exam 1 mental health nursing

Explain the importance of objective documentation for informed consent application and removal of restraints and other safety measures.

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Employ components of assessing the suicidal client and discuss significant risk factors

ASSESSMENT: ØSuicidal client assessment considerations: üDemographics: What demographics are assessed? üPresenting symptoms/medical-psychiatric diagnosis: What psychiatric diagnoses would increase risk of suicide? What medical diagnoses or symptoms would increase risk? üSuicidal ideas or acts What questions should be asked to determine suicidal threat? What behaviors and verbal cues would indicate suicidal threat? üInterpersonal support system What questions should be asked about their support system? üAnalysis of the suicidal crisis What questions should be asked to analyze the suicidal crisis? 1.Precipitating stressor: Adverse life events with other risk factors such as depression may lead to suicide. 2.Relevant history: At risk for dysfunctional response due to numerous failures or rejections. 3.Life-stage issues: Decreased ability to tolerate losses and disappointments during developmental stages. (adolescence, midlife) üPsychiatric/medical/family history What questions should be asked regarding history? üCoping strategies What questions should be asked regarding coping strategies? ØAssessment of client Risk: What behaviors/cues indicate Very high risk. § Threatening to harm or end life §Has a suicide plan §Seeking or has access to means: pills, weapons, other. §Expressing suicide ideation §Hopelessness §Rage, anger, seeking revenge. §Acting reckless; impulsively risky behavior. §Expressing feelings of being trapped; no way out. §Increasing substance use. §Withdrawing from family, friends, society. §Anxiety, agitation, abnormal sleep. §Dramatic mood changes. §Expresses no reason to live or purpose. SUICIDE ASSESSMENT QUESTION MNEMONIC: PLAN PALS: P-Plan L-Lethality A-Availability-means to carry out I-illness mental or physical D-depression-chronic or situational P-previous attempts-#?lethality?recent? A-alone-do they have a support system? partner? are they alone right now? L-loss-death, job, relationship, self esteem? S-substance abuse/use-drugs, alcohol, medicine? current, chronic? Warning signs: IS PATH WARM I-Ideation S-Substance abuse P-purposelessness A-Anxiety T-Trapped H-Hopelessness W-Withdrawal A-Anger R-Recklessness M-Mood changes RISK FACTORS: qMarital status §Single person, never married, twice as likely to commit suicide. §Divorce increases risk for suicide. Men 3x > women §Older people: Greater risk of suicide during the first year of marital status change. (divorce/widowed) qGender §Women attempt suicide more often. (overdose with 30 % success) §Women more likely to seek and accept help. §Men succeed more often. (guns with 70% success) §Men more likely to view help-seeking as a sign of weakness. qAge §Rates higher in males at 45-64 years, and rises again at 85 years and older. §Rates decline in females after age 65 years. §Greatest suicide risk: White males > 80 years (70% of suicides) §Adolescent males most common method of successful suicide is firearms. §Adolescents suicide is 2nd leading cause of death. (males: guns - females: suffocation) §5-11 years: 33 suicides per year in U.S. suffocation and hanging. (Peds, ED, school nurse) §Factors that put adolescences at risk of suicide include: §Impulsive and high-risk behaviors §Untreated mood disorders (including depression and bipolar disorder) §Access to lethal weapons §Substance abuse qReligion §Lower rates of suicide with religious affiliation. qEthnicity §Whites at highest risk for suicide.(14.7%) §Followed by Native Americans and Alaska Natives (10.9%), Hispanic Americans (6.3%), Asian Americans (5.9%), African Americans (5.5%). qSocioeconomic status §Higher rates among very highest and lowest social classes. §Higher rates among physicians, artists, dentists, law enforcement, lawyers, and insurance agents. OTHER: §90% with successful suicide have a diagnosable mental disorder §Most common a mood disorder or substance abuse disorder. §Suicide risk may increase in early treatment with antidepressants. §The return of energy brings increased ability to act out wishes. §Personal stressors: isolation, victimization, relationships with family, peers and community. §Severe insomnia increases risk of suicide. (even without depression) §Alcohol and increased risk with addition of barbiturates. §Psychosis, especially with command hallucinations. §Chronic pain or disabling illness. §Gay, lesbian, transgender. (isolation, victimization, stressful relationships with family, peers) §Family history of suicide is associated with higher risk, especially in a same-sex parent. §Personal stressors: isolation, victimization, relationships with family, peers and community. §Bullying victim and those who bully are at greater risk of suicide. §Cyberbullying also §Persons with previous attempts are at higher risk . §Loss of a loved one to death or separation. §Lack of employment or increased financial burden Neurochemical factors: §Deficiency of serotonin in depressed clients associated with suicide. §Changes in the noradrenergic system of suicide victims. §Statistical significance found in cytokines (anti-inflammatory response chemicals) and low levels of fish oil nutrients. (omega 3) Genetic factors: §Twin studies show higher rate for monozygotic twins over dizygotic twins. §Genotypic variations in the gene for tryptophan hydroxylase relates to suicide.

Define human trafficking, types, statistics, and legislative responses.

§Approx. 800,000 people trafficked across borders annually. §50,000 brought to United States (2nd largest market)from Mexico and E. Asia. §80% women or girls §50% are minors §32 billion dollar industry (3rd largest source of income for organized crime). §Twice as many enslaved as during the African slave trade. §Health care providers are may have the opportunity to interact with trafficked women and girls while in captivity. §28% of trafficked women saw a health care professional while in captivity. §Healthcare providers missed opportunities to intervene. -Human Trafficking: (Us Department of State) §Forced labor, bonded labor §Debt bondage among migrant laborers §Involuntary domestic servitude §Forced child labor §Child soldiers §Sex trafficking 0What is Sex trafficking? §A commercial sex act that is induced by force, fraud or coercion, or when the person is < 18 years old. 0 Victims suffer from physical and psychological problems. 0Why don't they leave? §Debt bondage, control of their money, confiscation of passports/visas and ID. §Isolated from family and friends. 0Physical Health Problems: §Deprivation of food and sleep §Extreme stress §Hazards of travel §Violence (physical, sexual) §Hazardous work (STDs, multiple abortions) §Torture (broken bones, dental problems, burns, head injury) 0Psychological Health Problems §PTSD §Depression §Suicidal §Drug addiction §Somatic symptoms 0Watch for clues of trafficking: §Evidence of being controlled §Bruises or other injuries §Tattoos §Fear of deportation §Non-English speaking §Recent to U.S. §Lack of passport, ID §Fearful of authority §Reluctant to give out personal information §Role of the Nurse: §Care for physical needs (injuries, STDs, pregnancy test, assess SI) §Get victim alone §Get an interpreter, if needed §Build a trusting rapport §Pay attention to verbal and nonverbal cues §Minors are reported to CPS §911 if adult wants to report a crime §Doesn't want intervention: Phone # National Human Trafficking Resource Center (resources)

Describe the APA definition of mental illness.

"a syndrome characterized by clinically signifiant disturbance in an individual's cognitions, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological or developmental processes underlying mental functioning. mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. an expected or culturally approved response to a common stressor or loss such as the death of a loved one is not a mental disorder"

Determine appropriate use for the brief mental status exam (MSE) (Mini Mental Status Exam - MMSE), the Hamilton Depression Rating Scale (HAM-D), Hamilton Anxiety Rating Scale (HAM-A), Clinical Institute Withdrawal Assessment (CIWA), and Abnormal Involuntary Movement Scale (AIMS).

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Explore the reasons that psychiatric patients have difficulty maintaining adherence to prescribed medications.

-Denial of psychiatric illness -Suspicion or false beliefs about medications -No timely therapeutic effects -Inability to tolerate side effects -Financial barriers to purchase medications/clinical care -Logistical barriers to clinical care (transportation, child care) -Lack of drug education -Lifestyle interferes with regimen

Discuss use of community mental health facilities.

-Hackley Behavioral Health Unit= For adults 18 years and over. Adult Inpatient Program to stabilize the crisis situation. Provides an evaluation, a multidisciplinary treatment plan and coordinate care. -Health West= Provides mental health care; provides services in the areas of developmental disabilities, substance use, physical health, and early intervention and prevention. -Pine Rest= The North Shore Clinic serves the entire Grand Haven/Muskegon community. Behavioral health services; therapy and psychiatric services for children, adolescents, adults, and families.

Discuss the role of the nurse in identifying, communicating, and intervening on behalf of potential victims of trafficking.

-care for physical needs (injuries, STDs, pregnancy test, assess SI) -get victim alone -get an interpreter if needed -build a trusting rapport -pay attention to verbal and nonverbal cues -minors are reported to CPS -911 if adult wants to report -doesnt want intervention: phone # national human trafficking resource center

Apply Jahoda's six characteristics to develop in childhood to have positive mental health.

1-a positive attitude toward self (accepts strengths and weaknesses, strong sense of personal identity and security within the environment) 2-growth, development and the ability to achieve self-actualization (successfully achieves tasks of each level of development, with achievement the person gains motivation for advancement to highest potential) 3-integration (ability to adapt and respond appropriately. maintain anxiety at a manageable level in response to stressful situations.) 4-autonomy (ability to perform independently, makes choices and accepts responsibility for the outcomes) 5-perception of reality (perception of the environment without distortion, capacity for empathy and social sensitivity, respect and concern for wants and needs of others) 6-environmental mastery (achieved a satisfactory role in society or environment, able to love and accept the love of others, able to strategize, make decisions, adjust and adapt when faced with life situations)

Differentiate facts from myths about suicide.

1-myth: people who talk about suicide do not act on their ideas, it happens without warning. fact: 8/10 people who kill themselves have given definite clues and warnings 2-myth: you cannot stop a suicidal person. fact: most suicidal people are ambivalent 3: myth: once a person is suicidal he or she is suicidal forever. fact: suicidal ideation and risk fluctuate over time and may be time limited 4: myth: improvement after severe depression means that a person is no longer at risk of suicide. fact: most suicides occur within about 3 mo after the beginning of "improvement" when the individual has the energy to carry out suicidal intentions 5-myth: suicide is inherited or runs in families. fact: suicide is not inherited however suicide by close family member increases an individuals risk of suicide 6-myth: all suicidal individuals are mentally ill, and suicide is the act of a psychotic person. fact: although a majority of people who attempt suicide are extremely unhappy or clinically depressed, they are not necessarily psychotic. they are unable at that point in time to see an alternative solution to what they consider an unbearable problem 7-myth: suicidal thoughts and attempts should be considered manipulative or attention-seeking behavior and should not be taken seriously. fact: all suicidal behavior must be approached with the gravity of the potential act in mind. attention should be given to the possibility that the individual is issuing a cry for help 8-myth: people usually take their own lives by overdosing on drugs. fact: gunshot wounds are the leading cause of death among suicide victims 9-myth: if an individual has attempted suicide, he or she will not do it again. fact: between 50-80 percent of all people who ultimately kill themselves have at least one previous attempt 10-myth: suicide always happens in an impulsive moment. fact: people often contemplate and an in-depth exploration and assess may reveal these plans 11-myth: young children 5-12 cannot be suicidal. fact: each year 30-35 children younger than 12 take their own lives and not all are clinically depressed

Describe the cycle of battering.

1-tension building-tension mounts and woman accepts abuse as legitimate 2-acute battering incident-most violent and shortest-help is usually only sought in event of severe injury or woman fearing for life 3-honeymoon-batterer is loving and kind, apologizes, won't happen again

Discuss pathophysiologic, situational, and maturational causes of violent behavior

1.Modeling: (Strongest form of learning) §Children model behaviors of parents/caregivers. §Physically abused children become physically abusive as adults. §Television, video game violence can lead to aggressive behaviors. 2.Operant conditioning §Occurs when specific behavior is reinforced. §Positive reinforcement- pleasurable or rewarded behavior. §Example: Students completing homework/projects to earn a higher grade. The possibility of rewards causes an increase in behavior. §Negative reinforcement- Removal of a desirable outcome or the application of a negative outcome can be used to decrease or prevent undesirable behaviors. § Example: The child is to pick up toys and instead throws a tantrum. Mom picks up the toys and child is rewarded by not picking up toys. 3. Neurophysiological Disorders: § Epilepsy of temporal and frontal lobe origin. §Tumors in brain, (limbic and temporal lobes) §Trauma to brain with cerebral changes §Encephalitis 4.Biochemical Factors: §Hormonal dysfunction §Cushing's disease or hyperthyroidism §Neurotransmitters (epinephrine, norepi, dopamine, acetylcholine and serotonin) §May facilitate or inhibit aggressive impulses. 5. Socioeconomic Factors: §Increased violence in subculture of poverty in U.S. §Lack of resources, separation of families, alienation, discrimination and frustration. 6.Environmental Factors: §Physical crowding due to increased contact and decreased defensible space. §Uncomfortable temperatures increase aggression. Extreme heat decreases aggression. §Alcohol increases violent behavior. Cocaine, amphetamines

Explain the six QSEN competencies (Quality and Safety Education for Nurses) and how they apply to mental health.

1.Safety: Minimize risk of harm to patients and providers 2.Teamwork and Collaboration: Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care. 3.Patient-centered Care: Recognize the patient as the source of control and a full partner in providing compassionate and coordinated care, based on respect for patient's preferences, values, and needs. 4.Evidence-Based Practice (EBP): Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care 5.Informatics: Use information and technology to communicate, manage knowledge, mitigate error, and support decision making 6.Quality Improvement (QI): Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of healthcare systems.

Name major developments in mental health during the 1950's, 1963, 1983, and 1990's.

1950's 1954: Introduction of antipsychotic medications § Thorazine (chlorpromazine) had FDA approval for psychiatric treatment. Recognized as the 1st antipsychotic drug. § By the 1970s, tardive dyskinesia had diminish its use. §Did you know that the sedative effect of Thorazine is so similar to a surgical lobotomy that the drug has been controversially labeled a "chemical lobotomy"? 1955: Incorporation of Psychiatric Nursing as a requirement for all nursing schools early 1950's Treatment of psychotic patients included lobotomy, electroshock, or insulin coma therapy. 1963-Community Mental Health Centers Act (President John F. Kennedy signed) §Antipsychotic medications led to this movement §Construction of community mental health centers . §Deinstitutionalization movement (closing of state mental hospitals) 1983-The Mental Health Act (MHA) info on rights of those with mental health problems on: §assessment and treatment in hospital §treatment in the community §pathways into hospital, which can be civil or criminal 1990's- 1990: Americans with Disabilities Act, protects mentally and physically disabled Americans from discrimination in employment, public accommodations, transportation, telecommunications, and state and local government services. 1996: Mental Health Parity Act," the first federal legislation to bring more equity to health insurance coverage of mental health care.

Describe Common Core Measures for mental health care.

Admission Screening for Violence Risk, Substance Use, Psychological Trauma History and Patient Strengths completed; Support systems Hours of physical restraint use Hours of seclusion use Patients discharged on multiple antipsychotic medications Patients discharged on 2 or more antipsychotic medications with appropriate justification Post discharge continuing care plan created. Post discharge continuing care plan transmitted to next level of care provider upon discharge

Explain the following patient rights in psych mental health nursing and outline the role of the nurse in securing these rights: Right to Confidentiality and Privacy Right to Informed Consent.

right to confidentiality and privacy- §Pertinent medical information may be released without consent in a life-threatening situation. Must document date of disclosure, reason written consent was not obtained, and specific information disclosed. §Right to privacy is exempted in civil or criminal proceedings. (Remember your documentation can be used in court). §Duty to Warn (protection of 3rd party) Ø1974 case of Tarasoff v Regents of the U of California § https://www.youtube.com/watch?v=PnRzwSDFMYM ØGuidelines for therapist to follow in determining their obligation to take protective measures: §Assessment of a threat of violence by a client toward another individual. §Identification of the intended victim. §Ability to intervene in a feasible, meaningful way to protect the intended victim. ØSpecific situations may require notification of the victim, law enforcement, and/or relatives of the intended victim. Voluntary or involuntary commitment of the client may also be considered to preventpotential violence informed consent- ØAll clients have the right to decide whether to accept or reject treatment. §Informed consent protects the clients autonomy. §Informed consent: A client's permission for a procedure/treatment , such as electroconvulsive therapy. Ø4 factors must be verified for a consent to be valid: 1.The person giving consent must be mentally and physically competent and be legally an adult (> 18 years of age or emancipated). 2.The consent must be given voluntarily; no forceful measures may be used to obtain it. 3.The person giving the consent must understand the procedure, its risks and benefits, and alternative procedures. 4. The person giving consent has the right to have all questions answered satisfactorily and confirm understanding of the treatment given. §The nurse's signature witnessing the consent means: §The client voluntarily gave consent §The client's signature is authentic §The client appears to be competent to give consent. §Example: consent needed for electroconvulsive therapy. Client was not impaired. ØExceptions: §Client is mentally incompetent and treatment is needed to preserve life or avoid serious harm. §Refusing treatment endangers the life or health of another. §During an emergency when the client is in no condition to exercise judgment. §Children (consent needed from parent or guardian) §Therapeutic privilege (page 97) qInformation about treatment may be withheld if the physician can show that full disclosure would: §Hinder or complicate necessary treatment. §Cause severe psychological harm or §Be so upsetting as to render a rational decision by the client impossible.

Explain the legal scope of court ordered and deferred client status.

Admission Process: Voluntary: §2/3 of admissions for psychiatric treatment. §Client makes direct application to the facility for services and may stay until discharge appropriate. §Must give notice of intent to leave (3 business days). §Status can be changed to involuntary, if criteria met. Involuntary: ØMeets criteria of the following: §In emergent situations: Danger to self (suicidal intent) §In emergent situations: Danger to others (physically aggressive, violent, or homicidal) Due to mental illness, the client is unable to meet basic personal needs, despite available resources Gravely disabled: §Due to mental illness, serious physical harm may result from inability to provide for basic needs such as a food, clothing, shelter, medical care and personal safety. (Despite available resources) §A guardian will be appointed by the court to ensure management of the person or their estate. To restore competency, a court hearing is required to reverse the previous ruling Involuntary outpatient committment: §Court ordered to for treatment as an outpatient. Eligibility criteria: §History of repeated decompensation requiring hospitalization. §Client will likely deteriorate without outpatient treatment. §Presence of severe and persistent mental illness and limited awareness of the illness or need for treatment. §Illness contributes to risk of homelessness, incarceration, violence, or suicide. Treatment plan likely to be effective and a service provider has agreed to provide treatment Emergency Commitment: §Behavior is dangerous to self §Behavior is dangerous to others §Usually initiated by family, police, court, or health care professional. §Time limited with court hearing within 72 hours. Court may discharge, patient may volunteer admission, or involuntary admission if patient refuses voluntary status Process for petition: §Person 18 years old signs petition for treatment. §Must show probable cause for hospitalization with statements. §http://courts.mi.gov/administration/scao/forms/courtforms/pcm201.pdf §Danger to self §Danger to others §Mentally ill and in need of treatment. (unable to meet needs) §Gravely disabled §May request police for pick up by police and transferred to treatment facility. The Clinical Certificate §The clinical certificate certifies that the individual personally examined is mentally ill and a person requiring treatment. §The first certificate can be executed by any physician or licensed psychologist and is good for up to 72 hours prior to hospitalization. §The second certificate must be completed by a psychiatrist within 24 hours of hospitalization §Court Date scheduled §A court hearing is scheduled to hear case. §The court will appoint an attorney for the person. §Deferral Agreement §Before the scheduled hearing on the petition, the person and his/her attorney will meet to discuss whether the person will voluntarily agree to undergo mental health treatment. §If the respondent so agrees, a deferral agreement will be filled out and signed. §Subsequent Non-Compliance with the Deferral Agreement §If the person deferring does not comply with the agreement signed, the court is to be notified immediately through a demand for hearing to convene a hearing on the deferred petition. A hearing before the judge on the original petition will be scheduled The Court Hearing §The person has a right to be present with attorney. §A physician or psychologist who has personally examined the person must testify at the hearing. §The petitioner must attend the hearing. The judge will listen to the testimony and make a decision whether or not to order mental illness hospitalization Court Ordered Care §The typical initial order for mental health treatment will authorize up to 60 days of hospitalization and up to 90 days of alternative treatment. §The initial order may contain a conditional pick-up order if the person fails to follow treatment plan.

Explain the ethical principles of autonomy, beneficence, nonmaleficence, and justice as they related to the care of psychiatric patients

Autonomy ◦Respect for persons and their right to self determination. Examples: ◦Presenting all treatment options to a patient ◦Explaining risks in terms that a patient understands, ◦Ensuring that a patient understands the risks and agrees prior to surgery. Exceptions: Children Comatose Serious mental illness; incapable of informed decisions. ◦A representative may give consent. ◦Must ensure that representative is respectful of client's best interest. Beneficence Promote client well-being Examples: ◦Resuscitating a drowning victim, ◦Providing vaccinations for the general population, ◦Encouraging a patient to quit smoking and start an exercise program, ◦Community education on STD prevention. Nonmaleficence Non-maleficence means to "do no harm." Examples: ◦Stopping a medication that is shown to be harmful ◦Refusing to provide a treatment that has not been shown to be effective/harmful. Justice Right of clients to be treated equally and fairly regardless of race, sex, marital status, medical diagnosis, social standing, economic level or religion. In health care, refers to resources are to be distributed evenly without respect to socioeconomic status.

Explain how personal values impact the care of psychiatric patients

Clarifying the Nurse's Values §The nurse needs to examine the values they hold about life, death, health, and illness. Imposing your values on clients: §To exert direct influence over beliefs, feelings, judgments, attitudes and behaviors. May occur if unaware of your own attitudes: §Beliefs and feelings or if you hold strong prejudices against specific groups of people. §Actively: §Making direct statements to influence their course of action §Passively: §Nonverbal communication; crossing your arms or facial expressions when you disagree. Prevention: Neutrality §When your values conflict with those of your clients, maintain as neutral an attitude as possible. § It involves simply listening to and acknowledging what the client says without judgment or bias.

Differentiate treatment alternatives within the community. Community mental health centers Program of Assertive Community Treatment (PACT) Day-evening treatment / partial hospitalization programs Community residential facilities Psychiatric home healthcare

Community Mental Health: -Hackley Behavioral Health Unit= For adults 18 years and over. Adult Inpatient Program to stabilize the crisis situation. Provides an evaluation, a multidisciplinary treatment plan and coordinate care. -Health West= Provides mental health care; provides services in the areas of developmental disabilities, substance use, physical health, and early intervention and prevention. -Pine Rest= The North Shore Clinic serves the entire Grand Haven/Muskegon community. Behavioral health services; therapy and psychiatric services for children, adolescents, adults, and families. Program of Assertive Community Treatment: •Provides locally based tx to people with serious and persistent mental illnesses. •Case-management program: individualized services to consumers. •Provides treatment, rehab and support at their home, parks, stores, restaurants...etc. Where assistance is needed with living skills. •Team approach; includes psychiatry, social work, nursing, and substance abuse and vocational rehab •Services available 24 hrs./day; 365 days a year. Studies: PACT clients spend less time in hospitals, > independence, < unemployment, earn more income, > positive social relationships, > Satisfaction with life, and < symptoms. Day-evening treatment/partial hospitalization programs: •Day-Evening Treatment Programs; also called Partial Hospitalization •To prevent institutionalization •To ease transition from inpatient to community living. •Services: •Crisis intervention •Medication administration and monitoring. Offer a tx. Plan with psychiatrists, psychologists, nurses, occupational and Community residential facilities: -is a half-way house. (foster homes, etc.) -Provide a bridge between the institution and the community. -They work on a system of gradual, supervised release. -Includes life skills, substance abuse, employment and/or crisis counseling Psychiatric home healthcare: -Serious mental illness; stay in their home. -Must be homebound or great difficulty to leave home. -Nurse monitors medications, symptoms, adherence to plan.

Explain the term "boundaries" in the professional nurse-patient relationship. Analyze situations where boundaries may be violated and plan strategies to maintain professional boundaries

Definition: §Personal space, both physical and psychological. §Limits or degree of comfort in a relationship. Physical boundaries: §Closeness §Touching §Sexual behavior §Eye contact §Privacy (mail, diary, doors, nudity, bathroom, telephone, pollution (noise, smoke) qExamples of Invasion of physical boundaries: §Touching without permission, reading diary/mail without permission. Psychological Boundaries §Beliefs §Feelings §Choices §Needs §Time alone §Interests §Confidentiality §Individual differences §Spirituality §Examples of invasion of psychological boundaries: §HIPPA violation, Imposing your values. Nurse-patient relationship §Analyze situation where boundaries may be violated. §Plan strategies to maintain professional boundaries.

Identify short-term and long-term goals (outcome criteria) for the client with risk for violence and list nursing interventions & rationale for the potentially violent or violent patient. Which patient diagnoses are most at risk for violence?

Diagnoses with association to violence: shizophrenia, major depression, bipolar disorder and substance use disorder -substance abuse with mental illness compounds the risk -dementia and antisocial, borderline personality and intermittent explosive personality disorders associated with risk of violent behaviors GOALS: §Is able to recognize angry feelings and seeks out staff/support person. §Is able to take responsibility for own feelings of anger. §Demonstrates the ability to exert internal control over feelings of anger. §Is able to diffuse anger before losing control. §Does not cause harm to self or others. §Uses steps of the problem-solving process rather than becoming violent. Ineffective coping Client will be able to recognize anger and take responsibility before losing control NI: §Remain calm §Do not touch client §Client to write feeling of anger in a diary. Triggers and response. §Assist with finding the true source of the anger. §Assist with alternate ways of tension release. §Role modeling Risk for self-directed or other violence. The client will not harm self or others. Client will verbalize anger rather than hit others. §Observe client for escalation of anger-Prodromal syndrome. §What are the behaviors associated with prodromal syndrome? §Attempt to defuse anger with the least restrictive means. §Ensure sufficient staff is available to assist with potentially violent situation. §De-escalation techniques: §Talking down- "John, you seem very angry. Let's go to your room and talk about it" §Never position yourself without easy exit from a room. §Physical outlets. "Maybe it would help if you punched your pillow or the punching bag for a while." "I'll stay here with you if you want." §Medication-voluntary. If a threat to self or others reassess situation. §Call for assistance. Remove self and others from the immediate area. §Call violence code, push panic button, use facility Policy and procedures. §May take medication voluntarily when show of strength is present. Restraints. Mechanical restraints or seclusion if talking down and medication is not successful. sufficient staff must be present for safety

Analyze indications for the monitoring of these measures.

HBIS 1-Admission Screening Rationale: Evidence exists of a high prevalence of co-occurring substance use disorders as well as history of trauma among persons admitted to acute psychiatric settings. HBIS 2-Hours of Restraint Use Rationale: The use of seclusion and restraint is limited to situations deemed to meet the threshold of imminent danger and when restraint and seclusion are used; such use is rigorously monitored and analyzed to prevent future use. HBIS 3-Seclusion Rationale: The use of seclusion and restraint is limited to situations deemed to meet the threshold of imminent danger and when restraint or seclusion are used; such use is rigorously monitored and analyzed to prevent future use.

Differentiate Neuroleptic Malignant Syndrome from Serotonin Syndrome.

Neuroleptic Malignant Syndrome: More common with typical antipsychotics. Potentially fatal complication of treatment with antipsychotic drugs. Onset can occur within hours or even years after drug initiation. Progression is rapid over 24-72 hours. Symptoms: the two characteristic lab findings reported in 75% of cases are a high CPK and leukocytosis. The classic triad involves the autonomic nervous system, the extrapyramidal system and cognitive changes. Severe parkinsonism muscle rigidity, very high fever, tachycardia, tachypnea, fluctuations in BP, diaphoresis, rapid deterioration of mental status, stupor, coma. Mneomonic is FEVER= fever, encephalopathy, vitals unstable, elevated enzymes (CPK), rigidity of muscles Nursing role: -Discontinue antipsychotic medication immediately. -Monitor vital signs, degree of muscle rigidity -Intake and output -Level of consciousness Treatment: Cooling, hydration, benzodiapines (chemical restraint) -Bromocriptine (Parlodel-dopamine agonist), dantrolene (Dantrium-muscle relaxant), amantadine (Symmetrel) Serotonin syndrome: The greatest risk of serotonin syndrome occurs if you are taking two or more drugs and/or supplements together that influence serotonin. The condition is more likely to occur when you first start a medicine or increase the dose. Major symptoms FEVER + MAN. Mental status changes, autonomic GI, neuromuscular disturbances

Develop nursing diagnoses and expected outcomes for victims of domestic abuse. What nursing interventions and teaching would be most important? Identify available community resources for referrals.

Powerlessness r/t cycle of battering evidenced by verbalizations of the attack; bruises and lacerations over areas of the body; severe anxiety. Outcomes: üImmediate attention to physical injuries. üVerbalizes assurance of immediate safety. üDiscusses life situation with nurse. üCan verbalize choices to receive assistance. -Safe house or shelter (nurses, psychologists, lawyers, and others) §Protection from abuser §Emotional support §Individual and group counseling §Help with police, legal representation, and social services. §Child care and children programs §Aid for future plans such as employment counseling and links to housing authorities. §Support groups. -Family Therapy §Help to develop democratic ways of solving problems. -Have a safety plan

Describe the views of mental health in the following periods: prehistoric, 17th - 20th centuries.

Prehistoric: •Dispossessed of soul -Treatment: Soul to be returned •Evil spirits or supernatural/magical powers had entered body -Treatment: Exorcism to purge body (beatings, starvation, torture) •Broken taboo or sinned -Treatment: Ritualistic purification or retribution. •Demons or witchcraft -Treatment: Burned at the stake •Hippocrates 400 BC -Believed body fluids; blood, black and yellow bile and phlegm (humors) were not aligned causing mental illness. -Treatment: induce vomiting and diarrhea with potent cathartics. Middle Ages (500-1500 AD) •Europe •Witchcraft and supernatural in Severe mental illness were sent out to sea on sailing boats to search for their lost rationality. (Expression "ship of fools" derived from this) •Middle Eastern Islamic countries •Actually ill •Special units within general hospitals for mental illness and residential institutions (first asylums) •Colonial Americans •Punished for behaviors associated with witchcraft U.S. 16th and 17th Century •Care of mentally ill was the family's responsibility •If no family, incarcerated to avoid harm to others U.S. 18th century •First hospital in America to admit clients with mental illness in Philadelphia. •Benjamin Rush, often called "father of American psychiatry", was a physician at the hospital. (Rush University Medical College was named the in honor of Benjamin Rush, MD, the only physician with medical school training to sign the Declaration of Independence.) •Initiated humanistic treatment and care with kindness, exercise and socialization. •Also used bloodletting, purging, physical restraints, and extremes of temperatures, 19th Century: State asylums §Dorothea Dix (school teacher) lobbied on behalf of mentally ill population §Belief that mental illness was curable and that state hospitals should provide humanistic therapeutic care. §Mentally ill populations grew faster than state hospitals leading to overcrowded, understaffed and deteriorated conditions. §Therapeutic care reverted to custodial care. §1873 Psychiatric Nursing: graduation of Linda Richards in Boston. (1st American psychiatric nurse) §Established a number of psychiatric hospitals §First school of psychiatric nursing in Massachusetts in 1882. (Training to provide custodial care) 1940s and early '50s §Treatment of psychotic patients included lobotomy, electroshock, or insulin coma therapy. 1946: National Mental Health Act (Post World War 11) §Provided funding for the education of psychiatrist, psychologists, social workers and psychiatric nurses as a result of veterans returning from the war. 1949: National Institute of Mental Health (NIMH). §US government agency for mental health 1954: Introduction of antipsychotic medications § Thorazine (chlorpromazine) had FDA approval for psychiatric treatment. Recognized as the 1st antipsychotic drug. § By the 1970s, tardive dyskinesia had diminish its use. §Did you know that the sedative effect of Thorazine is so similar to a surgical lobotomy that the drug has been controversially labeled a "chemical lobotomy"? 1955: Incorporation of Psychiatric Nursing as a requirement for all nursing schools 1963: Community Mental Health Centers Act (President John F. Kennedy signed) §Antipsychotic medications led to this movement §Construction of community mental health centers . §Deinstitutionalization movement (closing of state mental hospitals) 1983: The Mental Health Act (MHA) info on rights of those with mental health problems on: §assessment and treatment in hospital §treatment in the community §pathways into hospital, which can be civil or criminal 1990: Americans with Disabilities Act, protects mentally and physically disabled Americans from discrimination in employment, public accommodations, transportation, telecommunications, and state and local government services. 1996: Mental Health Parity Act," the first federal legislation to bring more equity to health insurance coverage of mental health care.

Explain patient rights in psych mental health nursing and outline the role of the nurse in securing the right to least-restrictive treatment alternative

Right to least-restrictive treatment alternative: §Outpatient §Day hospital §Voluntary hospitalization §Involuntary hospitalization Right to least-restrictive symptom treatment: §Verbal techniques §Behavioral techniques §Chemical restraints §Mechanical restraints ØThe Patient Self-determination Act (1990) requires health care facilities to provide information for every patient concerning their legal rights to make healthcare decisions including the right to accept or refuse treatment. Must use least restrictive first such as talking down or chemical restraint Need doctor's order within 1 hour of application ◦If phone order, need renewal order in 2 hours. ◦If seen in person, need renewal order in 4 hours. Orders time limited with periodic review Client is observed and assessed every 10 minutes including: ◦Circulation ◦Respiration ◦Nutrition ◦Hydration ◦Elimination Remove restraints every 2 hours Renewal order required every 4 hours.

Discuss the Bill of Rights for Psychiatric Patients and how it relates to clinical practice.

Right to refuse medication §Voluntary admits may refuse. §Involuntary admits may refuse meds. No Right to refuse Medication §Threat of harm to self or others cannot refuse ER interventions. §Court ordered cannot refuse. ØRefusal of psychotropic medication may lead to: §Voluntary changed to Involuntary status §Petition for Court hearing §Client discharge from hospital ØRight to the least-restrictive treatment alternative §Verbal (Talk them down) §Behavioral techniques (Crisis team) §Chemical intervention (medications) §Mechanical restraints (Seclusion)

Explain the AIMS assessment scale.

The Abnormal Involuntary Movement Scale (AIMS) Measures involuntary movements associated with tardive dyskinesia. (antipsychotics) Aids in early detection of movement disorders Provides a means for ongoing monitoring. **Score 0 (none) to 4 (severe) Interpretation of AIMS **0-1=low risk **2 in only 1 of the areas assessed=borderline/observe closely **2 in two or more of the areas or 3-4 in 1 area=indicative of TD

Identify a short-term and a long-term goal for the patient who has high risk for self-directed violence and practice nursing interventions for the actively suicidal patient.

The client will not harm self or others. The client will verbalize anger rather than hit others. NI actively suicidal patient: 1.What nursing interventions are needed to prevent client injury? Rationales? üClose observation; 1:1 observation if suicide attempted. üRoom cleared of potential weapons. üRemove all clothing and place in patient gown. Observe for weapons medications. üRemove all personal belongs from patient's reach. Medications to pharmacy. üRoom close to nursing station. üDo not assign a private room. üAccompany patient to BR and off unit for testing, etc. (ED and medical unit 1:1) 5.What is "special care" when administering medications? Rationale? §Nurse to observe patient taking medication. §Client to open mouth and show mouth clear of medications. (under tongue and cheeks) 6.When and how often should nursing rounds occur? Rationale? §Frequent rounds at irregular intervals. §Especially at busy times on unit. (shift change) 7. How would you ask a client about their feelings and anger? Rationale?

Describe assessment of the patient at risk for other-directed violence. What symptoms often precede violent behavior?

afety of client and others is the nurse's priority. Client feels underlying helplessness. 3 Factors to assess for potential violence: 1.Past history of violence §Major risk factor for violence in a treatment setting. 2.Client diagnosis §Diagnoses with association to violence: Schizophrenia, major depression, bipolar disorder and substance use disorders. §Substance abuse with mental illness compounds the risk. §Dementia and antisocial, borderline personality and intermittent explosive personality disorders associated with risk of violent behaviors. 3.Current behavior §A client's threatening behavior may be an overreaction to feelings of impotence, helplessness, feelings of humiliation. §Aggression rarely occurs suddenly and unexpectedly. Prodromal syndrome- characterized by anxiety and tension, verbal abuse and profanity and increasing hyperactivity Certain behaviors are predictive of impending violence and have been termed the prodromal syndrome, including § §Rigid posture §Clenched fists and jaws §Grim, defiant affect §Talking in a rapid, raised voice §Arguing and demanding §Using profanity and threatening verbalizations §Agitation and pacing §Pounding and slamming § §Prodromal syndrome behaviors should be considered emergent with immediate attention. Broset Violence checklist== What behaviors are scored? 1.Confusion 2.Irritability 3.Boisterousness 4.Physical threats 5.Verbal threats 6.Attacks on objects §Score 1 pt. for each behavior observed. §Interpretation of BVC score §Score = 0: Risk of violence is small §Score = 1-2: The risk of violence is moderate § Preventative measures should be taken §Sum = > 2: The risk of violence is high. §Preventative measures should be taken (De-escalation)

analyze indications for various medications.

antipsychotics/neuroleptics/major tranquilizers: indicated for acute and chronic symptoms of schizophrenia, maintenance therapy to prevent symptoms anxiolytics: benzos: indicated for anxiety disorders, temporary relief of anxiety, alcohol withdrawal, seizures antidepressants: indicated for panic disorder, OCD, GAD Beta blockers: indicated for phobias particularly social phobia and performance anxiety Antidepressants: indicated for dysthmic disorder, major depression, depression associated with organic disease, alcoholism mood stabilizers: lithium-indicated for prevention and treatment of manic episodes associated with bipolar disorder anticonvulsants-indicated to stabilize mood in bipolar disorder stimulants-indicated for ADHD, depression, narcolepsy, shift work sleep disorder, weight loss

Analyze assessment findings in regards to side effects of medication use.

antipsychotics: typical 1st gen-anticholinergic: dry mouth, blurred vision, constipation, urinary retention (cant pee cant see cant spit cant ....) EPS, galactorrhea, dizzy, orthostatic hypotension, tremors, tachycardia, weight gain and sedation 2nd gen-atypical-hyperglycemia zyprexa/olanzapine, seroquel/quetiapine, clozaril/clozapine agranulocytosis-clozaril cardiotoxicity-risperdal(risperidone) orthostatic hypotension cataracts eyes-eye exam q 6 mo-seroquel/quietiapine agranulocytosis-clozapine (clozaril) high risk baseline WBC count must be checked prior to initiation, weekly or biweekly for 6 mo, after 6 mo, monthly, meds given with each lab draw, usually occurs within the first 3 mo of treatment Symptoms: sore throat, fever, malaise, CBC with symptoms, hold med with WBC <3000 EPS: dystonia: involuntary muscle spasm of face, arms, legs and or neck, most often in men and < 25 years Pseudo-parkinsonism-tremor, shuffling gait, drooling, rigidity, symptoms 1-5 days post antipsychotic medications akathisia-continuous restlessness and fidgeting, may occur after 5-60 days after med initation tardive dyskinesia-bizarre facial and tongue movements, stiff neck and difficulty swallowing. most common with typical antipsychotics, but can occur with all classifications. potentially irreversible. stop med at first sign. akinesia-muscular weakness, same as pseudoparkinsonism ocululogyric crisis: uncontrolled rolling back of the eyes, may occur with dystonia (mistaken for seizures) neuroleptic malignant syndrome: FEVER=fever, encephalopathy, vitals unstable, elevated enzymes (elevated CPK&leukocytosis), rigidity of muscles anxiolytic drugs: benzos-drowsiness, dizzy, lethargy, N/V, ataxia, dry mouth, blurred vision, hypotension, physical/psych addiction and tolerance buspirone-dizzy, drowsiness beta blockers-light headedness, sleepiness, nausea, bradycardia antidepressants-serotonin syndrome: FEVER+MAN=mental status changes, autonomic GI, neuromuscular disturbances mood stabilizers: liver, pancreas impairment, Stevens johnson syndrome, thrombocytopenia stimulant drugs: weight loss, insomnia (admin in AM), fatigue, liver enzyme elevation

Analyze behaviors in psychiatric nursing that may result in charges of defamation of character, libel, slander, invasion of privacy, assault, and battery.

defamation of character-when shared information is detrimental to clients reputation, person sharing information may be liable for this, involves communication malicious and false libel-when information is in writing, action is called libel, also arises out of critical, judgmental statements written in client's medical record. nurses need to be objective and back up statements with factual evidence slander-oral defamation detrimental to clients reputation invasion of privacy-searched without probable cause. protection is provided in facility policies/procedures for search of belongings on admission. A body search requires a physician order and rationale for search assault-act that results in persons genuine fear and apprehension he or she will be touched without consent battery-nonconsensual touching of another person false imprisonment: -Deliberate and unauthorized confinement of a person by use of verbal or physical means. -Restraining or secluding against the wishes of the client when under voluntary status/not deemed emergent situation.

Practice documentation using focus charting be prepared to use in the clinical setting.

focus can be: nursing diagnosis, current pt concern or behavior, significant change in pt status or behavior, significant event in patient's therapy. the focus cannot be medical dx. the documentation is organized in DAR format as follows: -D: Data: information that supports the stated focus or describes pertinent observations about the patient -A: Action: immediate or future nursing actions that address the focus and evaluation of the present care plan along with any changes required -R: Response: description of patient's responses to any part of the medical or nursing care

Differentiate the admission process for voluntary, involuntary, and emergency commitment.

involuntary-the person is imminently dangerous to himself, danger to others or unable to take care of needs -person recommending must be able to show probable cause due to mental illness, client is unable to meet basic personal needs despite available resources (gravely disabled)= §Due to mental illness, serious physical harm may result from inability to provide for basic needs such as a food, clothing, shelter, medical care and personal safety. (Despite available resources) §A guardian will be appointed by the court to ensure management of the person or their estate. §To restore competency, a court hearing is required to reverse the previous ruling. emergency commitment-behavior is dangerous to self, behavior is dangerous to others, usually initiated by family, police, court, or health care professional, time limited with court hearing within 72 hours, court may discharge patient may volunteer admission or involuntary admission if patient refuses voluntary status voluntary: 2/3 of admissions, client makes direct application to facility for services and may stay until discharge is appropriate, must give notice of intent to leave (3 business days), status can be changed to involuntary if criteria met

Explain the profile of victims of domestic abuse and the profile of the victimizer/abuser.

largest percentage women many have low self esteem and accept blame for actions, some grew up in abusive homes adhere to feminine sex role stereotype and accept blame feelings of guilt shame isolation learned helplessness victimizer-men have low self esteem and are jealous, stressed, limited coping ability, possessive, strives for isolation, demands to know where person is at all times dual personality 1 to partner and 1 to rest of world considers spouse a posession, wants her totally dependent on him threatened when spouse shows signs of independence or shares self with others insults and humiliates spouse children can become pawns

Illustrate phases of the therapeutic nurse client relationship and the tasks of the nurse in the pre interaction, orientation, working and termination phases.

preinteraction-prep for first encounter w pt orientation-nurse and pt become acquainted, setting goals, developing plan, assessment, nursing diagnoses working-therapeutic work is here. maintaining trust, problem solving, evaluating progress, etc termination-goals may be reached, pt discharged, clinical ends

Differentiate examples of health promotion, illness prevention, and health restoration in mental health nursing. (primary, secondary, and tertiary preventions)

primary---services aimed at reducing the incidence of mental disorders within the population emphasis includes: 1) assisting individuals to increase their ability to cope w stress 2) targeting and diminishing harmful forces -nursing focus: teaching parenting skills and child development to prospective new parents, teaching effects of alcohol/drugs to elementary students, teaching stress management to general population secondary--interventions aimed at minimizing early symptoms of psychiatric illness and directed toward reducing prevalence and duration of illness. emphasis: early identification of problems and prompt initiation of effective treatment nurse: ongoing assessment of individuals at high risk for exacerbation of illness, provision of care, referrals tertiary--services directed at reducing residual defects associated with severe and persistent mental illness. prevent complications of illness. promote rehabilitation to achieve the person's maximal level of functioning. nurse-teaching the client daily living skills and encourage independence to their maximum ability, referrals to aftercare, support groups, day treatment, group home SEE CHART

Review the ANA Standards for Psychiatric Mental Health Nursing and be ready to apply to your assigned patients

see professional and ethical responsibilities pg 1-3

Formulate a definition of mental health.

successful adaptation to stressors from internal or external environment, evidenced by thoughts, feelings, and behaviors that are age-appropriate and congruent with local and cultural norms

Describe environmental safety risks and modifications for angry, suicidal, and violent patients.

suicidal- üClose observation; 1:1 observation if suicide attempted. üRoom cleared of potential weapons. üRemove all clothing and place in patient gown. Observe for weapons medications. üRemove all personal belongs from patient's reach. Medications to pharmacy. üRoom close to nursing station. üDo not assign a private room. üAccompany patient to BR and off unit for testing, etc. (ED and medical unit 1:1) angry/violent- §Remain calm §Do not touch client §Client to write feeling of anger in a diary. Triggers and response. §Assist with finding the true source of the anger. §Assist with alternate ways of tension release. §Role modeling §De-escalation techniques: §Talking down- "John, you seem very angry. Let's go to your room and talk about it" §Never position yourself without easy exit from a room. §Physical outlets. "Maybe it would help if you punched your pillow or the punching bag for a while." "I'll stay here with you if you want." §Medication-voluntary. If a threat to self or others reassess situation. §Call for assistance. Remove self and others from the immediate area. §Call violence code, push panic button, use facility Policy and procedures. §May take medication voluntarily when show of strength is present. §Restraints. Mechanical restraints or seclusion if talking down and medication is not successful. Sufficient staff must be present for safety.

Explain Peplau's sub roles within the role of the nurse as a health team member.

the stranger-at first the nurse is a stranger to pt the resource person-provides answers to questions and explains in way pt can understand the teacher-identifies learning needs and provides info required by the pt or family to improve the health situation the surrogate-symbol of other individual technical expert-professional devices and clinical skills leader- counselor-using interpersonal techniques

Examine co-dependency issues among professionals and between patients and families

§Lacks autonomy, self-esteem, and sense of power. §Able to achieve a sense of control only through fulfillling the needs of others. §Disowns their needs and wants to respond to demands of others. §Dysfunctional relationship with self. Behaviors of codependency: §History of focusing thoughts and behavior on other people §Are "people pleasures" and will do almost anything for approval of others. §Appear competent, but feel needy, helpless, or nothing at all. §Have experienced abuse or emotional neglect as a child. §Difficulty with self direction and sense of self. Between patients and families Co-dependent Nurse Short staffing and increase in seriously ill patients may result in nursing caring for others, not self. §Unmet emotional needs lead to compulsive behaviors such as work, spending, or addictions. §Need to be in control §Strive for unrealistic level of achievement. §Self-worth from feeling needed by others and control of their environment. §Nurture dependence of others and accept responsibility for the happiness and contentment of others §Rarely express their true feelings §Do what is necessary to preserve harmony and maintain control §At high risk for physical and emotional burnout

Apply de-escalation techniques to the plan of care for the client expressing anger.

§Talking down- "John, you seem very angry. Let's go to your room and talk about it" §Never position yourself without easy exit from a room. §Physical outlets. "Maybe it would help if you punched your pillow or the punching bag for a while." "I'll stay here with you if you want." §Medication-voluntary. If a threat to self or others reassess situation. §Call for assistance. Remove self and others from the immediate area. §Call violence code, push panic button, use facility Policy and procedures. §May take medication voluntarily when show of strength is present. §Restraints. Mechanical restraints or seclusion if talking down and medication is not successful. Sufficient staff must be present for safety.

Differentiate other factors that support diagnosis on DSM 5.

•Provides the standard language by which clinicians, researchers, and public health officials in the United States communicate about mental disorders. •Current DSM-5 was published in May 2013, marking the first major overhaul of diagnostic criteria and classification since the DSM-IV in 1994. •The previous version of DSM was completed nearly two decades ago; since that time, there has been a wealth of new research and knowledge about mental disorders. •What is DSM and why is it important? •Contains descriptions, symptoms, and other criteria for diagnosing mental disorders. •Provides a common language for clinicians to communicate about their patients and establishes consistent and reliable diagnoses that can be used in the research of mental disorders. •Provides a common language for researchers to study the criteria for potential future revisions and to aid in the development of medications and other interventions