and mental reframing may alleviate these problems or concerns.

Other second-generation antipsychotics

A subset of the second-generation antipsychotics—aripiprazole (Abilify), brexpiprazole (Rexulti), and cariprazine (Vraylar)—are sometimes referred to as third-generation antipsychotics. They are described as dopamine system stabilizers that reduce dopamine activity in some brain regions while increasing it in others. Aripiprazole and brexpiprazole act as D2 partial agonists. They attach to the D2 receptor without fully activating it, reducing the effective level of dopamine activity. Cariprazine acts as a partial agonist more on D3 than D2 receptors, which may help to improve cognitive symptoms.

acute dystonia

A sudden, sustained contraction of one or several muscle groups, usually of the head and neck. Acute dystonias can be frightening and uncomfortable, but unless they involve muscles affecting the airway, which is rare, they are not dangerous. However, they cause significant anxiety and should be treated promptly.

pseudoparkinsonism

A temporary group of symptoms that resemble Parkinson disease: tremor, reduced accessory movements (e.g., arms swinging when walking), gait impairment, reduced facial expressiveness (mask facies), and slowing of motor behavior (bradykinesia).

Case Study/Audience Response Question Eric becomes anxious and says, "There are worms under my skin eating the hair follicles." How would you classify this assessment finding? A.Positive symptom B.Negative symptom C.Cognitive symptom D.Depressive symptom

A.Positive symptom

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

A.State Boards of Nursing

Inpatient Care Settings: General Hospitals and Private Hospitals

Acute care hospital psychiatric units tend to be housed on a floor or floors of a general hospital. Private psychiatric hospitals are freestanding facilities. As noted, the dramatic growth of acute care psychiatric hospitals and hospital units is the result of a shift away from institutionalization in state-managed hospitals. Since that time, reduced reimbursement, increased managed care, enhanced outpatient options, and expanded availability of outpatient and PHPs have resulted in the steady decline of these facilities.

Acute

Acute symptoms vary, from few and mild to many and disabling. Symptoms such as hallucinations, delusions, apathy, social withdrawal, diminished affect, anhedonia, disorganized behavior, and impaired judgment and cognition result in functional impairment. The person can have difficulty coping, and symptoms become apparent to others. This phase can last several months, even with treatment. Increased support and additional treatment or hospitalization may be required.

Reslience (ppt)

Adaptation Ability to access resources to promote well-being Optimism Mastery Competence ^Pts w/ mental illness often feel like they lack mastery and competence

Wellstone-Domenici Parity Act

Added substance abuse --- was enacted in 2008 for group health plans with more than 50 employees. The law required that any plan providing mental health coverage must do so in a manner that is functionally equivalent or on par with coverage of other health conditions. This parity pertains to deductibles, copayments, coinsurance, and out-of-pocket expenses, as well as treatment limitations (e.g., frequency of treatment and number/frequency of visits).

first generation antipsychotics (ppt)

Advantage: tx. positive symptoms, less costly than 2nd generation, decreased risk metabolic syndrome Disadvantages: do not address negative symptoms, side effects: Anticholinergic (ACh) side effects- dry mouth, urinary retention/hesitancy, constipation, blurred vision, photosensitivity, dry eyes, sexual dysfunction Tardive dyskinesia Weight gain, sexual dysfunction, endocrine disturbances Hypotension and postural hypotension How would you manage postural hypotension? EPS--blockage of D2 receptors in motor centers Acute dystonia Akathisia Pseudoparkinsonism --- Typical Costly, but effective against positive symptoms. Does not impact negative symptoms at all. Weight gain and sexual function are big side effects. Akithisia= rapid, rapid movements

Affective symptoms: Symptoms involving emotions and their expression.

Affective symptoms involve an altered experience and expression of emotions. Mood may be unstable, erratic, labile (changing rapidly and easily), or incongruent (not what would be expected for the circumstances). A serious affective change often seen in schizophrenia is comorbid major depressive disorder. Depression may occur as part of a shared inflammatory reaction affecting the brain, or it may simply be a reaction to the stress and despair that can come from living with a chronic illness. Depression may signal an impending relapse, further impair functioning, and increase risk of substance use disorders. Most importantly, depression puts people at increased suicide risk.

Statutes for reporting child and older adult abuse

All 50 states and the District of Columbia have child abuse reporting statutes. Although these statutes differ from state to state, they generally include a definition of child abuse, a list of persons required or encouraged to report abuse, and the governmental agency designated to receive and investigate the reports. Most statutes include civil penalties for failure to report. Many states specifically require nurses to report cases of suspected abuse. There is a conflict between federal and state laws with respect to child abuse reporting. This conflict occurs when the healthcare professional discovers child abuse or neglect during the suspected abuser's alcohol or substance use treatment. Federal laws and regulations governing confidentiality of patient records, which apply to almost all drug abuse and alcohol treatment providers, prohibit any disclosure without a court order.

Admission Procedures

All admissions are based on several fundamental guidelines: • Neither voluntary admission nor involuntary commitment determines a patient's ability to make informed decisions about personal healthcare. • Care providers establish that a well-defined psychiatric problem exists based on current illness classifications in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association [APA], 2013). • The illness and its symptoms should result in an immediate crisis situation and other less-restrictive alternatives (i.e., outpatient care) are inadequate or unavailable. • There is a reasonable expectation that the hospitalization and treatment will improve the presenting problems. You are encouraged to become familiar with the laws in your state and provisions for admissions, discharges, patients' rights, and informed consent. The admissions described in the following paragraphs provide a general overview of the standards and process.

Alterations in perception

Alterations in perception involve errors in how one interprets perceptions or perceives reality. The most common perceptual errors are hallucinations. Hallucinations occur when a person perceives a sensory experience for which no external source exists (e.g., hearing a voice when no one is speaking). Types of hallucination include the following. • Auditory: Hearing voices or sounds • Visual: Seeing people or things • Olfactory: Smelling odors • Gustatory: Experiencing tastes • Tactile: Feeling bodily sensations (e.g., feeling an insect crawling on one's skin)

Alterations in speech= textbook

Alterations in speech Unusual speech patterns are common in schizophrenia. , associative looseness, Word salad Clang association Neologisms

Positive Symptoms--thought alterations:

Altered reality testing- thinking not based in reality *Delusions*--false, fixed beliefs, cannot reason with them, experienced by 75% individuals with schizophrenia, persecutory, grandiose, religiosity Can you provide examples? How would you respond? See text p.206 *Concrete thinking*--inability to abstract, assess through proverbs, difficult to comprehend world

Inpatient Care Settings: State Psychiatric Hospitals

Although the quality of care in state hospitals has improved dramatically, today's state-operated psychiatric hospitals are an extension of what remains of the old system. The clinical role of state hospitals is to serve the most seriously ill patients. However, this role varies widely, depending on available levels of community care and on payments by state Medicaid programs. In some states, these hospitals primarily provide intermediate treatment for patients unable to be stabilized in short-term general hospital units and long-term care for individuals judged too ill for community care. In other states, the emphasis is on acute care that is reflective of gaps in the private sector, especially for the uninsured or for those who have exhausted limited insurance benefits. In most states, state hospitals provide forensic (court-related) care and monitoring as part of their function. The state or county system also advises the courts as to a defendant's sanity. In some criminal cases, defendants may be judged to have been so ill when they committed the criminal act that they cannot be held responsible but instead require treatment. These judgments are termed "not guilty by reason of insanity" (NGRI). One tragic example is that of Andrea Yates, the Texas woman who, in 2001, drowned her five young children under the delusional belief she was saving them from their sinfulness. She was found NGRI and was committed to a Texas state psychiatric facility.

paranoia

An irrational fear, ranging from mild (being suspicious, wary, guarded) to profound (believing irrationally that another person intends to kill you). Fear may result in dangerous defensive actions, such as harming another person before that person can harm the patient.

Epidemiology of Mental Disorders (ppt)

Annually 1 in 4 adults have a mental disorder in the US 46% adults meet criteria for psychiatric disorder in a lifetime Often comorbid disorders Leading cause of disability Incidence Prevalence See text p. 9-10

Anticholinergic toxicity vs NMS

Anticholinergic toxicity= very similar SE. HYPERPYREXIA WITHOUT DIAPHORESIS NMS= hyperpyrexia WITH diaphoresis --- ^I feel in my gut that this will be a test question. It was emphasized super hard

Pharmacological Therapies (ppt)

Antipsychotic medications •First-generation •Second-generation •Third-generation Injectable antipsychotics •Short-acting •Long-acting

Pharmacological Therapies (textbook)

Antipsychotics in general: used to treat psychotic disorders such as schizophrenia. The first of these medications became available in the 1950s. Until the late 1960s, had emotional and financial costs to patients, families, and society. Antipsychotic drugs at last provided symptom control and allowed most patients to live and be treated in the community. It usually takes 2 to 6 weeks for antipsychotic drugs to become effective. Antipsychotics are not addictive but should be discontinued gradually to minimize a discontinuation syndrome, whose symptoms include dizziness, nausea, tremors, insomnia, electric shock-like pains, and anxiety. Antipsychotic agents are unlikely to be lethal in overdose. A lesser-known risk of all antipsychotic medications, due to dopamine blockade or sedation, is impaired swallowing. This may cause drooling and the risk of choking. Also, patients taking these medications are at increased fall risk due to orthostatic (postural) hypotension, sedation, and gait impairment.

Side effects of second-generation antipsychotics

As is the case with first-generation antipsychotics, second-generation antipsychotics can cause sedation, sexual dysfunction, seizures, and increased mortality in older adults with dementia. However, most drugs in this classification are less likely to cause tardive dyskinesia or significant EPSs. Although they have the same potential side effects as the first-generation antipsychotics, second-generation antipsychotic side effects are usually fewer, milder, and better tolerated. All second-generation antipsychotics carry a risk of metabolic syndrome, which includes weight gain (especially in the abdominal area), dyslipidemia, increased blood glucose, and insulin resistance. Metabolic syndrome is a significant concern and increases the risk of diabetes, certain cancers, hypertension, and cardiovascular disease, making its prevention an important role for nurses. Metformin (Glucophage), an anti-diabetic medication, has shown promise in reducing antipsychotic weight gain in children, adolescents, and adults. Some second-generation antipsychotics also have antidepressant properties and are FDA approved for adjunctive use in the treatment of major depressive disorder as well bipolar disorder. As with all antidepressants, they carry a theoretical risk of increased suicidality, particularly in adolescents. Other potentially dangerous second-generation antipsychotic side effects include anticholinergic toxicity, neuroleptic malignant syndrome, and prolongation of the QT interval.

Future issues for psychiatric mental health nursing: An Aging Population

As the number of older adults grows, the prevalence of Alzheimer's disease and other neurocognitive disorders requiring skilled nursing care in inpatient settings is likely to increase. Healthier older adults will need more services at home, in retirement communities, or in assisted living facilities. Psych nurses will be on the forefront in managing care for older adults.

assault

Assault is the intentional threat designed to make another person fearful that you will cause that person harm --- Verbal threats such as "You'll never get out of here" or pretending to hit a patient are both examples of assault that can occur in a healthcare setting. Assault can even occur in the context of workplace bullying.

Outpatient settings: Assertive Community Treatment

Assertive community treatment (ACT) is an intensive type of case management developed in the 1970s in response to the hard-to-engage, community-living needs of people with serious and persistent psychiatric symptoms. Due to the severity of their symptoms, they are often unable or unwilling to participate in traditional forms of treatment. As a result, this population has unnecessary and expensive repeat hospitalizations for services such as emergency room and inpatient care. ACT teams work intensively with patients in their homes or in agencies, hospitals, and clinics—whatever settings patients find themselves in. The ACT concept takes into account that people need support and resources after 5 p.m. Therefore, teams are on call 24 hours a day. ACT teams are multidisciplinary and typically composed of psych nurses, social workers, psychologists, advanced practice registered nurses, and psychiatrists. One of these professionals (often the registered nurse) serves as the case manager and may have a caseload of patients who require visits three to five times per week. An APN or a psychiatrist usually supervises the case manager. Length of treatment may extend to years until the patient is more stabilized or ready to accept transfer to a more structured site for care.

Affective Symptoms

Assessment for depression is crucial WHY? May herald impending relapse Increases substance use D/O Increases suicide risk Further impair functioning

Assessment guidelines - areas to assess (ppt cont.)

Assessment: Based on observation, interview (primary and secondary) Mental status exam Physical exam Lab work Imaging if indicated Therapeutic communication and nurse-patient relationships Have you seen an assessment conducted?

In the unit Mr. Oswald's paranoia continues and he becomes agitated and threatens to assault another staff person. He tells you, "You're the only one I think I can trust. But can I? Are you going to take their side?" Audience Response Question Select the best initial intervention for Mr. Oswald at this point. A. Say, "If you do not calm down, seclusion will be needed." B. Address him with simple directions and a calming voice. C. Help him focus by rubbing his shoulders. D. Offer him a dose of antipsychotic medication.

B. Address him with simple directions and a calming voice. Ex: Priority-> Least to most invasive

Audience Response Question: Which patient behavior is a criterion for mechanical restraint? A. Screaming profanities B. Assaulting a staff person C. Refusing a medication dose D. Throwing a pillow at another patient

B. Assaulting a staff person Explanation: Danger to others; If D was something heavy, the question would be a SATA

Audience Response Question: Finally, Mr. Oswald is restrained. As his nurse, what is your first priority? A. Debrief the patient B. Ensure the patient's safety C. Administer a sedating medication D. Obtain an order from the health care provider

B. Ensure the patient's safety Explanation: Maslow; Safety is priority

Levels of nursing practice- Basic Level

Basic level RNs are qualified to work in most any general or specialty area. The psychiatric-mental health registered nurse (PMH-RN) is a nursing graduate who possesses a diploma, an associate degree, or a baccalaureate degree and chooses to work in the specialty of psychiatric-mental health nursing. At the basic level, nurses work in various supervised settings and perform multiple roles, such as staff nurse, case manager, home care nurse, etc. After 2 years of full-time work, 2000 clinical hours in a psych setting, and 30 hours of CE in psych nursing, a baccalaureate-prepared nurse may take a certification examination administered by the ANCC (part of ANA), to demonstrate clinical competence in psych nursing. After passing the exam, a board-certified credential is added to the RN title, resulting in RN-BC.

Prodromal

Before acute symptoms of schizophrenia occur, people may experience mild changes in thinking, reality testing, and mood. Speech and thoughts may be odd, and anxiety, obsessive thoughts, and compulsive behaviors may present. Concentration, school or job performance, and social functioning can deteriorate. The person may feel "not right" or that "something strange" is happening. Symptoms typically appear 1 to 12 months before the first full episode of schizophrenia. Early assessment is key to improving the prognosis for individuals with schizophrenia. Reducing risk factors (such as high levels of stress or substance abuse), coupled with enhancing social and coping skills, can reduce the risk of developing schizophrenia in biologically vulnerable people.

Outpatient settings: Community Mental Health Centers

Beginning in the 1960s, patients with severe mental illness were diverted from state psychiatric hospitals to community mental health centers. Since that time, these centers have become the mainstay for those who lack funding for mental healthcare. They offer free or low-cost sliding scale care. Community mental health centers provide emergency services, community/home-based services, and outpatient services. Common treatments include medication prescription and administration, individual therapy, psychoeducational and therapy groups, family therapy, and dual-diagnosis (mental health and substance use) treatment. A clinic may also be aligned with a structured program that offers rehabilitation, vocational services, and residential services. Some community mental health centers have an associated intensive psychiatric case management service to assist patients in finding housing or obtaining entitlements. Community mental health centers also utilize multidisciplinary teams. Psych nurses are key members of these teams, providing med administration and mental health education to help individuals continue treatment and reach an optimal level of functioning. Advanced practice psych nurses conductpatient intakes, psychotherapy, and medication management.

Audience Response Questions: After a suicide attempt, Edgar tells the nurse, "I need my belt to keep my pants up. They keep falling down." Which response should the nurse provide? A. "Your belt is locked in the business office for safekeeping, along with all your other valuables." B. "For safety reasons, hospitalized clients are not allowed to keep certain personal possessions." C. "I cannot provide your belt, but I will help you get some pants with an elastic waistband." D. "I will ask the psychiatric technician to get your belt for you." See Canvas Link for NYS Office of Mental Health Patient Rights

C. "I cannot provide your belt, but I will help you get some pants with an elastic waistband."

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

C.An individual with bipolar disorder, manic phase, who has not eaten in 4 days Explanation: Hasn't eaten in four days-> Danger to self

Case Study/Audience Response Question: During assessment, Eric has trouble staying on topic, zipping rapidly from one thought to the next, making it hard to follow what he's trying to say. Which speech disturbance is he exhibiting? A.Pressured speech B.Circumstantiality C.Flight of ideas

C.Flight of ideas

Case Study/Audience Response Question: Eric agrees to see a psychiatrist and an initial assessment and history indicate that he has only been experiencing some mild changes in his thinking and mood for about a month—ever since returning from the winter holiday. The examiner confirms that his speech is sometimes disorganized and his ability to concentrate and study is diminished from his previous long standing as a strong student. Given the evidence we have so far, if Eric has schizophrenia, which is suspected, which phase is he most likely experiencing? A.Acute B.Residual C.Prodromal D.Stabilization

C.Prodromal

Capacity vs competency

Capacity= the ability to make a decision Competency= the ability to carry out that decision -- everyone is deemed competent until a psychologist determines otherwise

Inpatient Care Settings: Crisis Stabilization/Observation Units

Care models that prioritize rapid stabilization and short length of stay have become more prevalent in medical and psychiatric settings. Overnight short-term observation, often 1 to 3 days, is designed for individuals who have symptoms that are expected to remit in 72 hours or less. This observation is also helpful for individuals who have a psychosocial stressor that can be addressed in that timeframe, maximizing their stability and allowing them to rapidly return to a community treatment setting.

Future issues for psychiatric mental health nursing: Educational Challenges

Caring for more acutely ill patients. In the 1980s, it was common for patients who were depressed and suicidal to have insurance coverage for approximately 2 weeks. Currently, patients are lucky to be covered for 3 days, if they are covered at all. This means that nurses need to be more skilled and be prepared to discharge patients for whom the benefit of their care will not always be evident. Providing educational experiences for nursing students is challenging as a result of this level of acute care and also due to the declining inpatient populations. Clinical rotations in general medical centers are becoming more difficult to obtain. Difficult to secure rotations in state psych hospitals, VA facilities, and community settings. Community psychiatric settings also provide students with valuable experience, but the logistics of placing and supervising students in multiple sites is also a challenge. Some schools have established integrated rotations that theoretically allow students to work outside the psychiatric setting with patients who have psychiatric disorders. For example, a student may provide care for a person with major depressive disorder on an orthopedic floor. Some faculty are concerned that without serious commitment, this type of specialty integration may water down a previously rich clinical experience.

Cognitive Symptoms

Concrete thinking Impaired memory Impaired information processing Impaired executive functioning Anosognosia

Cognitive symptoms include the following:

Concrete thinking is an impaired ability to think abstractly, resulting in interpreting or perceiving things in a literal manner. For example, a nurse might ask what brought the patient to the hospital, and the patient answers "a cab" rather than "a suicide attempt." The meanings of proverbs can be used to assess abstract thought. An abstract interpretation of "The grass is always greener on the other side of the fence" is that we feel that we might be happier given other circumstances. A concrete interpretation could be "That side gets more sun, so it's greener there." Concreteness reduces one's ability to understand and respond to concepts requiring abstract reasoning, such as love or humor. Nurses can assist by communicating in more concrete terms that do not require abstract reasoning. Concreteness, especially when combined with an impaired ability to recognize variations in affect or tone of voice, can also make it difficult to recognize social cues, such as sarcasm. A patient who had forgotten his wallet asked a store clerk if he could pay later for a bag of chips. When the clerk sarcastically replied, "Oh sure, you can pay whenever you want," the patient took this literally. The patient was distressed when police later arrested him for theft despite his protests that he had permission not to pay. Memory impairment primarily affects short-term memory and the ability to learn. Repetition and verbal or visual reminders (cues) may help the patient to learn and recall information. For example, a picture of a toothbrush in the bathroom may serve as a reminder to brush teeth. Impaired information processing can lead to problems such as delayed responses, misperceptions, or difficulty understanding others. Patients may lose the ability to screen out insignificant stimuli such as background sounds or objects in their peripheral vision, leading to overstimulation. Reducing stimulation can be helpful. Impaired executive functioning includes difficulty with reasoning, setting priorities, comparing options, placing things in logical order or groups, anticipating and planning, and inhibiting undesirable impulses or actions. Impaired executive functioning interferes with problem solving and can contribute to inap

Rights Regarding Confidentiality

Confidentiality is an ethical responsibility of healthcare professionals that prohibits the disclosure of privileged information without the patient's consent. Confidentiality of care and treatment remains an important right for all patients, particularly psychiatric patients. Only the patient can waive the legal privilege of confidentiality. Discussions about a patient in public places such as elevators and the cafeteria should be completely avoided. Even if the patient's name is not mentioned, such discussions can lead to disclosures of confidential information and liability for you and the facility. Your clinical paperwork for school should never contain full patient identifiers. The Health Insurance Portability and Accountability Act (HIPAA), enacted in 1996, legally protects the psychiatric patient's right to receive treatment and to have medical records kept confidential. Generally, your legal duty to maintain confidentiality is to protect the patient's right to privacy. According to the 2003 HIPAA Privacy Rule, you may not, without the patient's consent, disclose information obtained from the patient or the medical record to anyone except those persons for whom it is necessary for implementation of the patient's treatment plan. HIPAA also gives special protection to notes taken during psychotherapy that are kept separate from the patient's health information.

implied consent

Consent indicated by a patient's actions; for example, if you approach the patient with a medication in hand, and the patient indicates a willingness to receive the medication, implied consent has occurred. Also if pt is unconscious, implied consent can allow for treatment to be given in an emergency

DSM 5 (from ppt)

DIAGNOSTIC CRITERIA: guidelines for making a dx SUBTYPES: allows for increased specificity; subgroups within a dx; [i.e., major depressive d/o with mixed features] SEVERITY SPECIFIERS: rating of intensity, frequency, duration, sx count; [i.e. major depression, single episode, mild]

Inpatient Care Settings (crisis stabilization, observation units, general, state, private) (ppt)

Crisis Stabilization/Observational Units General Hospital and Private Hospital State Hospital Declining number of beds--Why? ^We have way more outpatient beds now. May not need to be in a state hospital --- Hospitalization is available for the treatment of acute symptoms or safety concerns for patients with mental disorders and emotional crises. In 2014, 2.4 million adult patients with a mental illness were treated in hospitals. The top five mental health diagnoses treated were mood disorders, substance use disorders, neurocognitive disorders, anxiety disorders, and schizophrenia. Admission is commonly reserved for those people who are suicidal, homicidal, or extremely disabled and in need of acute care.

Cultural Diversity

Cultural diversity is steadily increasing in the US. The US Census Bureau notes that the US will have a majority minority population by 2044. Psych nurses will need to increase and maintain their cultural competence. Cultural competence= nurses adjust their practices to meet their patients' cultural beliefs, practices, needs, and preferences.

Culture-Bound Syndromes

Cultures differ not only in their views regarding mental illness but also the types of behavior categorized as mental illness. Culture-bound syndromes seem to occur in specific sociocultural contexts, and people in those cultures easily recognize them. Example: , one syndrome recognized in parts of Southeast Asia is running amok, in which a person (usually a male) runs around engaging in almost indiscriminate violent behavior. In the US and other developed countries such as those in Europe and Australia, anorexia nervosa is recognized as a disorder characterized by voluntary starvation. Until recently, this disorder was unheard of in third-world countries. However, social media may be contributing to the proliferation of anorexia through increased awareness of its existence.

Audience Response Question: Mr. Oswald becomes increasingly agitated, and when you come back from break, you find out he wants to talk to you alone. Your response is to A. Respect his privacy and see him alone. B. Do not speak to him in private; it's time for the team to confront him (calmly) as a group. C. Ask for him to be put in restraints first or take security staff with you. D. Go speak to him in a non-confrontational way, but ensure that there are other staff nearby for backup.

D. Go speak to him in a non-confrontational way, but ensure that there are other staff nearby for backup. Used to be a question on exam, but was pulled out bc people kept picking B.

Positive symptoms--perceptual alterations:

Depersonalization--feeling of things being unreal or different, not part of self, sense self differently Derealization--feeling that the environment has changed Hallucinations--sensory perception with no external stimuli, may involve any of the 5 senses, most common is auditory (approx 60% of individuals experience) Command hallucinations --safety is key Give an example of each type of hallucination Illusion-misinterpretation of a real experience

Restraints and Seclusion (textbook cont.)

Despite strong interventions, patients may progress to violence and require seclusion or restraint. Legally, seclusion and restraint are implemented only when a patient creates a risk of harm to self or others and no less restrictive alternative is available. These measures should never be used for punishment or for the convenience of staff. Seclusion or physical restraint is used only after alternative interventions have been tried. These interventions include verbal interventions, offering an as needed medication, decreasing sensory stimulation, presence of a significant other, frequent observation, or one-on-one observation of the patient. Seclusion refers to "the involuntary confinement of a patient alone in a room, or area from which the patient is physically prevented from leaving." The goal of seclusion is never punitive. ^Rather, the goal of seclusion is safety of the patient and others. Seclusion is less restrictive than restraint and may be helpful in reducing sensory overstimulation. Restraint is defined as "any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely."

Negative Symptoms

Develop over time and most interfere with functioning What areas of an individual's life can negative symptoms impact? Why? The six A's: Anhedonia Avolition Asociality Affective Blunting Apathy Alogia Thought blocking What do each of these mean? Affect- An additional "A" word: Blunted Flat Constricted Inappropriate/incongruent Bizarre

The family of JS asks if you can "force"him to take his medications. How do you respond?

Explanation for both questions: Pts have rights; JS has right to refuse

Exceptions to the Rule

Duty to warn and protect third parties The California Supreme Court in its 1974 landmark decision Tarasoff v. Regents of University of California ruled that a therapist has a duty to warn a patient's potential victim of potential harm. This duty to warn is an obligation to warn third parties when they may be in danger from a patient. This ruling came about as a result of a tragic case. Prosenjit Poddar, a university student who was being counseled at the University of California, was despondent over a rejection by Tatiana Tarasoff, whom he had once kissed. The psychologist notified police verbally and in writing that the young man might pose a danger to Tarasoff. The police questioned the student, found him to be rational, and he promised to stay away from his love interest. Subsequently, he stalked and fatally stabbed Tarasoff 2 months later. This case created much controversy and confusion in the psychiatric and medical communities over issues concerning (1) breach of patient confidentiality and its impact on the therapeutic relationship in psychiatric care and (2) the ability of the therapist to predict when a patient is truly dangerous. The court found the patient-therapist relationship sufficient to create a duty of the therapist to warn the victim. When a therapist determines that a patient presents a serious danger of violence to another, the therapist has the duty to protect that other person. In fulfilling this duty, the therapist may be required to call and warn the intended victim, the victim's family, or the police or to take whatever steps are reasonably necessary under the circumstances.

Managing EPS

EPSs can be minimized by lowering doses of the drug, and they can be prevented by using antipsychotics less liable to cause EPSs. These unusual side effects may diminish over time. Oral antiparkinsonian drugs are also useful, either prophylactically or when EPSs develop. However, antiparkinsonian drugs have their own side effects (e.g., most are anticholinergic). Abuse of some antiparkinsonian drugs, particularly trihexyphenidyl (Artane) but also benztropine (Cogentin) and diphenhydramine (Benadryl), may occur.

Restraints- a team approach

Each team member is trained in the correct use of seclusion and restraint. The team should be organized before approaching the patient so that there is a clear leader and each team member has a role. The team leader is the only person talking to the patient to decrease stimuli. The patient must be given every opportunity to regain control so that the least restrictive method can be used. If restraints are to be used, the patient is informed at this point of the team's intent and the reason for the actions. The team remains calm and acts as quickly as possible. Once the patient is placed in seclusion or restrained, the nurse must get an order from the appropriate healthcare provider. The nurse may also get an order for medication and administer it to the patient. The team leader continues to communicate with the patient in a calm, steady voice indicating decisiveness, consistency, and control.

Assessment Pre-psychotic Phase

Early detection and treatment is crucial Monitor those at risk --who are they? Adherence to treatment

Health teaching and health promotion (textbook)

Education should include the causes, nature, and symptoms of the illness, what to expect, and how it is treated. Patients should be taught ways to cope and control the illness and its symptoms. They should also be taught about medications and side effects, helpful resources, and relapse prevention. This knowledge will help them to become actively involved in the course of their recovery. Ideally, significant others and caregivers are included in teaching. Often, relationships have been stressed by the illness. Significant others may have become critical, controlling, or intrusive. Lack of understanding of the disease and its symptoms can lead others to mistake symptoms such as apathy and poor hygiene as intentionally bad behavior. Teaching significant others how to recognize and respond helpfully to symptoms and how to negotiate and help the patient to achieve needed changes is important.

Future issues for psychiatric mental health nursing (ppt)

Educational Challenges: acuity, placements, coverage and length of stay Demand for Mental Health Professionals: growth of psych workforce not kept pace with demand Aging Population: neurocognitive disorders, home services for older adults Cultural Diversity: cultural competence Technology: genes, telepsychiatry, electronic healthcare Advocacy: patient advocate, confidentiality, reduce stigma, need to be involved on boards and task forces

Patient Protection and Affordable Care Act of 2010

Employers with more than 50 employees must provide health insurance --- Parity laws were a good first step in providing more equitable coverage for mental healthcare. However, they do not require health plans to cover psychiatric care only applied to large insurers. The Patient Protection and Affordable Care Act (ACA) of 2010 improved coverage for most Americans who are uninsured through a combination of expanded Medicaid eligibility (for the very poor) and the creation of Health Insurance Exchanges in the states to serve as a broker to help uninsured consumers choose among various plans. The "insurance mandate" added a requirement that people without coverage obtain it.

Epidemiology

Epidemiology= the quantitative study of the distribution of mental disorders in human populations. Understanding this distribution helps to identify high-risk groups and risk factors associated with illness onset, duration, and recurrence. According to SAMHSA (2020), nearly 52 million adults in the United States experienced a diagnosable mental illness in 2019. MDD is the leading cause of disability worldwide, with more than 300 million people affected. Individuals may have more than one mental disorder or another medical disorder. The presence of two or more disorders is known as comorbidity. They can occur at the same time or in sequence. For example, schizophrenia is frequently comorbid with diabetes due to side effects of antipsychotic medications. The interactions between the illnesses can worsen the course of both. A disease with a short duration such as the common cold tends to have a high incidence (many new cases in a given year) and a low prevalence (not many people suffering from a cold at any given time). Conversely, a chronic disease such as diabetes will have a low incidence because people will be dropped from the list of new cases after the first year (or whatever time increment is being used) and a high prevalence (given the long-term nature of the illness). Lifetime risk data, or the risk that one will develop a disease in the course of a lifetime, will be higher than both incidence and prevalence. 46.4% of all Americans will meet the criteria for a psychiatric disorder in their lifetimes.

Mental Health Laws:

Federal and state legislatures have enacted laws to regulate the care and treatment of people with mental illness. At the state level, mental health laws—or statutes—vary from state to state. Therefore, you are encouraged to review your state's code to better understand the legal climate in which you will be practicing. You can accomplish this by visiting the web page of your state's mental health department or by doing an internet search using the keywords "mental + health + statutes + (your state)." Many of the state laws underwent substantial revision after the landmark Community Mental Health Centers Act of 1963 enacted under President John F. Kennedy that promoted deinstitutionalization of people with mental illness. The changes reflect a shift in emphasis from institutional care to community-based care. There was an increasing awareness of the need to provide people who have psychiatric disorders with humane care that respects their civil rights. Widespread, progressive use of psychotropic drugs in the treatment of mental illness enabled many patients to integrate more readily into the larger community. Additionally, the legal system has adopted a more therapeutic approach to persons with substance use disorders and mental health disorders. There are now drug courts where the emphasis is more on rehabilitation than punishment. Similarly, mental health courts handle criminal charges against people with mental illness by diverting them to community resources to prevent reoffending by, among other things, monitoring medication adherence. Federal legislation providing equality for the people with mental illness with other patients in terms of payments for services from health insurance plans also improves access to treatment. This equal payment is called parity. The Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act, which went into effect in July 2010, and the Affordable Care Act, also enacted in 2010, provide for insurance funding for mental illness

Schizophrenia CT Findings

Findings from brain imaging techniques: • Reduced volume in the right anterior insula (may contribute to negative symptoms) • Reduced volume and changes in the shape of the hippocampus • Accelerated age-related decline in cortical thickness • Gray matter deficits in the dorsolateral prefrontal cortex area, thalamus, and anterior cingulate cortex as well as in the frontotemporal, thalamocortical, and subcortical-limbic circuits • Reduced connectivity among various brain regions • Neuronal overgrowth in some areas, possibly due to inflammation or inadequate neural pruning • Widespread white matter abnormalities (e.g., in the corpus callosum) PET scans also show a lowered rate of blood flow and glucose metabolism in the prefrontal cortex. This part of the brain governs executive functional skills such as planning, abstract thinking, social adjustment, and decision making. Such structural and functional changes may worsen as the disorder continues. Postmortem studies of schizophrenic individuals show a reduced volume of gray matter, especially in the temporal and frontal lobes, and people with the most tissue loss had the worst symptoms.

Long-acting medications/Depot drugs

First Generation: •Haldol Decanoate-every 4 weeks •Fluphenazine decanoate-every 2 weeks Second Generation: •Zyprexa Relprevv-every 2-4 weeks •Invega Sustana-every 4 weeks •Invega Trinza-every 3 months •Risperidone Consta-every 2 weeks •Aripiprazole (Maintena or Aristada)-every 4 weeks

Side effects of first-generation antipsychotics

First-generation antipsychotics are dopamine (D2) antagonists in both limbic and motor centers. Blockage of D2 receptors in motor areas causes extrapyramidal side effects (EPSs), including the following: 1. Acute dystonia—A sudden, sustained contraction of one or several muscle groups, usually of the head and neck. Acute dystonias can be frightening and uncomfortable, but unless they involve muscles affecting the airway, which is rare, they are not dangerous. However, they cause significant anxiety and should be treated promptly. 2. Akathisia—A motor restlessness that causes pacing and/or an inability to stay still or remain in one place. It can be severe and distressing to patients and can be mistaken for anxiety or agitation. These symptoms may lead to mistakenly administering more of the drug that originally caused the akathisia, making it worse. A tardive form can persist despite treatment. 3. Pseudoparkinsonism—A temporary group of symptoms that resemble Parkinson disease: tremor, reduced accessory movements (e.g., arms swinging when walking), gait impairment, reduced facial expressiveness (mask facies), and slowing of motor behavior (bradykinesia).

Why are first generation antipsychotics used less often?

First-generation antipsychotics are used less often because of their minimal impact on negative symptoms and their generally higher level of challenging side effects. However, they are as effective in treating positive symptoms as newer antipsychotics and are much less expensive than some second-generation antipsychotics. For patients untroubled by their side effects, first-generation antipsychotics can remain an appropriate choice, especially when cost or the risk of a metabolic syndrome, which is more common with the newer drugs, is a concern.

First-generation antipsychotics (textbook)

First-generation antipsychotics, also known as typical antipsychotics or neuroleptics, comprise the oldest and hence first generation of antipsychotics. They are dopamine (D2 receptor) antagonists. Examples include haloperidol (Haldol) and chlorpromazine (Thorazine). The first-generation antipsychotics work primarily by reducing positive symptoms (e.g., hallucinations and delusions) but have little effect on negative symptoms.

Documentation of Care- Medical Records as Evidence

From a legal perspective, the medical record is a recording of data and opinions made in the normal course of the patient's hospital care. Courts consider it good evidence because it is presumed to be true, honest, and untainted by memory lapses. Accordingly, the medical record finds its way into a variety of legal cases for a variety of reasons.

Biological factors of schizophrenia

Genes and epigenetics play a big role in schizophrenia --- Genetic About 80% of the risk of schizophrenia is genetic. Over 100 loci in the human genome are associated with an increased risk of schizophrenia. Concordance rates—that is, the percentage of twins each having the disorder—are about 50% for identical twins and about 15% for fraternal twins. Evidence suggests that multiple genes on different chromosomes interact with one another in complex ways to create vulnerability for schizophrenia. Epigenetic factors include toxins and psychological trauma that affects the expression of genes. Even psychological trauma in a parent or grandparent may cause epigenetic changes that increase vulnerability, and this increased risk can be passed on to one's descendants. Neurobiological Neurotransmission The first antipsychotic drugs blocked the activity of dopamine-2 (D2) receptors in the brain and reduced symptoms such as hallucinations and delusions. Symptom reduction suggested that dopamine plays a significant role in psychosis. However, because medications that reduce dopamine activity do not alleviate all the symptoms of schizophrenia, it seems likely that other neurotransmitters or other factors are involved as well. Amphetamines and cocaine enhance dopamine activity and can induce psychosis or precipitate schizophrenia. Almost any drug of abuse, particularly marijuana, can increase the risk of schizophrenia in biologically vulnerable individuals. Newer antipsychotics block serotonin (5-hydroxytryptamine 2A, or 5-HT2A) and dopamine, which suggests that serotonin may play a role in schizophrenia as well. Phencyclidine (PCP) induces a state that resembles schizophrenia, suggesting a possible role of glutamate in the pathophysiology of schizophrenia. Glutamate, dopamine, and serotonin act synergistically in neurotransmission; thus, glutamate may also play a role in causing psychosis. Neurotransmission by gamma-aminobutyric acid (GABA), another calming neurotransmitter, is also altered in schizophrenia. Acetylcholine, active in the muscarinic system, may also play a role in psychosis.

Future issues for psychiatric mental health nursing: Science, Technology, and Electronic Healthcare

Genetic mapping from the Human Genome Project has resulted in a steady stream of research discoveries concerning genetic markers implicated in a variety of psychiatric illnesses. This information could be helpful in identifying at-risk individuals and in targeting medications specific to certain genetic variants and profiles Despite some concerns (see next card), the next decade holds great promise in the diagnosis and treatment of psychiatric disorders, and nurses will be central as educators and caregivers. Scientific advances through research and technology are certain to shape psych nursing practice. MRI research, in addition to comparing healthy people to people diagnosed with mental illness, is now focusing on the development of preclinical profiles of children and adolescents. The hope of this type of research is to identify people at risk for developing mental illness, which allows earlier interventions to try to decrease impairment. Electronic healthcare services provided from a distance are gaining wide acceptance. The internet allows people to be their own advocates. In 2020, the coronavirus pandemic resulted in many psychiatric professionals adopting telehealth. The pandemic will likely alter the healthcare landscape for the foreseeable future. Telepsychiatry through audio and visual media is an effective way to reach underserved populations and those who are homebound. Providing healthcare in this private setting also destigmatizes the experience by offering greater privacy. It allows for assessment and diagnosis, medication management, and even group therapy. Psychiatric nurses may become more active in developing websites for mental health education, screening, or support, especially to reach geographically isolated areas. Many health agencies hire nurses to staff help lines or hotlines, and as provision of these cost-effective services increases, so too will the need for bilingual resources.

Acute Phase-Interventions--Therapeutic milieu:

Goals--safety and structure Practice social skills, stress reduction, symptom management Groups and activities--creative arts, recreation, & communication

Implementation

Ideally, intervention begins before any sign of escalation. It is important to develop a relationship of trust with the patient by having numerous brief, nonthreatening, nondirective interactions (e.g., talking about the weather, sports, or something of interest to the patient).

List of disorder categories in the DSM-5

Neurodevelopmental Disorders, Schizophrenia Spectrum Disorders, Bipolar and Related Disorders, Depressive Disorders, Anxiety Disorders, Obsessive-Compulsive Disorders, Trauma and Stressor-Related Disorders, Dissociative Disorders, Somatic Symptom Disorders, Feeding and Eating Disorders, Elimination Disorders, Sleep-Wake Disorders, Sexual Dysfunctions, Gender Dysphoria, Disruptive, Impulse Control, and Conduct Disorders, Substance-Related and Addictive Disorders, Neurocognitive Disorders, Personality Disorders, Paraphilic Disorders, Other Disorders

General Interventions

If you can attempt to determine what the patient is feeling, you have already begun to intervene. Frequently, you can accomplish this by telling the patient that you are concerned and want to listen. It is essential to acknowledge the patient's needs, regardless of whether the expressed needs are rational or possible to meet. It is equally as important to clearly state your expectations for the patient's behavior: "I expect that you will stay in control." However, patient behavior may escalate quickly, or the patient may mask early signs of distress. Nurses may be distracted and miss those early signs. Some agitated patients may be so acutely upset that they do not respond to early nursing interventions. In these situations, the problem with anger may not be resolved before the risk for violence arises. Pharmacological intervention, seclusion, or restraint may be necessary to ensure the safety of patients and staff. Approach the patient in a controlled, nonthreatening, and caring manner. If you are experiencing fear, you may find that this is quite challenging. Maintaining a calm exterior while your interior is in an upheaval requires considerable self-discipline and will come with experience. Patients who are at risk for violence need much more personal space than those who are not. Allow the patient enough space so that you are perceived as less of a threat. Always stay approximately 1 foot farther than the patient can reach with arms or legs. Be sure you have left yourself an escape route if necessary; that is, make sure that the patient is not between you and the door. When anger is escalating, a patient's ability to process decreases. It is important to speak to the patient slowly and in short sentences using a low and calm voice. Never yell but continue to model controlled behavior. Use open-ended statements and questions such as "You think people are treating you unfairly?" rather than challenging statements such as "What is going on right now?" Avoid ending statements with "Okay?" because it may give the impression that choices exist. Find out what is behind the angry feelings and behaviors. Identify the patient's options, and encourage the individual to assume responsibility for choices made. Yo

Positive symptoms--alterations in behavior:

Impaired boundaries--intrusive, body space Catatonia--change in rate and amount of behavior, most common is catalepsy Motor retardation or agitation Stereotyped behaviors--repetitive motor behavior, with no purpose Waxy flexibility--maintenance of a posture (often in catatonia) Echopraxia--mimic others' movements Negativism-- does opposite or fails to do what is asked of him/her Impaired impulse control-reduced ability to control one's impulses Posturing--unusual expressions or positioning

Orders and Documentation with Restraint and Seclusion

In an emergency, a nurse may place a patient in seclusion or restraint but obtains a written or verbal order as soon as possible thereafter. Orders for restraint or seclusion are never written as an as needed or as a standing order. These orders to manage self-destructive or violent behavior may be renewed for a total of 24 hours with limits depending upon the patient's age. Adults 18 years or older are limited to 4 hours, children and adolescents 9 to 17 years old are limited to 2 hours, and children under 9 years old have a 1-hour limit. After 24 hours, a physician or an advanced practice professional responsible for the patient's care will personally assess the patient. Restraint or seclusion is discontinued as soon as safer and calmer behavior begins. Once a patient is removed from restraints or seclusion, a new order is required to reinstitute the intervention. The nurse should carefully document restraint or seclusion in the treatment plan or plan of care. The documentation should include the specific behaviors leading to restraint or seclusion, and the time the patient is placed in and released from restraint. The patient is monitored through continuous observation. Patients in restraints are assessed at regular and frequent intervals, such as every 15 to 30 minutes for physical needs (e.g., food, hydration, and toileting), safety, and comfort. Each of these assessments requires documentation. While in restraints, patients require protection from harm since they are in a vulnerable state.

defamation of character

In the context of healthcare, defamation of character occurs when a provider makes a false statement that causes some degree of harm, usually to the reputation of the patient. Defamation includes slander (verbal), such as talking about patients in the lunchroom with others around, and libel (printed), where written information about the patient is shared, intentionally or unintentionally, with people outside the professional setting

Promoting recovery and continuation of treatment

In the not-too-distant past, treatment for mental illness consisted of patients being told what medications to take and what treatments to accept. Good patients were those who were compliant. A newer model of recovery promotes self-involvement in care. Recovery is "a process of change through which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential." Nurses are real assets in supporting patients in the recovery process, especially with medication management. Nurses are in a position to help the patient recognize side effects and be aware of interactions among medications prescribed for both physical illness and mental illness. This knowledge increases the individual's ability to self-advocate. Patient-family education and behavioral strategies, in the context of a therapeutic relationship with the nurse, promote adherence with a medication regimen. Patient-centered care, also referred to as person-centered care, supports values in the recovery model. It is respectful and responsive care that incorporates patients' preferences, needs, and values. This concept is essential for ensuring that the patient's wishes and values are the guiding principle for care management and shared decision making. --- Role of Outpatient nurse: Promoting recovery and continuation of treatment- RECOVERY Model

Mental Health Parity Act

In the past, insurance companies: • Did not cover mental healthcare • Identified yearly or lifetime limits on mental health coverage • Limited hospital days or outpatient treatment sessions • Assigned higher copayments or deductibles In response, advocates fought for parity, a term that refers to equivalence or equal treatment. The Mental Health Parity Act was passed in 1996. This legislation required insurers that provide mental health coverage to offer annual and lifetime benefits at the same level provided for medical/surgical coverage. Unfortunately, by 2000, it was found that although 86% of health plans complied with the 1996 law, 87% of those plans actually imposed new limits on mental health coverage. --- Used to have to pay out of pocket now it is different

Involuntary Commitment

Involuntary commitment, also known as assisted inpatient psychiatric treatment, is a court-ordered admission to a facility without the patient's approval. State laws vary, but they address both the criteria for commitment and the process for commitment. The criteria for commitment are the legal standards under which the court decides whether admission is necessary. These standards include a person who is: 1. Diagnosed with mental illness 2. Posing a danger to self or others 3. Gravely disabled (unable to provide for basic necessities such as food, clothing, and shelter) 4. In need of treatment and the mental illness itself prevents voluntary help-seeking

Stabilization

In this phase, symptoms are stabilizing and diminishing, and there is movement toward a previous level of functioning. This phase can last for months. Care in an outpatient mental health center or a partial hospitalization program may be needed. The person may receive care in a residential crisis center (similar to a mental health unit but based in the community) or a staff-supervised residential group home or apartment.

Maintenance or Residual

In this phase, the condition has stabilized and a new baseline may be established. Positive symptoms (described later) are usually significantly diminished or absent, but negative and cognitive symptoms continue to be a concern. Ideally, recovery with few or no residual symptoms will occur, and the patient is again able to live independently or with family. A pattern of recurrent exacerbations (relapses) separated by periods of reduced or dormant symptoms is common. Some people have one or several episodes and none thereafter. For most patients, however, schizophrenia is a chronic or relapsing disorder that, like diabetes or heart disease, is managed with ongoing treatment.

Guidelines for Use of Mechanical Restraints

Indications for use Legal requirements Documentation Clinical assessments Observation Release procedure Restraint tips --- Last resort; danger to self or others

Risk and protective factors

Individual attributes and behaviors Social and economic circumstances Environmental factors --- Individual attributes: characteristics that are both inborn and learned that make us who we are; managing thoughts and feelings and navigating the everyday pressures of life; the ability to respond to social cues and participate in social activities influences our view of ourselves and how others view us. Biological and genetic factors: Prenatal exposure to alcohol and oxygen deprivation at birth are two examples of biological factors. Genetic factors are huge predictors of mental health and are implicated in nearly every psychiatric disorder Resilience: (to be expanded upon in its own card) Your immediate social surroundings impact personal attributes. The earliest social group, the family, has tremendous effects on developing and vulnerable humans. The family sets the stage in promoting confidence and coping skills or for instilling anxiety and feelings of inadequacy. The social environment extends to schools and peer groups. Socioeconomic status dictates the sort of resources available to support mental health and reduce concerns over basic needs such as food, clothing, and shelter. Educational advancement is a tremendous supporter of mental health by providing opportunities for a satisfying career, security, and economic benefits. Political climate: Access and lack of access to basic needs and commodities such as healthcare, water, safety services, and a strong highway system have a profound effect on community mental health. Socioeconomic policies also impact mental health. For example, in the US, laws have been gradually shifting toward better reimbursement for mental health services. This shift makes it easier to access and improve mental healthcare.

Signs of Mental Illness (textbook)

Individuals may have emotional problems or concerns and experience mild to moderate discomfort and distress. Mild impairment in functioning such as insomnia, lack of concentration, or loss of appetite may be felt. If the distress increases or persists, individuals might seek professional help. Problems in this category tend to be temporary, but individuals with mild depression, generalized anxiety disorder, and attention-deficit disorder may fit into this group. The most severely affected individuals fall into the mental illness portion of the continuum. At this point, individuals experience altered thinking, mood, and behavior. It may include relatively common disorders such as depression and anxiety, as well as major disorders such as schizophrenia. The distinguishing factor in mental illness is typically chronic or long-term impairments that range from moderate to disabling.

Interventions--Hallucinations:

Listen and attempt to understand patient experience Provide reality and convey patient's reality Provide safety measures especially command hallucinations Focus on here and now Distraction techniques Give examples of what you would say to a patient who is talking to him or herself

Prenatal Stressors

Infection during or after pregnancy increases the risk of mental illness. Other factors associated with an increased risk of schizophrenia include a father above 35 years of age at the child's conception and being born during late winter or early spring.

Guidelines for Electronic Documentation

Informatics provides the healthcare system with essential technology to manage knowledge, communicate, reduce error, and facilitate decision making. However, electronic record keeping creates challenges for protecting the confidentiality of the records of psychiatric patients. Sensitive information regarding treatment for mental illness can adversely impact patients seeking employment, insurance, and credit. Federal laws address concerns for the privacy of patients' records and provide guidelines for agencies that use electronic documentation. Only staff members who have a legitimate need to know about the patient are authorized to access a patient's electronic medical record. There are penalties, including termination of employment, if a staff member enters a record without authorization. You are responsible for all entries into records using your password. As a result, your password should remain private and should be changed periodically. In the event a documentation error is made, the various systems allow specific time frames to make medical record corrections. Institutions should encourage documentation methods that improve communication between care providers. Courts assume that nurses and physicians read each other's notes on patient progress. They also assume that if care is not documented, it did not occur. Your notes may serve as a valuable memory refresher if the patient sues years after the care is provided.

Right to Informed Consent

Informed consent is a legal term that means the patient has been provided with basic information regarding risks and benefits, and alternatives to treatment. The person must be voluntarily accepting the treatments. While registered nurses routinely provide education about treatment, typically it is the prescriber who is legally responsible for securing informed consent. The principle of informed consent is based on a person's right to self-determination as described in the landmark case of Canterbury v. Spence (1972). Consent is secured for surgery, electroconvulsive treatment, or the use of experimental drugs or procedures. Patients have the right to refuse participation in experimental treatments or research and the right to voice grievances and recommend changes in policies or services offered by the facility, without fear of punishment or reprisal.

Outpatient settings: Intensive Outpatient Programs and Partial Hospitalization Programs

Intensive outpatient programs (IOPs) and partial hospitalization programs (PHPs) function as intermediate steps between inpatient and outpatient care. The primary difference between the two groups is the amount of time that patients spend in them. PHPs meet Monday through Friday and have longer hours (about 6 hours because they are "partially hospitalized"), while IOPs meet anywhere from three to five times each week for sessions lasting around 3 hours. They provide structured activities along with nursing and medical supervision, intervention, and treatment. These programs tend to be located within general hospitals, psychiatric hospitals, or community mental health facilities. A multidisciplinary team facilitates group therapy, individual therapy, other therapies (e.g., art and occupational), and medication management. Coping strategies learned during the program can be applied and practiced between sessions, then later explored and discussed. Patients admitted to IOPs and PHPs are closely monitored in case of a need for readmission to inpatient care.

Invasion of privacy

Invasion of privacy in healthcare has to do with breaking a person's confidences or taking photographs without explicit permission.

Alterations in behavior

Involve changes in the speed of movement and behaviors that are illogical or inappropriate. Behavioral alterations include the following: • Catatonia: A pronounced increase or decrease in the rate and amount of movement. Excessive motor activity is purposeless. The most common form of catatonia is when the person moves little or not at all. Muscular rigidity, or catalepsy, may be so severe that the limbs remain in whatever position they are placed. Persistent catatonia may contribute to exhaustion, pneumonia, blood clotting, malnutrition, or dehydration. • Motor retardation: A pronounced slowing of movement. • Motor agitation: Excited behavior, such as running or pacing rapidly, often in response to internal or external stimuli. It can put the patient at risk (e.g., from exhaustion, by running into traffic) or put others at risk (e.g., by being knocked down). • Stereotyped behaviors: Repetitive behaviors that do not serve a logical purpose. • Echopraxia: The mimicking of movements of another. • Negativism: A tendency to resist or oppose the requests or wishes of others. • Impaired impulse control: A reduced ability to resist one's impulses. Examples include interrupting others or throwing unwanted food on the floor. It can increase the risk of assault. • Gesturing or posturing: Assuming unusual and illogical expressions (often grimaces), posture, or positions. • Boundary impairment: An impaired ability to sense where one's body or influence ends and another's begins. For example, a patient might stand too close to others or might drink another person's beverage, believing that because the beverage is near, it is the patient's.

Psychoeducational strategies for patient and family/Health teaching and health promotion/prognosis (ppt)

Involve patient and family Symptom management Relapse prevention Stress management Support groups - NAMI Substance use avoidance Healthful lifestyle-nutrition, sleep, hygiene Good prognosis- acute onset, high baseline functioning Less positive prognosis--younger age onset, longer duration between symptoms and treatment, more negative symptoms Is this acute? Is this the first time we are seeing this?= better prognosis Has this been going on for like a year; did you get treated, go home, go off meds and decompensate?= worse prognosis

Confidentiality and Social Media

It is essential that people working in mental health understand the legal implications of social media and the internet. The internet is not confidential and is open to legal subpoenas. Some mental health workers have blogged about patients, thinking that they had disguised the identity. People in these posts have been identified and lawsuits have followed. Even what seems to be a fairly innocent electronic transmission can be disastrous. Consider the nursing students in Kansas who posted a picture of a placenta on social media. Standing next to the placenta were four smiling nursing students wearing lab coats and surgical gloves. What they considered to be victimless fun resulted in these students being expelled from nursing school. Fortunately for them, a federal judge ruled for reinstatement of one of the students. Subsequently, the other three were also allowed back in school.

Right to Refuse Treatment

Just as patients have the right to receive treatment, they also have the right to refuse it. Patients may withhold consent or withdraw consent at any time, even if they are involuntarily committed. Patients can also retract consent previously given, and care providers must respect this whether it is a verbal or written retraction. However, the patient's right to refuse treatment with psychopharmacological drugs has been debated in the courts. This debate is based partly on the issue of patients' mental ability to give or withhold consent to treatment and their status under the civil commitment statutes. Early court cases—initiated by patients in state psychiatric hospitals—considered medical, legal, and ethical issues such as basic treatment problems, the doctrine of informed consent, and the bioethical principle of autonomy.

Interventions: Psychosocial:

Listen to patient--concerns, feelings State safety expectations Anxiety is contagious! Stay calm, simple language Space, escape route Limit choices Decrease stimuli --- If someone comes in anxious, it spreads like wildfire! Decreasing stimuli even be moving other pts out of the day room (context: for when the pt won't leave and is acting up, can move the other pts instead)

Restraints & Seclusion: (ppt)

Least restrictive environment Orders and Documentation Safety and Assessment --- "Fragrantly psychotic"= pt's are verbally in a state, but they are not a danger to themselves or others. Max time in restraints is 4 hrs. HIPAA: we don't tell people that pts are on the unit --- psychiatric advance directives can only be made when not in the hospital ^danger to self or others will override this (e.g. if they have an AD saying "no restraints" but they are violent, it will be overridden)

Self-Assessment

Like patients, nurses have their own histories. The nurse's ability to intervene effectively depends on self-awareness of strengths, needs, concerns, and vulnerabilities. Without this awareness, nursing interventions can end up being impulsive or emotion-based responses. Self-awareness includes recognizing choice of words and tone of voice, as well as nonverbal communication through body posture and facial expressions.

Liver impairment may also occur during antipsychotic therapy

Liver impairment may also occur during antipsychotic therapy, particularly with first-generation agents. Second-generation drugs also lead to serum enzyme elevations but rarely to injury or jaundice. Liver impairment usually occurs in the first weeks of therapy. Monitoring of liver function values is essential. Signs of liver problems include jaundice, abdominal pain, ascites, vomiting, lower extremity edema, dark urine, pale or tar-colored stool, and easy bruising. The patient may complain of itchy skin, chronic fatigue, nausea, and decreased appetite.

Continuum of care

Locked acute inpatient unit Primary care provider Fluid, can go in both directions --- A continuum of care model helps differentiate between levels of acuity within treatment settings. What if you/your friend/a family member needed psychiatric treatment or care? The continuum of psychiatric-mental healthcare may help you to decide what to do. Movement along the continuum is fluid and can go in either direction. For example, patients discharged from the most acute levels of care (e.g., hospitalization) may need intensive services to maintain their initial gains. Failure to follow up with outpatient treatment increases the likelihood of rehospitalization and other adverse outcomes. Patients may also reverse direction on the treatment continuum. If symptoms do not improve, professionals from a lower-intensity service may refer the patient to a higher level of care to prevent decompensation (deterioration of mental health) and hospitalization.

Positive Symptoms--speech alterations:

Looseness of association--thinking is illogical, difficult to follow, disjointed, loosely connected Clang associations--using words that rhyme or similar sound rather than meaning Word salad--jumbled words, meaningless to listener, highly disorganized Neologisms--made-up words, have meaning to individual Echolalia- pathological repeating of another's words Religiosity--preoccupied with religion Magical thinking--belief one's actions affect others Paranoia--irrational fear of others, varies in severity Circumstantiality--unnecessary and overuse of details, but gets to the point Tangentiality--going on tangents/off-topic in conversation, never reaches the point Alogia (poverty of speech)--reduced volume or spontaneity in speech Rapid or pressured speech-urgent/intense speech, reluctant to allow others to speak Flight of ideas--move rapidly one thought to next, difficult to follow the conversation Thought blocking-reduced or abrupt stoppage of thoughts Thought insertion--feelings one's thoughts are not their own (they are inserted) Thought deletion--belief one's thoughts missing or taken Illogical or bizarre thinking Inattentiveness--easily distracted

Seclusion (cont.)

MUST BREAK SECLUSION Q. 2 HRS MUST OBSERVE & DOCUMENT AT LEAST Q. 15 MINS PHYSICAL NEEDS [TOILETING, FOOD, HYGIENE] MUST BE MET MONITOR BP

Fidelity

Maintaining loyalty and commitment to the patient and doing no wrong to the patient (e.g., maintaining expertise in nursing skill through continuing nurse education).

Prevalence (Examples) (ppt)

Major depressive disorder: Leading cause of disability in U.S. at 6.7% prevalence over 12 months Schizophrenia: 1.1% prevalence over 12 months; affects men and women equally Panic disorder: 2.7% prevalence over 12 months; typically begins in adolescence; 1 in 3 develop agoraphobia Generalized anxiety: 3.1% prevalence over 12 months; risk is highest between childhood and middle age Clinical Epidemiology: Groups treated for specific mental disorders studied for: -Natural history of illness -Diagnostic screening tests Interventions Results used to describe frequency of: -Mental disorders

Interventions-First-generation antipsychotics-EPS:

Management of EPS--lower dose, add antiparkinsonian drug, benzodiazepine for akathisia, generally will develop a tolerance over time Low potency drugs cause increased sedation and high anticholinergic effects, low EPS High potency drugs cause less sedation and anticholinergic effects, more EPS Can you identify at least 2 low potency first generation antipsychotics? Can you identify at least 2 high potency first generation antipsychotics? Text p.212, Table 12-5- be able to identify antipsychotics and their generation class

Mental illness continuum

Mental health and mental illness can be conceptualized as points along a continuum. *On one end of the continuum is mental health.* Well-being is characterized by adequate to *high-level functioning.* No serious impairments in daily functioning. *At the opposite end of the continuum is mental illness.* Individuals may have emotional problems or concerns and experience mild to moderated discomfort and distress. --> Mild impairment in functioning such as insomnia, lack of concentration, or loss of appetite may be felt. --> Mild depression, generalized anxiety disorder, and ADD. --> Mental Illness - experience altered thinking, mood and behavior --- All of us fall somewhere on the mental health-mental illness continuum and experience gradual or sudden shifts. Many people will never experience the mental illness stage. On the other hand, many people who do reach a more severe level of impairment can experience recovery that ranges from a glimmer of hope to leading a satisfying and fulfilling life. People who have experienced mental illness can testify to the existence of changes in functioning.

illusions

Misinterpretations of a real experience. For example, a man sees a coat on a shadowy coat rack and believes it to be a bear

Side Effects (cont.)

NMS usually occurs early in therapy but has also occurred 20 years into treatment. Prompt detection, discontinuation of the antipsychotic agent, management of fluid balance, temperature reduction, and monitoring for complications are essential. Severe neutropenia, though most often associated with clozapine (Clozaril), is also possible with most other antipsychotics. Severe neutropenia is an acute condition involving a dangerously low white blood cell count (neutropenia), which increases the risk of a serious infection. Neutropenia is defined by an ANC of less than 500/μL. Left untreated, this life-threatening condition leads to death, most commonly through bacterial infection of the blood, or septicemia. Monitoring for neutropenia is done as part of the complete blood count throterm-356ugh an ANC. Symptoms of severe neutropenia include signs of infection (e.g., fever, chills, and sore throat) or increased susceptibility to infection. Some individuals have naturally lower levels of ANC. This is referred to as benign ethnic neutropenia. It is most common in those of African descent (about 25% to 50%), some Middle Eastern groups, and other non-Caucasians with darker skin. They are not at greater risk for developing severe neutropenia but should have a baseline ANC before starting clozapine. The Clozapine Risk Evaluation and Mitigation Strategies (REMS) is a mandatory FDA program for prescribers and pharmacies. It calls for the enrollment, education, and certification of prescribers and dispensers who are authorized to administer periodic ANC checks.

Kendra's Law

NY Assisted Outpatient Treatment; Kendra's Law" (§9.60 of the Mental Hygiene Law) mandates mental health services for a small number of individuals who have difficulty engaging in rehabilitation and can pose a risk to themselves or others in the community. The order is granted in civil court. ACT vs AOT= ACT is assertive community treatment, not court ordered. AOT is COURT ORDERED.

echopraxia

The mimicking of movements of another.

Neuroleptic malignant syndrome (NMS) (cont.)

Neuroleptic malignant syndrome (NMS), caused by excessive dopamine receptor blockade, occurs in about 0.2% to 1% of patients who have taken first-generation antipsychotics. It is characterized by reduced consciousness and responsiveness, increased muscle tone (generalized muscular rigidity), and autonomic dysfunction. Although less likely, NMS can also occur with second-generation antipsychotics. NMS is a life-threatening medical emergency that is fatal in about 6% of cases. Complications of this condition include rhabdomyolysis (protein in the blood from muscle breakdown), which can cause organ failure (30%), acute respiratory failure (16%), acute kidney injury (18%), sepsis (6%), and other systemic infections. Respiratory failure is the strongest predictor of mortality.

Outpatient settings: Other Outpatient Venues for Psychiatric Care

New forms of treatment through technology are becoming increasingly popular. The COVID-19 pandemic resulted in adaptations to support social distancing that are likely to transform the delivery of mental health. Telepsychiatry, a subset of telemedicine, is providing therapy and even prescription services from a distance, usually through videoconferencing. Online counselors such as BetterHelp and Talkspace identify themselves as more --- ^This is just me saying this, it's not a lecture note or anything. I would not recommend BetterHelp, they're fairly notorious

Acute Phase-Interventions--Aggressive client:

Not all patients aggressive greater risk in acute phase Potential for violence to self and/or others Often response to altered reality testing Decrease stimulation Increase observation Distraction and outlets De-escalation

Standards for Nursing Care

Nurses are held to a basic standard of care. This standard is based on what other nurses who possess the same degree of skill or knowledge in the same or similar circumstances would do. State boards of nursing, professional associations, policies and procedures from various institutions, and even historical customs influence how nurses practice. They contribute standards by which nurses are measured and are important in determining legal responsibility and liability.

Potential Outcomes (ppts)

Outcomes Identification: Phase I—acute •Patient safety and medical stabilization Phase II—stabilization •Help patient understand illness and treatment •Stabilize medications •Control or cope with symptoms Phase III—maintenance •Maintain achievement •Prevent relapse •Achieve independence, satisfactory quality of life

Outcomes (Textbook)

Outcomes should focus on illness knowledge, management, coping, and quality of life. Outcomes should be consistent with the recovery model, which stresses hope, living a full and productive life, and eventual recovery rather than focusing on controlling symptoms and adapting to disability. Desired outcomes vary with the phase of the illness.

Rights of the hospitalized patient

Patients admitted to any psychiatric unit retain rights as citizens, which vary from state to state, and are entitled to certain privileges. Laws and regulatory standards require that patients' rights be provided in a timely fashion after an individual has been admitted to the hospital, and that the treatment team must always be aware of these rights. Any infringement by the team during the patient's hospitalization—such as a failure to protect patient safety—must be documented and actions must be justifiable. All mental health facilities must provide a written statement of patients' rights often with copies of applicable state laws attached.

Nursing Diagnosis

Patients may have coping skills that are adequate for day-to-day events but may be overwhelmed by the stresses of illness or hospitalization. Other patients may have a pattern of maladaptive coping that is marginally effective and coping strategies that may increase the possibility of anger and aggression. When the nursing assessment identifies potential for anger or aggression, risk for violence is a logical choice. Sometimes, patients may turn their anger inward. Therefore, risk for suicide should be addressed. Anger and aggression may be related to poor methods of coping; impaired coping is the nursing diagnosis used to address this problem. Stress overload and impaired impulse control are also important nursing diagnoses to consider for this population

right to refuse treatment

Patients may withhold consent or withdraw consent at any time, even if they are involuntarily committed. Patients can also retract consent previously given, and care providers must respect this whether it is a verbal or written retraction. However, the patient's right to refuse treatment with psychopharmacological drugs has been debated in the courts. This debate is based partly on the issue of patients' mental ability to give or withhold consent to treatment and their status under the civil commitment statutes.

psychiatric-mental health nursing

promoting mental health through the assessment, diagnosis, and treatment of human responses to mental health problems and psychiatric disorders

Rights Regarding Psychiatric Advance Directives

Patients who have experienced an episode of severe mental illness have the opportunity to express their treatment preferences in a psychiatric advance directive. This document is prepared when the individuals are well and identifies, in detail, their wishes and treatment choices. These directives vary somewhat from state to state, but generally cover the same basic areas. The following choices are addressed in Ohio's Declaration for Mental Health Treatment: • Designation of preferred physician and therapists • Appointment of someone to make mental health treatment decisions • Preferences regarding medications to take or not take • Consent or lack of consent for ECT • Consent or lack of consent for admission to a psychiatric facility • Preferred facilities and unacceptable facilities • Individuals who should not visit

prevalence

Prevalence describes the total number of cases, new and existing, in a given population during a specific period of time, regardless of when they became ill. An example of prevalence is the number of 8-year-olds from 11 states with autism spectrum disorder. In 2014, 16.8 children out of 1000 (1 in 59) screened positively for these disorders at specific clinical sites. This prevalence rate of nearly 2% was higher than previously demonstrated at these clinical sites. Because these sites do not provide a representative sample of the entire United States, the results are not generalizable to all 8-year-olds.

Planning

Planning interventions requires a sound assessment, including patient history (e.g., previous acts of violence, comorbid disorders, and past triggers) and present coping skills. Patients need to be willing and able to learn alternative and nonviolent ways of handling angry feelings.

Potential nursing diagnoses (ppt)

Positive symptoms •Disturbed sensory perception •Risk for self-directed or other-directed violence •Impaired verbal communication Negative symptoms •Social isolation •Chronic low self-esteem

Key symptoms of schizophrenia (positive, negative, cognitive...)

Positive symptoms--presence of something that shouldn't be there (hallucinations, delusions, paranoia, thinking disorder, abnormal movements, bizarre behaviors Negative symptoms--absence of something that should be there, anhedonia, avolition, apathy, alogia Cognitive symptoms--changes memory, attention issues, illogical thinking, poor problem solving & decision making skills, impaired judgment Affective symptoms--emotions and emotional expression, suicidality, hopelessness

Culture

Predominant cultural beliefs, attitudes, and practices influence mental health. There is no standard measure for mental health, partly because it is culturally defined. One approach to differentiating mental health from mental illness is to consider what a particular culture regards as acceptable or unacceptable. In this view, those with mental illness are those who violate social norms and thus threaten (or make anxious) those observing them. Throughout history, people have interpreted health or sickness according to their own current views. Treatment for this condition, thought to be the result of sexual deprivation, often involved sexual activity. Thankfully, this diagnosis fell into disuse as women's rights improved, the family atmosphere became less restrictive, and societal tolerance of sexual practices increased.

Prevention in Outpatient care (primary, secondary, and tertiary prevention)

Primary prevention occurs before any problem manifests and seeks to reduce the incidence or rate of new cases. Primary prevention may prevent or delay the onset of symptoms in genetically or otherwise predisposed individuals. Coping strategies and psychosocial support for vulnerable young people are effective interventions in preventing mood and anxiety disorders. Secondary prevention is also aimed at reducing the prevalence of psychiatric disorders. Early identification of problems, screening, and prompt and effective treatment are hallmarks of this level. While it does not stop the actual disorder from beginning, it is intended to delay or avert progression. Tertiary prevention is the treatment of disease with a focus on preventing the progression to a severe course, disability, or even death. Tertiary prevention is closely related to rehabilitation, which aims to preserve or restore functional ability. In the case of treating major depressive disorder, the aim is to avoid loss of employment, reduce disruption of family processes, and prevent suicide.

Evaluating progress

Progress should be reevaluated regularly and treatment adjusted when needed. Staff, patients, and significant others should remember that gains may be small and difficult to see at first. Even when it seems to others that symptoms have improved considerably, the patient may still be recovering. As with other serious illnesses, full recovery can take months. Setting small goals makes it easier to identify progress that may occur in small increments. Conveying interest in the patient's progress communicates concern and caring. This promotes recovery and treatment adherence and reduces feelings of helplessness. Involving the patient collaboratively as a true partner in care is central to the Recovery Model and increases patient trust, motivation, and buy-in.

Outpatient settings: Psychiatric Home Care

Psychiatric home care is a community-based treatment modality. Medicare requires that four elements be met in order for these services to be reimbursed: (1) homebound status of the patient, (2) presence of a psychiatric diagnosis, (3) need for the skills of a psychiatric registered nurse, and (4) development of a plan of care under orders of a physician or advanced practice registered nurse. Reimbursement and guidelines for psychiatric home care by other payers besides Medicare vary greatly. Homebound = patient unable to leave home independently due to physical or mental conditions. Patients may be referred for psychiatric home care after an acute inpatient hospitalization episode of care or to prevent hospitalization. Medicare allows social workers with a master's degree and psychiatric nurses to be involved in psychiatric home care. Social workers provide counseling and medical social services such as linking people with necessary healthcare and services. Psychiatric registered nurses provide evaluation, therapy, and teaching. Typically, the nurse visits the patient one to three times per week for a limited period of time. By going to the patient's home, the nurse is better able to address the concerns of access to services and adherence with treatment. Nurses working in the home have to be especially adept at assessing anxiety, agitation, and the potential for violence in this nonclinical setting.

Implementation-Acute Phase:

Psychiatric, medical, and neurological evaluation Psychopharmacological treatment Support, psychoeducation, and guidance Supervision and limit setting in the milieu Monitor fluid intake Working with aggression - Regularly assess for risk and take safety measures

Potentially dangerous side effects of SGA

Some side effects, such as sedation, occur initially but improve thereafter. Potentially dangerous side effects are infrequent but include anticholinergic toxicity, neuroleptic malignant syndrome, and prolongation of the QT interval. Side effects that are not addressed by healthcare professionals increase the risk of treatment nonadherence.

critical incident debriefing

Staff analysis of the episode of violence

Implications for psychiatric-mental health nursing

Staff nurses are obligated to report a patient's threats of harm against specified victims or classes of victims to other members of the treatment team. Advanced practice psychiatric-mental health nurses in private practice who provide individual therapy are obligated to warn the endangered party themselves.

Stigma

Stigma, the belief that the overall person is flawed, is characterized by social shunning, disgrace, and shame.

Environmental Factors

Stress increases cortisol levels, impairing hypothalamic development and causing other changes that may precipitate schizophrenia in vulnerable individuals. Schizophrenia often manifests at times of developmental and family stress, such as when a person is beginning college or moving away from home. Social, psychological, and physical stressors may play a significant role in both the severity and course of the disorder and the person's quality of life. Toxins such as tetrachloroethylene, used in dry cleaning and to line water pipes and sometimes found in drinking water, are also believed to contribute to the development of schizophrenia in vulnerable people. Other risk factors include childhood sexual abuse, exposure to social adversity (e.g., crime or chronic poverty), migration to or growing up in a foreign culture, and exposure to psychological trauma or social defeat. These factors may cause structural changes in the brain due to epigenetic changes in the genome.

Brain Structure Abnormalities

Structural abnormalities such as atrophy cause disruption in communication within the brain. Structural differences may be neurodevelopmental errors or errors in the normal pruning of neuronal tissue, as happens in late adolescence and early adulthood. Inflammation or neurotoxic effects from factors such as oxidative stress, infection, or autoimmune dysfunction may also alter the brain's structure.

DSM 5 (from textbook)

The Diagnostic and Statistical Manual (DSM) is a publication of the American Psychiatric Association (APA). Describes criteria for 157 disorders. The DSM identifies disorders based on specific criteria. It is used in inpatient, outpatient, partial hospitalization, consultation-liaison, clinics, private practice, primary care, and community settings. The DSM also serves as a tool for collecting epidemiological statistics about the diagnosis of psychiatric disorders. A common misconception is that a classification of mental disorders classifies people, when the DSM actually classifies disorders. For this reason, the DSM and this textbook avoid the use of stigmatizing labels such as he is "a schizophrenic" or "an alcoholic." Viewing the person as a person and not an illness requires more accurate terms such as "an individual with schizophrenia" or "my patient has major depressive disorder."

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)

The Diagnostic and Statistical Manual (DSM) is a publication of the American Psychiatric Association (APA); identifies 157 disorders based on specific criteria. It is used in inpatient, outpatient, partial hospitalization, consultation-liaison, clinics, private practice, primary care, and community settings. The DSM also serves as a tool for collecting epidemiological statistics about the diagnosis of psychiatric disorders.

negative symptoms

The absence of qualities that should be present. Negative symptoms include the inability to enjoy activities (anhedonia), social discomfort, or lack of goal-directed behavior.

Negative symptoms

The absence of qualities that should be present. Negative symptoms include the inability to enjoy activities (anhedonia), social discomfort, or lack of goal-directed behavior. Positive symptoms are obvious to others and can make treatment seem more urgent than negative symptoms do. Yet negative symptoms are a serious problem for people with schizophrenia because they amount to the absence of essential human qualities. Treating negative symptoms is more difficult than treating positive symptoms.

Beneficence

The duty to act to benefit or promote the health and well-being of others (e.g., spending extra time to help calm an anxious patient).

Veracity

The duty to communicate truthfully (e.g., describing the purpose and side effects of psychotropic medications in a truthful and non-misleading way).

Justice

The duty to distribute resources or care equally, regardless of personal attributes (e.g., an intensive care unit [ICU] nurse devotes equal attention to someone who has attempted suicide as to someone who suffered a brain aneurysm).

Design of the units

The goal in designing psychiatric units is to provide a therapeutic and aesthetically pleasing environment while balancing the need for safety since patients on inpatient psychiatric units may be at risk for suicide or violence. Full compliance with regulatory and accrediting bodies should be required for each clinical setting. Promoting an environment of safety and empowering patients to partner with clinical staff and take ownership of their own health and safety is critical. Safety precautions are considered for all areas of the unit. For example, closets may be equipped with breakaway bars or hooks designed to hold a minimal amount of weight to prevent strangulation by hanging. Windows are locked and are made of safety glass, and safety mirrors are typically used. Showers may have non-weight-bearing or non-looping designed showerheads. Beds are often platforms rather than mechanical hospital beds, which can be dangerous because of their crushing potential, looping hazard, and cords. However, standard hospital beds may be indicated, depending on patient physical health needs.

Future issues for psychiatric mental health nursing: A Demand for Mental Health Professionals

The growth of the psychiatric workforce has not been keeping pace with demand. In 2019, nearly 52 million US adults (about 21%) older than the age of 18 had a mental illness, but only 16% of adults received treatment. Lack of treatment results in disability, impaired relationships, and, in the case of suicide, mortality. Nurse-led medical/health homes and clinics are becoming increasingly common.

Rights Regarding Restraint and Seclusion

The history of restraint and seclusion is marked by abuse, overuse, and even a tendency to use restraint as punishment. This was especially true before the 1950s when there were no effective medications to calm agitation, hyperactivity, and psychosis. In the book The Shame of the States, Deutsch (1949) wrote that in 1948 one out of every four patients was restrained during the day. The practice of restraining patients rose to one in three patients at night. Legislation and accreditation requirements have dramatically reduced this problem by mandating strict guidelines. In fact, the pendulum has swung so far from the days of rampant use of restraint and seclusion that these methods have been referred to disparagingly as therapeutic assault. The American Psychiatric Nurses Association (APNA) promotes a culture that minimizes and eventually eliminates the use of seclusion and restraint (APNA, 2018). As previously mentioned, the use of the least restrictive means of restraint for the shortest duration is always the general rule. According to the Centers for Medicare and Medicaid Services (CMS, 2008), in emergency situations, less-restrictive measures do not necessarily have to be tried; they only need to be considered ineffective in the staff's professional judgment. Sometimes agitation, confusion, and combative behavior can have physical origins. Drug interaction, drug side effects, temperature elevation, hypoglycemia, hypoxia, and electrolyte imbalances can all result in behavioral disturbances. Addressing these problems can reduce or eliminate the need for restraint or seclusion.

Documentation of Care- Medical Records and Quality Improvement

The medical record has many other uses aside from providing information on the course of the patient's care and treatment by healthcare professionals. According to the Institute of Medicine (2011), quality improvement is a key goal for the future of nursing and healthcare. A retrospective medical record review provides valuable information to the facility on the quality of care provided and on ways to improve that care. A facility may also conduct reviews for risk management purposes. These reviews help to determine areas of potential liability for the facility and to evaluate methods used to reduce the facility's exposure to liability. For example, risk managers often review documentation of the use of restraints and seclusion for psychiatric patients. Accordingly, risk managers may use the medical record to evaluate care for quality assurance or peer review. Utilization review analysts evaluate the medical record to determine appropriate use of hospital and staff resources consistent with reimbursement schedules. Insurance companies and other reimbursement agencies rely on the medical record in determining which payments they will make on the patient's behalf.

Positive symptoms (textbook)

The presence of symptoms that should not be present. Positive symptoms include hallucinations, delusions, paranoia, or disorganized or bizarre thoughts, behavior, or speech. Positive symptoms usually appear early. They can be dramatic and are often what precipitates treatment. Positive symptoms are what most individuals associate with mental illness, often making schizophrenia what people imagine "mental illness" to be. One positive symptom is alterations in reality testing. Reality testing is the automatic and unconscious process by which we determine what is and is not real. We all experience thoughts that are irrational or distorted, yet we usually catch and correct them via reality testing. You might think you hear a voice, but you see that no one is present, so you conclude you are mistaken—it wasn't real. With impaired reality testing, the person experiences hallucinations or delusions as real.

comorbid condition

The presence of two or more disorders is known as comorbidity

How has the process for commitment has evolved?

The process for commitment has evolved. Many years ago, it was fairly easy to have someone committed. For example, a common problem in 1930s Maine was husbands ridding themselves of wives through psychiatric commitment. Legislation was enacted to penalize husbands who brought false testimony. One startling chief complaint listed on an actual admitting record was, "Patient does not do her housework." Forced hospitalization was also considered appropriate for "treating" homosexuality. In reaction to abusive practices of the past, the pendulum has swung the other way and forced hospitalization is far less common. The US has a complex system for involuntary commitment. Generally, involuntary commitment begins with someone who is familiar with the individual and believes that treatment is necessary. Often, when things become unbearable, a call is made to a primary care provider, police, or a local mental health facility: "I can't take it anymore. He's making threats and hearing voices. Can you help us get him into treatment?" The person making the call might be a family member, legal guardian, custodian, or someone who lives with the individual. It could also be a healthcare professional. At this point, a formal application for admission is initiated. To support the application, a specified number of physicians (usually two) or a combination of other mental health professionals certify that a person's mental health status justifies detention and treatment.

Documentation of Care

The purposes of the medical record are to provide accurate and complete information about the care and treatment of patients. It also gives healthcare personnel a means of communicating with one another, allowing for continuity of care. A record's usefulness is determined by how accurately and completely it portrays the patient's behavioral status at the time it was written. The patient has the right to see the medical record, but it belongs to the institution. The patient is instructed on the facility's protocol to view personal records. For example, if a psychiatric patient describes intent to harm himself or another person and the nurse fails to document the information—including the need to protect the patient or the identified victim—the information will be lost when the nurse leaves work. If the patient's plan is carried out, the harm caused could be linked directly to the nurse's failure to communicate the patient's intent. Even though documentation takes time away from patient care, its importance in communicating and preserving the nurse's assessment and memory cannot be overemphasized.

de-escalation techniques

The use of communication or other techniques during an encounter to stabilize, slow, or reduce the intensity of a potentially violent situation without using physical force, or with a reduction in force

Therapeutic milieu

Therapeutic milieu has a lot of components so that the unit remains safe. - For example, if there was a limit set by a nurse from the previous shift, you should uphold it. If you disagree with a restriction, put it in a note for that nurse to change on their next shift. —- Milieu (meel-yoo) is a word of French origin (mi "middle" + lieu "place") and refers to surroundings and physical environment. In a therapeutic context, it refers to the overall environment and interactions within that environment. Peplau (1989) referred to this as the therapeutic milieu. It is an all-inclusive term that recognizes the people (patients and staff), the setting, the structure, and the emotional climate as important to healing. Regardless of whether the setting involves treatment of psychotic children, adult patients in a psychiatric hospital, substance users in a residential treatment center, or psychiatric patients in a day treatment program, a well-managed milieu offers patients a sense of security and promotes healing. Structured aspects of the milieu include activities, rules, reality orientation practices, and environment.

Contraindications for the use of seclusion and restraint

There are several contraindications for the use of seclusion and restraint. Patients who have extremely unstable medical and psychiatric conditions are not considered safe candidates for these treatments. Chronic obstructive pulmonary disease, spinal injury, seizure disorder, and pregnancy are examples of contraindicated problems. Delirium or dementia may make seclusion and restraint intolerable due to the absence of stimulation. These restrictive measures should be avoided in patients who are overtly suicidal and those who require monitoring for severe drug reactions or overdoses. A patient may not be held in seclusion or restraint without an order from a licensed practitioner, although in emergency situations, the order may be received after the fact. Once in restraint, a patient must be directly observed and formally assessed at frequent regular intervals for level of awareness, level of activity, safety within the restraints, hydration, toileting needs, nutrition, and comfort. Licensing and accreditation agencies mandate how frequently you need to observe patients in seclusion and restraint.

Timothy's Law

Timothy's Law is New York State's Mental Health Parity Law which mental health parity is defined as coverage for mental health services that is equal to the health plan medical coverage in terms of visits, days, deductibles, co-payments, and other cost sharing mechanisms. --- Parent has to sign for children, but child can agree to be admitted.

Laws and Standards of Nursing Care (false imprisonment, assault/battery, negligence...)

Tort-what is it? Intentional tort—willful or intentional acts that violate another person's rights or property Unintentional tort—unintended acts against another that produce injury or harm Five Elements to Prove Negligence --- You have a duty to intervene (as in understand more about it, do not physically intervene) and a duty to report even as a student. Definitions of the intentional torts asked for in the study guide were already on cards in this set.

T o F: Put on constant observation for voices

True; Put on constant observation for voices, especially if they are listening to them

Interventions--Delusions:

Trust Don't argue with patient or try to talk patient out of delusion Acknowledge patient experience Empathy and understanding Label feelings Gentle reality orientation--validate what is real Focus on here and now

Evaluation

Ultimately, the most important outcome when working with patients who respond with anger, aggression, and violence is the safety of everyone concerned. Therefore, no violence and no suicide are the basic measures. Beyond safety, patients with poor coping and stress overload will demonstrate improved coping and improved stress management.

Psych NP vs CNS

Unlike other specialty areas, there is no significant difference between a psychiatric NP and a CNS as long as the CNS has achieved prescriptive authority. Certification is required and is obtained through the ANCC. Only one examination—the Psychiatric-Mental Health Nurse Practitioner—Board Certified (PMHNP-BC)—is currently available

Voluntary Admissions

Voluntary admissions occur when patients apply in writing for admission to the facility. The person should understand the need for treatment and be willing to be admitted. If the individual is under 16, the parent, legal guardian, custodian, or next of kin may have authority to apply on the person's behalf. Adolescents between 16 and 18 may seek admission independently or on the application by an authorized individual or agency. Voluntarily admitted patients have the right to request and obtain release. Before being released, reevaluation may be necessary. Reevaluation can result in a decision on the part of the care provider to initiate an involuntary commitment according to criteria established by state law.

Pharmacological Interventions (textbook)

When a patient is showing increased signs or symptoms of anxiety or agitation, it is appropriate to offer the patient an as-needed medication to alleviate symptoms. When used in conjunction with psychosocial interventions and de-escalation techniques, this can prevent an aggressive or violent incident. Antipsychotics and antianxiety agents are used in the treatment of acute symptoms of anger and aggression. Haloperidol (Haldol) has historically been the most widely used first-generation antipsychotic. An inhaled first-generation antipsychotic, loxapine (Adasuve), has been approved for use in limited settings due to the potential for a fatal bronchospasm. Second-generation antipsychotics such as olanzapine (Zyprexa) and ziprasidone (Geodon) have gained popularity due to reduced side effects compared with first-generation drugs. Orally disintegrating tablet versions of second-generation antipsychotics such as olanzapine (Zyprexa Zydis) are alternatives to injectable medication. The tablets disintegrate in saliva almost immediately and effects occur rapidly. Antianxiety benzodiazepines such as lorazepam (Ativan) may reduce the amount of antipsychotic that is needed to control agitation. A combination of an antipsychotic such as haloperidol (Haldol) and a benzodiazepine such as lorazepam (Ativan) is also used intramuscularly. Diphenhydramine (Benadryl) or benztropine (Cogentin) added to the injection reduces extrapyramidal side effects. The long-term treatment of anger, aggression, and violence is based on treating the underlying psychiatric disorder. Selective serotonin reuptake inhibitors (SSRIs), lithium, anticonvulsants, benzodiazepines, second-generation antipsychotics, and beta-blockers are all used successfully for specific patient populations. Anger and aggression related to attention-deficit/hyperactivity disorder may be reduced through the use of psychostimulants.

duty to warn

When a therapist determines that a patient presents a serious danger of violence to another, the therapist has the duty to protect that other person

General Assessment

When patients are experiencing anger, you often see it manifested behaviorally. Increased demands, irritability, frowning, redness of the face, pacing, twisting of the hands, or clenching and unclenching of the fists are all signs of irritation. Speech may either be increased in rate and volume or may be slowed, pointed, and quiet. You should address any change in behavior from what is typical for that patient. Box 27.1 identifies signs and symptoms that indicate the risk of escalating anger leading to aggressive behavior. It is also important to assess the patient's history of aggression or violence. Most of our reactions to stimuli come from our previous experiences; therefore, identifying patients' triggers is essential. Initial and ongoing assessment of the patient can reveal problems before they escalate to anger and aggression. Such assessment also leads directly to the appropriate nursing diagnosis and intervention. Some hospitals use the electronic medical record (EMR) to assist in the potential for violence. The violence assessment starts in the emergency department or nursing unit and continues every shift. If the patient is considered to be at risk of violence, an electronic flag is shown both on the EMR and in the patient's room.

Second-generation antipsychotic clozapine (Clozaril)

When the first second-generation antipsychotic clozapine (Clozaril) was approved in the United States in 1989, it produced dramatic improvement in some patients whose disorder had been resistant to first-generation antipsychotics. Clozapine helped improve negative symptoms as well. Unfortunately, clozapine causes severe neutropenia in 0.5% to 1% of those who take it. As a result, patients taking clozapine are routinely monitored for absolute neutrophil counts (ANCs). Clozaril can also cause myocarditis and in rare cases can contribute to life-threatening bowel emergencies and new-onset diabetes as well as, rarely, ketoacidosis. Owing to these serious concerns, clozapine use in the United States has declined. However, it is one of the few drugs that have FDA approval for the treatment of suicidality in schizophrenia and is the drug of choice for individuals who are unresponsive to other antipsychotics. One wide-scale study of more than 62,000 people found that taking antipsychotics was associated with a substantially reduced mortality, especially among patients treated with clozapine.

Restraints- pt monitoring

While the patient is in seclusion or restraint, close monitoring to determine the patient's ability to reintegrate into unit activities is mandatory. Reintegration should be gradual and geared toward the patient's ability to handle increasing amounts of stimulation. If the reintegration proves to be too much for the patient and results in increased agitation, the individual is returned to the room or another quiet area. Patients must be able to follow commands and control behaviors before reintegration can occur. In general, a structured reintegration is the best approach. Once the patient no longer requires the locked seclusion room or restraints and is able to exercise self-control, the patient can be returned to the unit. Afterward, the patient should be observed carefully to maintain safety. In some cases, the patient may require further seclusion or restraint for which you would have to obtain another order.

What are considered restraints?

While we tend to think of classical restraining devices, a restraint can actually be any mechanical or physical device, equipment, or material that prevents or reduces movement of the patient's legs, arms, body, or head. Even side rails are a restraint if you use them to prevent the patient from exiting the bed. Restricting a person's movement by holding is also a restraint. This controversial and dangerous method of behavior management is often referred to as "therapeutic holding" or "physical management." These so-called therapeutic holds have resulted in the deaths of many young people. A 16-year-old boy in a residential treatment center for disturbed youth in New York died after being placed in a therapeutic hold by several staff members. According to witnesses, the boy had complained he could not breathe, then became unresponsive. As of 2019, 23 states had enacted legislation to limit restraint of children to threats of physical danger. A restraint may be chemical. Chemical restraints are medications or doses of medication that are not being used for the patient's condition. Chemical interventions are usually less restrictive than physical or mechanical interventions. However, they can have a greater impact on the patient's ability to relate to the environment due to their effect on levels of awareness and their side effects. Still, when used for symptom management, medication can be extremely effective and helpful as an alternative to physical methods of restraint.

clinical epidemiology

a broad field that examines health and illness at the population level. Studies use traditional epidemiological methods and are conducted in groups usually defined by the illness or symptoms or by the diagnostic procedures or treatments given for the illness or symptoms. Clinical epidemiology includes the following: • Studies of the natural history—what happens if there is no treatment and the problem is left to run its course—of an illness • Studies of diagnostic screening tests • Observational and experimental studies of interventions used to treat people with the illness or symptoms

ethical dilemma

a conflict between two or more courses of action, each carrying favorable and unfavorable consequences

Prolongation of the QT interval

a delay of ventricular repolarization. This condition may result in tachycardia, fainting, seizures, and even sudden death. The first-generation antipsychotic drugs that can prolong the QT interval include chlorpromazine (Thorazine), haloperidol (Haldol), and thioridazine (Mellaril); the second-generation antipsychotic drugs quetiapine (Seroquel), risperidone (Risperdal), and ziprasidone (Geodon) can do so as well. Before being started on any antipsychotic agent, a patient should receive an electrocardiogram to detect pre-existing QT prolongation, which magnifies the risk from medication-related prolongation.

Anticholinergic toxicity (cont)

a potentially life-threatening medical emergency caused by antipsychotics or other anticholinergic medications, including many antiparkinsonian drugs and over-the-counter cold/allergy medicines. Older adults and those on multiple anticholinergic drugs are at greatest risk. Symptoms include autonomic nervous system instability, dilated pupils, urinary retention, and delirium with altered mental status. Mental status changes can include hallucinations and may be mistaken for a worsening of the patient's psychosis, so people whose psychosis is inexplicably worsening should immediately be evaluated for possible anticholinergic toxicity.

anticholinergic toxicity

a potentially life-threatening medical emergency caused by antipsychotics or other anticholinergic medications, including many antiparkinsonian drugs and over-the-counter cold/allergy medicines. Older adults and those on multiple anticholinergic drugs are at greatest risk. Symptoms include autonomic nervous system instability, dilated pupils, urinary retention, and delirium with altered mental status. Mental status changes can include hallucinations and may be mistaken for a worsening of the patient's psychosis, so people whose psychosis is inexplicably worsening should immediately be evaluated for possible anticholinergic toxicity.

recovery

a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential; The focus is on the consumer and the consumer's abilities.

malpractice

a special type of professional negligence. The five elements required to prove negligence are: 1. Duty, 2. Breach of duty, 3. Cause in fact, 4. Proximate cause, 5. Damages

mental health

a state of well-being in which individuals reach their own potential, cope with the normal stresses of life, work productively, and contribute to the community. Mental health provides people with the capacity for rational thinking, communication skills, learning, emotional growth, resilience, and self-esteem.

milieu

a word of French origin (mi "middle" + lieu "place") and refers to surroundings and physical environment. In a therapeutic context, it refers to the overall environment and interactions within that environment. Peplau (1989) referred to this as the therapeutic milieu. It is an all-inclusive term that recognizes the people (patients and staff), the setting, the structure, and the emotional climate as important to healing. Structured aspects of the milieu include activities, rules, reality orientation practices, and environment.

extrapyramidal side effects

acute dyskinesias and dystonic reactions, tardive dyskinesia, Parkinsonism, akinesia, akathisia, and neuroleptic malignant syndrome.

associative looseness

aka looseness of association, results from haphazard and illogical thinking where concentration is poor and thoughts are only loosely connected. For example: "My friends talk about French fries but how can you trust the French?" Word salad, the most extreme form of associative looseness, is a jumble of words that is meaningless to the listener (e.g., "agents want strength of policy on a boat reigning supreme").

Outpatient settings: Patient-centered medical homes

aka primary care medical homes; received strong support from the ACA; developed in response to fragmented care that resulted in some services never being delivered while others were duplicated. Five key characteristics: 1. Patient centered—Care is relationship based with the patient and takes into account the unique needs of the whole person. The patient is a core member of the team. 2. Comprehensive care—All levels (preventive, acute, and chronic) of mental and physical care are addressed. Physicians or advanced practice nurses lead teams that include nurses, physician assistants, pharmacists, nutritionists, social workers, educators, and care coordinators. 3. Coordination of care—Care is coordinated with the broader health system, such as hospitals, specialty care, and home health. 4. Improved access—Patients are not limited to Monday through Friday from 9 a.m. to 5 p.m. to get the care they need. In addition to extended hours of service, these homes provide e-mail and phone support. Electronic communication (e.g., follow-up e-mails and reminders) and record keeping are viewed as essential aspects of this process. 5. Systems approach—Evidence-based care is provided with a continuous feedback loop of evaluation and quality improvement.

clinical pathway

aka, care pathways, aka, integrated care pathways; task-oriented plans that detail the essential steps in the care of patients with specific clinical problems based on the usual and expected clinical course. These tools provide an essential link between evidence-based knowledge and clinical practice. The treatment plan is revised if the patient's progress differs from the expected outcomes. Care pathways result in decreased costs, lengths of stay, and complications while improving outcomes.

emergency commitment

also known as a temporary admission or emergency hospitalization. Emergency commitment is used (1) for people who are so confused they cannot make decisions on their own or (2) for people who are so ill they need emergency admission. In some states, anyone can initiate these proceedings through the court system. Other states require that care providers—such as a physician, an advanced practice psychiatric nurse, a social worker, or an officer of the law—initiate a temporary admission. Generally, a psychiatrist employed by the facility needs to confirm the need for hospitalization. The primary purpose of this type of hospitalization is observation, diagnosis, and treatment of patients who have mental illness or pose a danger to themselves or others. The length of time that patients can be held in a temporary admission ranges from 24 to 96 hours depending on the state. A court hearing is held and a decision is made for discharge, voluntary admission, or involuntary commitment.

involuntary commitment

also known as assisted inpatient psychiatric treatment, is a court-ordered admission to a facility without the patient's approval. State laws vary, but they address both the criteria for commitment and the process for commitment. The criteria for commitment are the legal standards under which the court decides whether admission is necessary. These standards include a person who is: 1. Diagnosed with mental illness 2. Posing a danger to self or others 3. Gravely disabled (unable to provide for basic necessities such as food, clothing, and shelter) 4. In need of treatment and the mental illness itself prevents voluntary help-seeking

neuroleptic malignant syndrome

caused by excessive dopamine receptor blockade, occurs in about 0.2% to 1% of patients who have taken first-generation antipsychotics. It is characterized by reduced consciousness and responsiveness, increased muscle tone (generalized muscular rigidity), and autonomic dysfunction. Although less likely, NMS can also occur with second-generation antipsychotics.NMS is a life-threatening medical emergency that is fatal in about 6% of cases. Complications of this condition include rhabdomyolysis (protein in the blood from muscle breakdown), which can cause organ failure (30%), acute respiratory failure (16%), acute kidney injury (18%), sepsis (6%), and other systemic infections. Respiratory failure is the strongest predictor of mortality.

clang association

choosing words based on their sound rather than their meaning and often involves words that rhyme or have a similar beginning sound ("On the track ... have a Big Mac" or "Click, clack, clutch, close").

The Psychiatric-Mental Health Nursing Scope and Standards of Practice

defines the specific activities of the psychiatric-mental health nurse. jointly written in 2014 by the ANA, the American Psychiatric Nurses Association (APNA), and the International Society of Psychiatric-Mental Health Nurses (ISPN) defines the focus of psychiatric-mental health nursing as "promoting mental health through the assessment, diagnosis, and treatment of human responses to mental health problems and psychiatric disorders."

decompensation

deterioration of mental health

triage

determining the severity of the problem and the urgency of a response

A diathesis-stress model

diathesis represents biological predisposition and stress represents environmental stress or trauma—is the most accepted explanation for mental illness. This nature-plus-nurture argument asserts that most psychiatric disorders result from a combination of genetic vulnerability and negative environmental stressors. One person may develop major depressive disorder largely as the result of an inherited and biological vulnerability that alters brain chemistry. Another person with little vulnerability may develop depression as a result of a stressful environment that causes changes in brain chemistry.

parity

equality for the people with mental illness with other patients in terms of payments for services from health insurance plans also improves access to treatment

What is psychiatric mental health nursing? (textbook)

nursing specialty dedicated to promoting mental health through the assessment, diagnosis, and treatment of behavioral problems, mental disorders, and comorbid conditions across the life span. They work with people throughout their lifespan, assisting people who are in crisis/experiencing life problems, as well as those with long-term mental illness. These nurses work with patients with dual diagnoses (e.g., a mental disorder and a comorbid substance disorder), homeless persons and families, forensic patients (i.e., people in jail), and individuals who have survived abusive situations. Psych nurses work with individuals, couples, families, and groups in every nursing setting (e.g. hospitals, homes, halfway houses, shelters, clinics, in storefronts, on the street). The psychiatric-mental health nurse uses the same nursing process you have already learned to assess and diagnose patients' illnesses, identify outcomes, and plan, implement, and evaluate nursing care.

Psychosis (cont.)

often involves auditory hallucinations, but they can also occur in individuals who are not psychotic. They are the most common form in psychosis, being experienced by about 70% of people with schizophrenia. They may be vague sounds or indistinct or clear voices. Hallucinations seem to come from outside the person's head and are perceived similarly to real voices. Auditory processing areas of the brain are activated during these hallucinations, just as they are when a genuine sound is heard. E.g., command and visual hallucinations

Health Insurance Portability and Accountability Act (HIPAA)

protects the psychiatric patient's right to receive treatment and to have medical records kept confidential.

community mental health center

provide emergency services, community/home-based services, and outpatient services across the lifespan. Common treatments include medication prescription and administration, individual therapy, psychoeducational and therapy groups, family therapy, and dual-diagnosis (mental health and substance use) treatment

patient-centered medical home

primary care medical homes received strong support from the Affordable Care Act of 2010 under President Barack Obama. These health homes were developed in response to fragmented care that resulted in some services never being delivered while others were duplicated.

confidentiality

privacy of patient

prodromal phase

prodromal phase during which milder symptoms of the disorder occur, often months or years before the full disorder becomes manifest. During the prodromal phase of schizophrenia, people may experience diminished school performance and cognitive ability. They may become less socially engaged or adept. They may also demonstrate attenuated (mild) psychotic symptoms, such as suspiciousness and/or eccentric or disorganized speech or thought

Schizophrenia usually progresses through predictable phases, although the presenting symptoms during a given phase and the length of the phase can vary widely. These phases are as follows:

prodromal, acute, stabilization, maintenance/residual

Other first-generation antipsychotic side effects include:

sedation, orthostatic (postural) hypotension, lowered seizure threshold (which can lead to seizures in seizure-vulnerable individuals), and photosensitivity, cataracts, or other visual changes (with chlorpromazine [Thorazine] and thioridazine [Mellaril]). Neuroendocrine abnormalities, such as increased release of prolactin (hyperprolactinemia), may result in sexual dysfunction (impotence, anorgasmia, impaired ejaculation). Galactorrhea (a milky nipple discharge), amenorrhea, and gynecomastia are also side effects of first-generation antipsychotics. Weight gain can be more than 50 lb per year, causing significant psychological distress and increasing the risk of cardiovascular disorders and diabetes

Therapist-patient abuse

sexual, misdiagnosis, restraint use (safety)

Signs of Mental Illness (ppt)

significant dysfunction in mental functioning, definable diagnosis (DSM-V)

assisted outpatient treatment

similar to a conditional release. The main difference is in legal implications since, unlike conditional release, this is a court-ordered outpatient treatment. While patients are often discharged into this care, they may also be committed directly from the community. This type of involuntary outpatient commitment arose in the 1990s when states began to pass legislation that permitted court-ordered outpatient treatment as an alternative to forced inpatient treatment. As of 2019, only three states—Connecticut, Massachusetts, and Maryland—had not adopted this model of less restrictive care.

recovery model

stresses hope, living a full and productive life, and eventual recovery rather than focusing on controlling symptoms and adapting to disability. Desired outcomes vary with the phase of the illness.

bioethics

study of specific ethical questions that arise in healthcare

What does the AIMS assess?

tardive dyskinesia; The National Institute of Mental Health (NIMH) developed the Abnormal Involuntary Movement Scale (AIMS) to identify and monitor involuntary movements. Assessing patients using the AIMS is a key nursing role in treating this population.

unconditional release

the termination of the legal patient-institution relationship; most common type of hospital release; may be ordered by the attending psychiatrist or other advanced practice mental health professional (e.g., psych NP or PA) or it may be court ordered. Sometimes, patients wish to be released due to issues such as being unsatisfied with care, lack of insurance coverage, or the need to return to work. When the patient requests a discharge, the care provider may agree with the request. If the clinician has doubts as to the safety of a discharge, a patient may be held for similar to an involuntary admission. As previously discussed, nearly every state allows a 72-hour holding period for professional evaluation

unintentional torts

unintended acts against another person that produce injury or harm

continuum of psychiatric-mental healthcare

used to help determine the level of psych care a pt should receive (based on level of restrictiveness)

antipsychotic medication (definition)

used to treat psychotic disorders such as schizophrenia.

conditional release

usually requires outpatient treatment for a specified period of time. During this time, the individual is evaluated for follow-through with the medication regimen, ability to meet basic needs, and the ability to reintegrate into the community. Generally, a voluntarily admitted patient who is conditionally released can only be involuntarily admitted through the usual methods described earlier. However, an involuntarily admitted patient who is conditionally released may be readmitted based on the original commitment order

Negative symptoms include the following six, which all start with the letter A:

• Anhedonia (an = without + hedonia = pleasure): A reduced ability or the inability to experience pleasure. • Avolition (a = without + volition = initiating an action): reduced motivation or goal-directed behavior; difficulty beginning and sustaining goal-directed activities. • Asociality: Decreased desire for social interaction or discomfort during it; social withdrawal. • Affective blunting: Reduced or constricted affect. • Apathy: Decreased interest in activities or beliefs that would otherwise be interesting or important or little attention to them. • Alogia: Reduction in speech, sometimes called poverty of speech. These symptoms can contribute to poor social functioning and social withdrawal. They can impair a person's ability to initiate and maintain conversations and relationships or to succeed in school or work. Apathy and avolition result in deficits in basic activities, such as maintaining adequate hygiene, grooming, and other activities of daily living. Affect, an additional "A" word, is the external expression of a person's emotional state. In schizophrenia, affect may be diminished or may not coincide with the person's inner emotions. Some antipsychotic medications can also cause diminished affect.

Most states have similar laws regarding the duty to protect third parties of potential life threats. The duty to protect usually includes the following:

• Assessing and predicting the patient's danger of violence toward another • Identifying the specific persons being threatened • Taking appropriate action to protect the identified victims

Note that alterations in speech often reflect altered cognitive abilities and thus can reflect cognitive deficits. The following are other pathological speech patterns:

• Circumstantiality: Including unnecessary and often tedious details in conversation but eventually reaching the point. • Tangentiality: Wandering off topic or going off on tangents and never reaching the point. • Cognitive retardation: Generalized slowing of thinking, which is represented by delays in responding to questions or difficulty finishing thoughts. • Pressured speech: Urgent or intense speech; reluctance to allow comments from others. • Flight of ideas: Moving rapidly from one thought to the next, often making it difficult for others to follow the conversation. • Symbolic speech: Using words based on what they symbolize, not what they mean. For example, a patient reports "demons are sticking needles in me" when what he means is that he is experiencing a sharp pain (symbolized by needles). • Thought blocking: A reduction or stoppage of thought. Cognitive disorganization or interruption of thought by hallucinations can cause this. • Thought insertion: The often uncomfortable belief that someone else has inserted thoughts into the patient's brain. • Thought deletion: A belief that thoughts have been taken or are missing. Other positive symptoms manifested in disorders of thought include these: • Magical thinking: Believing that reality can be changed simply by thoughts or unrelated actions. This thinking is common in children (e.g., "Because I was mad at him, he fell down"). • Paranoia: An irrational fear, ranging from mild (being suspicious, wary, guarded) to profound (believing irrationally that another person intends to kill you). Fear may result in dangerous defensive actions, such as harming another person before that person can harm the patient.

Associative looseness is part of disorganized thinking. Increased anxiety or overstimulation worsens cognitive disorganization. Guidelines for helping those with disorganized thinking include the following:

• Do not pretend or allow the patient to think that you understand when you don't. • Place the difficulty in understanding on yourself, not on the patient. Example: "I'm having trouble following what you are saying," not "You're not making any sense." • Tell the patient what you do understand, and reinforce clear communication of needs, feelings, and thoughts when it occurs. • Look for recurring issues and themes in the patient's communications, and tie these to possible triggers. Example: "You've mentioned trouble with your brother several times, usually after your family has visited. Tell me about your brother and your visits with him." • Summarize or paraphrase the patient's communications to role-model clearer communication and to give the patient a chance to correct anything you may have misunderstood. • Speak concisely, clearly, and concretely, in sentences rather than paragraphs.

Other important design elements on inpatient psychiatric units include:

• Doors that open out instead of in to prevent patients from barricading themselves in their rooms. • Continuous hinges on doors rather than three butt hinges to prevent hanging risk. • Furniture that is anchored in place with the exception of a desk chair to prevent their use as a weapon or barricade. • Drapes that are mounted on a track firmly anchored to the ceiling rather than curtain rods. • Mini blinds contained within window glass provide significantly more safety than those whose mountings are accessible. • Plumbing fixtures that are boxed in.

The ACA improved mental healthcare coverage in several ways:

• Eliminated medical underwriting in the individual and small group markets, so medical history no longer resulted in enrollment denials for preexisting conditions or higher premiums. • Required all individual and small group health plans to cover 10 essential health benefits with no annual or lifetime dollar limits. Mental health and addiction treatment were among the essential benefits. • Made health insurance with mental health benefits available for many individuals who previously had been uninsured. Significant numbers of these (mostly low-income) persons had untreated mental health problems. • Allowed young adults to remain on their parents' health plans until age 26. This is important to mental health since most psychiatric disorders emerge in adolescence or early 20s.

Affect in schizophrenia can usually be categorized in one of four ways:

• Flat: Immobile or blank facial expression • Blunted: Reduced or minimal emotional response • Constricted: Reduced in range or intensity (e.g., shows sadness or anger but no other moods) • Inappropriate: Incongruent with the actual emotional state or situation (e.g., laughing in response to a tragedy) • Bizarre: Odd, illogical, inappropriate, or unfounded; includes grimacing

In this case, federal law supersedes state reporting laws, although compliance with the state law may be maintained under the following circumstances:

• If a court order is obtained • If a report can be made without identifying the abuser as a patient in an alcohol or drug treatment program • If the report is made anonymously, although some states, to protect the rights of the accused, do not allow anonymous reporting States may require health professionals to report other kinds of abuse. Most states have enacted older adult abuse reporting statutes, which require registered nurses and others to report cases of abuse of adults 65 and older. Agencies that receive federal funding (e.g., Medicare or Medicaid) are required to follow strict guidelines for reporting and preventing this type of abuse. These laws also apply to dependent or disabled adults. These are adults between the ages of 18 and 64 whose physical or mental limitations restrict their ability to carry out normal activities or to protect themselves. Under most state laws, failure to report suspected abuse, neglect, or exploitation of a disabled adult may result in a misdemeanor crime. Most state statutes protect individuals who make a report in good faith by providing immunity from civil liability. Because state laws vary, students should become familiar with the requirements of their states.

Other alterations in perception include the following.

• Illusions: Misinterpretations of a real experience. For example, a man sees a coat on a shadowy coat rack and believes it to be a bear. • Depersonalization: A feeling of being unreal or having lost an element of one's person or identity. For example, body parts do not belong, or the body has drastically changed (e.g., a patient may see her fingers as being smaller than they actually are or not as hers). • Derealization: A feeling that the environment has changed (e.g., that one is detached from the environment, that everything seems bigger or smaller, or that familiar surroundings seem somehow strange and unfamiliar).

Patients are informed of the following elements:

• The nature of the problem or condition • The nature and purpose of a proposed treatment • The risks and benefits of that treatment • The alternative treatment options • The probability that the proposed treatment will be successful • The risks of not consenting to treatment

Nurses should consider the following before using seclusion and restraint:

• Verbally intervening (e.g., asking the patient for cooperation) • Reducing stimulation • Actively listening • Providing diversion • Offering as needed (PRN) medications

Legal and ethical Implications of advancements in genetics

• Would you want to know you were at risk for a psychiatric illness such as bipolar disorder? • Who should have access to this information—your primary care provider, insurer, future spouse, or a lawyer in a child-custody battle? • Who will regulate genetic testing centers to protect privacy and prevent 21st-century problems such as identity theft and fraud?