Professional Identity: Mental Health Nursing

John is a 24-year-old-male brought in by spouse for "strange behavior". He has not slept in three days. There is a weight loss of 6 pounds, and he has a disheveled look. Hygiene is poor, and he was pacing during the interview. He states being frustrated because he is about to make a breakthrough on a cure for a rare disease, and his wife won't leave him alone. He speaks rapidly and demonstrates a flight of ideas. He denies visual or auditory hallucinations. He has periods of crying mixed with periods when he laughs uncontrollably. In addition, he makes sudden decisions about being thirsty or needing a cigarette. - Valerie, RN John is up eating breakfast. The previous shift documented 4 hours of sleep last night. He has also had less episodes of crying and laughter. He took a shower this morning without assistance, and his weight today was the same as on admission. He continues to be impatient when he wants a cigarette and refuses to wait for the scheduled breaks. He spent yesterday on a jigsaw puzzle. Review John's goals and select which ones have been met based on the most recent progress note: 1. John will demonstrate less periods of crying or intense laughter 2. John will demonstrate an appropriate emotional response to external stimuli 3. John will demonstrate the ability to wait for water and cigarettes 4. John will verbalize that his previous thoughts were not based on reality 5. John will independently perform self-care consistently 6. John will sleep at least 6 hours at night 7. John will maintain or increase this weight

1. Met 2. Unable to Evaluate 3. Not Met 4. Unable to Evaluate 5. Met 6. Not Met 7. Met John has not verbalized anything about his previous thoughts. He continues to be impatient about his cigarette use. He only slept four hours the previous night, so these goals have not yet been met. There is not evidence to evaluate if John is having appropriate emotional responses or acknowledging that his thoughts were not based on reality.

Professional identity in mental health nursing starts with a nurse's use of self. Which statement is the best example of this? a. A nurse completing a personality test b. A nurse asking a client to complete a depression scale c. Practicing a regular exercise regimen d. Eating healthy foods on a regular basis

a. A nurse completing a personality test Professional identity in mental health nursing starts with a nurse's use of self. This involves knowing and understanding one's own thoughts, feelings, and actions, and how they relate to the care of the client with alterations in mental health. A nurse completing a personality test would best help them understand use of self, not by completing a depression scale, practicing a regular exercise program, or eating healthy foods on a regular basis.

A client is having an argument with another client in the main area of the facility. Which intervention will help the situation? a. Bring the client back to their room b. Encourage the client to verbalize their feelings c. Give the client their prescribed anti-anxiety medication d. Ask the client not to talk to the other clients

a. Bring the client back to their room To best diffuse the situation, bringing the client back to their room will reduce the potential for an escalation in the argument. The other choices may not deescalate the situation or may make things worse.

John (pronouns he/him/his) is brought into the crisis center by his wife. The wife is concerned about recent behaviors. Analyze the following assessment findings. John is a 24-year-old-male brought in by spouse for "strange behavior". He has not slept in three days. There is a weight loss of 6 pounds, and he has a disheveled look. Hygiene is poor, and he was pacing during the interview. He states being frustrated because he is about to make a breakthrough on a cure for a rare disease, and his wife won't leave him alone. He speaks rapidly and demonstrates a flight of ideas. He denies visual or auditory hallucinations. He has periods of crying mixed with periods when he laughs uncontrollably. In addition, he makes sudden decisions about being thirsty or needing a cigarette. - Valerie, RN When seeing a client for a mental health alteration, which findings need further assessment? Select all that apply. a. Disheveled appearance b. Avoidance of eye contact c. Rapid speech d. Client states that he has cured cancer e. Irregular heart rate

a. Disheveled appearance b. Avoidance of eye contact c. Rapid speech d. Client states that he has cured cancer Disheveled appearance, grandiosity, abnormally fast speech patterns, and avoidance of eye contact can all be signs of worsening mental health issues. Irregular heart rate, while important, does not indicate an alteration in mental health.​

John is a 24-year-old-male brought in by spouse for "strange behavior". He has not slept in three days. There is a weight loss of 6 pounds, and he has a disheveled look. Hygiene is poor, and he was pacing during the interview. He states being frustrated because he is about to make a breakthrough on a cure for a rare disease, and his wife won't leave him alone. He speaks rapidly and demonstrates a flight of ideas. He denies visual or auditory hallucinations. He has periods of crying mixed with periods when he laughs uncontrollably. In addition, he makes sudden decisions about being thirsty or needing a cigarette. - Valerie, RN Based on the information, which nursing diagnoses could be used for John? Select all that apply. a. Disturbed thought processes b. Disturbed sensory perception c. Hopelessness d. Impaired mood regulation e. Self-mutilation f. Self-care deficit

a. Disturbed thought processes d. Impaired mood regulation f. Self-care deficit John has a disordered state of mind (re: breakthrough on a cure for a rare disease and flight of ideas) displaying disturbed thought processes. John has self-care deficits with lack of sleep, poor hygiene, and a disheveled appearance. John has periods of crying mixed with laughter consistent with impaired mood regulation. There is no evidence in John's history to support hopelessness or self-mutilation. John denies visual or auditory hallucinations, and therefore, does not have disturbed sensory perception.

John was diagnosed with bipolar psychosis. Which treatments would you expect him to receive during this hospitalization? Select all that apply. a. Group therapy b. Sertraline c. Therapeutic communication d. Olanzapine e. Electroconvulsive therapy

a. Group therapy c. Therapeutic communication d. Olanzapine John will be getting group therapy, therapeutic communication, and olanzapine (atypical antipsychotic). We might also expect that he receives lithium sodium for maintenance as well. Sertraline and electroconvulsive therapy are used for major depressive disorder.

Which findings are concerning for a mental health illness? Select all that apply. a. Hallucinations b. Flight of ideas c. Rapid speech d. Insomnia e. Poor hygiene

a. Hallucinations b. Flight of ideas c. Rapid speech d. Insomnia e. Poor hygiene Assessment findings such as insomnia, poor hygiene, hallucinations, flight of ideas, and rapid speech are concerning for mental illness. Elements of a mental status assessment include components reflective of appearance, behavior, cognition, and thought processes.

Review the available nursing diagnoses and match with most optimal goals for John's care: John will demonstrate less periods of crying or intense laughter a. Labile emotional control b. Impaired mood regulation c. Ineffective impulse control d. Disturbed thought processes e. Insomnia f. Altered nutrition level

a. Labile emotional control

Which nursing diagnosis would you expect a client experiencing major depressive disorder (MDD) to experience? a. Self-care deficit b. Disturbed thought processes c. Disturbed sensory perception d. Ineffective impulse control

a. Self-care deficit Someone with major depressive disorder can experience self-care deficits (specifically hygiene-related care), hopelessness, and possibly self-esteem issues. They are not likely to experience disturbed sensory perception or thought processes (hallucinations and delusions), or ineffective impulse control. These types of diagnoses are more likely with a bipolar disorder.​

Prioritizing Nursing Diagnoses​

always prioritize life-threatening behavior first, & consider Maslow's hierarchy in understanding each circumstance

A new nurse is orienting to the impatient mental health unit. Which statement suggests the nurse may need additional guidance? a. "Using a validated survey instrument is something I will be doing frequently in this population." b. "I will be frequently using my stethoscope to listen to heart and lung sounds." c. "I should always know where the exits are, and which staff are available if I need assistance with a client." d. "Reviewing a client's behavior and actions is important to the care of this population."

b. "I will be frequently using my stethoscope to listen to heart and lung sounds." While stethoscopes are used routinely in this population, they are not used often unless there is a specific medical concern to address. In addition, they can be a hazard on the unit as they could be used as a weapon.

Review the available nursing diagnoses and match with most optimal goals for John's care: John will demonstrate an appropriate emotional response to external stimuli a. Labile emotional control b. Impaired mood regulation c. Ineffective impulse control d. Disturbed thought processes e. Insomnia f. Altered nutrition level

b. Impaired mood regulation

A nurse was just hired as a case manager for a local outpatient mental health facility. Which of the following things can the nurse expect to do in their new position? Select all that apply. a. Administer medications to clients b. Organize interdisciplinary meetings for the clients c. Clean the client's room d. Evaluate the client to determine the best discharge plan e. Assess the client's vital signs

b. Organize interdisciplinary meetings for the clients d. Evaluate the client to determine the best discharge plan A case manager will usually plan interdisciplinary meetings and create a discharge plan. Most case managers do not administer medications, clean the client's room, or assess vital signs; these are things that the assigned clinical nurse might do.

While John is experiencing bipolar psychosis or mania, which conditions could present with similar signs and symptoms? Select all that apply. a. Meningitis b. Substance misuse c. Closed head injury d. Hyperthyroidism e. General anxiety disorder

b. Substance misuse d. Hyperthyroidism e. General anxiety disorder Hyperthyroidism, substance misuse (especially methamphetamines or cocaine), and generalized anxiety disorder can display similar symptoms. Meningitis and closed head injury usually present with an altered level of consciousness.

Review the available nursing diagnoses and match with most optimal goals for John's care: John will demonstrate the ability to wait for water and cigarettes a. Labile emotional control b. Impaired mood regulation c. Ineffective impulse control d. Disturbed thought processes e. Insomnia f. Altered nutrition level

c. Ineffective impulse control

The nurse is answering the crisis line at the local mental health facility. The following call comes in: Caller: "Hi my name is Sarah, there is something wrong with my husband and I don't know what to do." Nurse: "I am so sorry to hear you're having some problems. Can you tell me more about how your husband is acting, and when it started?" Caller: "A few days ago I noticed that he just hasn't been sleeping as well. He's always awake and working on something. When I asked, he said he had been up at night trying to find a cure to brain cancer. He told me he didn't need to sleep. I've also noticed that he hasn't been taking showers or shaving at all, and he talks real fast sometimes - so fast I have a hard time understanding him. When he talks, it seems like he jumps from one thing to another, he just isn't making much sense. I just don't know what to do!" Complete the nurse's phone note below with the findings noted by the caller: Partner is calling about her husband. She states three days ago he started exhibiting ________, ____________, and__________. She notices that he has ________ and a _______. I recommended immediate evaluation by our crisis team. She agreed, and a call was placed to them with request to respond. - Linda B., RN a. hypersomnia b. sleep apnea c. insomnia a. hallucinations b. delusions of grandeur c. hyperactivity a. poor hygiene b. good self-care c. no need to shave a. low speech b. word salad c. rapid speech a. rapid thoughts b. flight of ideas c. much to say

c. insomnia b. delusions of grandeur a. poor hygiene c. rapid speech b. flight of ideas Partner is calling about her husband. She states three days ago he started exhibiting insomnia, hypersomnia, sleep apnea, delusions of grandeur, and poor hygiene. She notices that he has rapid speech and a flight of ideas. I recommended immediate evaluation by our crisis team. She agreed, and a call was placed to them with request to respond.

Review the available nursing diagnoses and match with most optimal goals for John's care: John will verbalize that his previous thoughts were not based on reality a. Labile emotional control b. Impaired mood regulation c. Ineffective impulse control d. Disturbed thought processes e. Insomnia f. Altered nutrition level

d. Disturbed thought processes

In taking care of a client with depression, the nurse notes a worsening in symptoms. Which assessment findings would be included in the nurse's report when calling the healthcare provider? Select all that apply. a. They have been in the common area playing board games b. The client ate more of their lunch today than normal c. The client is combing their hair d. They scored 70 on the Zung Depression Scale today, which is 10 more than yesterday e. The client refuses to eat today

d. They scored 70 on the Zung Depression Scale today, which is 10 more than yesterday e. The client refuses to eat today When notifying a provider, it is important to include scale measurement which may be repeated from a previous measurement, symptoms of worsening depression include not eating, avoiding self-care activities, and avoiding social interaction with others.

Which of the following assessment items is most common in the mental health settings? a. Reflex hammer b. Electrocardiogram c. Stethoscope d. Validated survey tools

d. Validated survey tools The most common assessment tool used in a mental health setting is a validated survey tool. These tools enable the nurse to identify changes in behavior or emotion, and severity of symptoms. Electrocardiograms, stethoscopes, and reflex hammer, while used, do not give as much information specific to mental health issues.​

Review the available nursing diagnoses and match with most optimal goals for John's care: John will sleep at least 6 hours at night a. Labile emotional control b. Impaired mood regulation c. Ineffective impulse control d. Disturbed thought processes e. Insomnia f. Altered nutrition level

e. Insomnia

Environmental Situations

environmental situations may be the cause or result of these diagnoses, including:​ ● dysfunctional family processes​ ● ineffective relationship

Review the available nursing diagnoses and match with most optimal goals for John's care: John will maintain or increase this weight a. Labile emotional control b. Impaired mood regulation c. Ineffective impulse control d. Disturbed thought processes e. Insomnia f. Altered nutrition level

f. Altered nutrition level

Mental Health Nursing Assessment

focuses less on physical findings, & more on psychosocial, cognitive, emotional, & behavioral symptoms

Professional Identity

in mental health nursing starts with a nurses use of self

Case Management in Mental Health​

is a model of care delivery meant to bring different disciplines together & assist with the planning of the clients in hospital care & pending discharge

Common Nursing Diagnoses

some common nursing diagnoses used in this environment include: ● labile emotional control/Impaired mood regulation (frequent mood changes)​ ● ineffective impulse control (risk taking behavior)​ ● hopelessness (depressive symptoms)​ ● disturbed personal identity (personality disorder)​ ● disturbed body image/chronic low self-esteem (passive behaviors, anorexia)​ ● ineffective or defensive coping (anger or aggression)​ ● self-mutilation (cutting behavior)​ ● disturbed sensory perception (hallucinations)​ ● disturbed thought processes (delusions)​ ● self-care deficit (poor personal hygiene)

Causes for Behaviors

there are also causes for these behaviors that may need to be addressed too, including:​ ● post-trauma syndrome​ ● post-rape syndrome​ ● relocation stress syndrome

Interdisciplinary Team Approach​

will help ensure that someone with a mental health alteration will get the best care available from the right professional

Examples of Survey Tools

● Generalized Anxiety Disorder screener (GAD-7)​ ● Social Phobia Inventory (SPIN)​ ● Altman Self-Rating Mania scale (ASRM) ​ ● Borderline Evaluation of Severity over Time (BEST)​ ● Suicide Behaviors Questionnaire - Revised (SBQ-R)​ ● Sex, Age, Depression or hopelessness, Previous attempts or psychiatric illness, Excessive alcohol or drug use, Rational thinking loss, Separated/divorced/widowed, Organized or serious attempt, No social supports, & Stated future attempt (SAD PERSONS) ​this scale has also been adapted for children & youth (Adapted- SAD PERSONS)​ ● Clinical Opioid Withdrawal Scale (COWS)​ ➥ for example, a client admitted with a substance misuse disorder is experiencing opioid withdrawal symptoms → the nurse may chart: ​ "The client scored 28 on the COWS assessment, alprazolam was given by mouth per provider orders." ● Cut down, Annoyed, Guilty, & Eye-opener (CAGE) & Adapted to Include Drug use (CAGE-AID)​

Goals of Nursing in Mental Health​

● assist them in adapting to stressors in their environments, this can include, but is not limited to helping them with a change in thoughts, feelings, or behaviors to match local & cultural norms ​ ● use the skills of crisis intervention & management when appropriate & safe ● try to establish a nurse-client relationship right away so clients can begin to feel safe & comfortable as they recover through an extremely vulnerable process of healing during a mental health crisis → early intervention is key!​ ● help to restore, promote, & maintain optimal mental health & emotional well-being for themselves & their clients

Nursing Actions in Mental Health​

● crisis intervention & aggression management​ ● administration of medication as scheduled or as needed with worsening symptoms ● therapeutic communication including re-framing or reassurance ● modification of the environment including separation from the general client population, decreasing external stimuli in the environment, reducing lighting, decreasing noise or sound volumes on televisions or portable devices ● communication with a multi-disciplinary team regarding new behaviors or assessment findings ​ ● encourage client activities to distract ● removing the client from areas in which they could cause harm to themselves or others = SAFETY!

Mental Health Setting Potential Outcomes

● demonstrating a behavior​ ● verbalizing & understanding of a fact​ ● completing a task without a loss of control & significant change in mood​ ● performing self-care independently

Mental Health Assessment Findings

● hearing voices or seeing things that aren't there, inability to accept facts ● poor hygiene (infrequent bathing, no hair care or make-up, rashes associated with lack of self-care [i.e., scabies, fungal infections, etc.]) ● lack of eye contact or direct responses to questions (be sure to consider if lack of eye contact is a symptom of their disorder & not a cultural variation) ● behavior inappropriate for setting; including aggression, shouting, name-calling, throwing objects, inappropriate sexual innuendos or touching (self or others) ● substance misuse ● suicidal ideation (passive or active thoughts that may or may not include a plan) ● self-injury or violence towards others ● self-defeating behavior ● frequent interactions with law enforcement and/or security personnel ● score changes on an evidenced-based survey tool (it is very important to have a baseline assessment as a point of reference to recognize if changes better or worse exist)

Nurses as Case Managers

● involved with contacting or referring clients to specialists ● planning for discharge or transfer to other levels of care ● arranging with outside services when the client is discharged ● communicating with family and/or friends

Use of Self or Nurses Self-Awareness

● one of the most important parts to mental health nursing ● this involves knowing & understanding one's own thoughts, feelings, & actions ● how they relate to the care of the client with alterations in mental health

Survey Tools in Mental Health​

● these tools allow the nurse to be able to take subjective information from the client ● assign it to a severity to better understand the degree of symptoms the client may be experiencing ● it serves as a baseline for the severity of their illness as well ● it also allows for proper documentation if PRN medications are needed to treat symptoms

Mental Health Therapies​

● two tools that are important in helping a client adapt to their environment include drugs & therapy (must be used together to get the best outcomes) ● therapy primarily is the use of therapeutic communication both interpersonally & through group interactions ● listening to the client, asking clarifying questions, and reframing, redirecting, or clarifying facts are an important part of this process ● it is important for the nurse to be able to assess a crisis, do crisis intervention, be assertive, handle client anger, & reduce the potential for uncontrolled aggression, including a client's potential for violence to themselves or others