Mental Health 1
Regression:
- Moving back to a previous developmental stage to feel safe or have needs met • Five-year-old asks for a bottle when new baby brother is being fed. • Manpoutslikea4-year-oldif he is not the center of his girlfriend's attention.
Psychopharmacology : development of psychotropic drugs developed when? -What were the first 2 psycho drugs?
-(1950s) -First psychotropic meds developed were Thorazine and Lithium. Then came Haldol, antidepressants, and antianxiety agents which were able to reduce agitation, psychotic thinking, and depression for the first time
Reaction formation:
-Acting the opposite of what one thinks or feels • Woman who never wanted to have children becomes a supermom. • Person who despises the boss tells everyone what a great boss she is.
Factors contributing to mental illness can also be viewed within what 3 things? Describe:
-Also included: Ineffective coping with life events Lack of personal growth Contributing factors to mental illness can be viewed according to the following categories: -individual, interpersonal, and social/cultural. -Individual factors include: biologic makeup, intolerable or unrealistic worries or fears, inability to distinguish reality from fantasy, intolerance of life's uncertainties, a sense of disharmony in life, and a loss of meaning in one's life. *chronic pain* -Interpersonal factors include: ineffective communication, excessive dependency on or withdrawal from relationships, no sense of belonging, inadequate social support, and loss of emotional control. -Social/cultural factors include: lack of resources, violence, homelessness, poverty, an unwarranted negative view of the world, and discrimination such as stigma, racism, classism, ageism, and sexism.
-What % of Americans have a mental disorder? -It is the leading cause of what?
-Current state *More than 26% of Americans 18 and older have diagnosable mental disorder* (NIMH, 2008) -15 million adults, 4 million children and adolescents with impaired daily activities -Economic burden exceeds that by all types of cancer ........... -Current state -*Leading cause of disability* in United States, Canada for those 15-44 years of age -1 in 4 adults and 1 in 5 children and adolescents getting care *Only 1/4 getting the treatment needed?*
The Interview
-Open-ended questions --Clear --Simple --Focused on one specific behavior or symptom -Use nonjudgmental language/matter-of-fact tone -Open-ended questions are those that elicit information about the client's perceptions and feelings, not asking for specific information Examples of open-ended questions: What brings you here today? How can we help you?
-Interdisciplinary Team:
-Pharmacist (Box 4.5) -Psychiatrist -Psychologist -Psychiatric nurse -There are differences between a psychiatrist and a psychologist -Psychiatrist is a physician specializing in psychiatry and neurology that can diagnose mental disorders and prescribe medical treatment
Psychosocial Assessment
-Purpose: -Picture of emotional state -Plan of care -Clinical baseline .......... -Purpose of psychosocial assessment - includes a mental status exam: Picture of current emotional status, mental capacity, and behavioral function Basis for the plan of care Clinical baseline to evaluate effectiveness of treatment/interventions or measure of progress
Sensory Perception Alterations
Hallucinations - include all 5 senses: -Auditory -Visual -Hallucinations - false sensory perceptions or perceptual experiences that do not really exist Auditory or hearing voices is the most common -Visual or seeing things that don't really exist are second most common
-Treatment Settings- -Transitional care:
Transitional care: Two essential components of this model: -Peer support -Bridging staff -2 of essential aspects: -Peer support - provided by person now living successfully in community -Bridging staff - an overlap between hospital and community care. EX. hospital staff do not terminate their therapeutic relationship with the client until a therapeutic relationship has been established with the community care provider.
Assessment Content
*History (Box 8.1)!!!!* Age Developmental stage Cultural considerations Spiritual beliefs -All of this information may provide insight into the client's current situation ...... Appearance/motor: behavior -Hygiene/grooming -Appropriate dress -Posture -Eye contact Unusual movements/mannerisms Automatisms, psychomotor retardation, waxy flexibility Speech (neologisms) ... -Mood/affect Expressed emotions/facial expressions: Blunted Broad Flat -Blunted -showing little or slow to respond facial expression -Broad - displaying a full range of emotional expressions -Flat - showing no facial expression -Inappropriate - displaying a facial expression that is incongruent with mood or situation -Restricted - displaying one type of expression, usually serious or somber The rest of the categories of the assessment are important -Labile- Depressed to crying for no reason. Rapidly changing.
Things LPN Would do:
- Counseling Interventions and communication techniques Problem solving Crisis intervention Stress management Behavior modification -Milieu therapy Maintain therapeutic environment Teach skills Encourage communication between clients and others Promote growth through role modeling -Self-care activities Encourage independence Increase self-esteem Improve function and health -Psychobiologic interventions Administer medications Teach Observe -Health teaching -Case management -Health promotion and maintenance
Self-Awareness Issues:
-*Self-awareness is the process by which the nurse gains recognition of his or her own feelings, beliefs, and attitudes. In nursing, being aware of one's feelings, thoughts, and values is a primary focus.* -Everyone with unique or different values, ideas, beliefs -Possible conflict between personal values/beliefs, those of client -Need to accept differences, view each client as worthwhile regardless of opinions or lifestyle -Self-awareness through reflection
-Historical Perspectives: --Ancient times: -What was the name of the person who attempted to relate mental disorders to physical disorders in 382 bc? ................ -When was the Period of Enlightenment and who was the main person of that era? What did she do? -Asylums were started to provide what? Who formulated the concept? .................... The period of scientific study and treatment of mental disorders began with?
-Ancient times Sickness as displeasure of gods; punishment for sins; view as demonic or divine -*Aristotle* and imbalances of the four humors (blood, water, yellow and black bile); balance/restoration - bloodletting, starving, purging .............. -Period of Enlightenment (1790s) Creation of asylums; moral treatment Dorothea Dix -Asylums were started to provide a refuge to protect the mentally ill from whippings, beatings, and starvation -Dorthea Dix reformed the treatment of mental illness where she was instrumental in opening 32 state hospitals where she was an advocate for providing shelter, food, and warm clothing. Phillippe Pinel in France and William Tukes formulated them. -Freud was one of the first to view human beings objectively through scientific study and provide treatment Sigmund Freud: scientific study, treatment of mental illness ........................... -Sigmund Freud -He studied the mind, its disorders, and their treatment as no one had done before.
Factors Influencing Assessment
-Client participation/feedback -Client's health status -Client's previous experiences/ misconceptions about health care -Client's ability to understand ............. Client participation/feedback - active client participation or the assessment will be incomplete and may need to be done in several sessions. Client's health status - if the client is anxious, tired, in pain, may have difficulty getting the client's full participation and therefore, an accurate assessment. The nurse needs to recognize these situations and perform interventions such as giving pain meds, allowing the client to rest or calmed before the assessment is completed. Client's previous experiences/misconceptions about health care - the nurse has to address the client's feelings and/or perceptions and establish a trusting working relationship before proceeding with the assessment Client's ability to understand - the nurse must determine the client's ability to hear, read, and understand what the nurse is asking. The info in the assessment must be an accurate reflection of the client's health status rather than poor communication. Nurse's attitude, approach - can influence the outcome of the psychosocial assessment. If the client perceives the nurse as nonaccepting, defensive, or judgmental, the client may be reluctant to relate information that might be crucial to the assessment. It is important for the nurse to approach the assessment in a matter-of-fact way. *Helpfull to get information from family and friends*
What is mental illness?
-Clinically significant behavioral or psychological syndrome/pattern associated with distress, disability ... *-Mental disorder: behavioral or psychological syndrome or pattern (clinically significant) Association with present distress or disability or increased risk of death, pain, disability or important loss of freedom This definition is according to American Psychiatric Association*
Community support service programs were developed to:
-Community support service programs were developed to meet the needs of persons with mental illness outside the walls of an institution. These programs focus on rehabilitation, vocational needs, education, and socialization as well as on management of symptoms and medication. *-Availability, quality of services highly variable Inaccurate anticipation of extent of people's needs* -Despite flaws, positive aspects making them preferable for treatment
Dissociation:
-Dealing with emotional conflict by a temporary alteration in consciousness or identity • Adult remembers nothing of childhood sexual abuse.
What is the general criteria for diagnosis?
-Dissatisfaction with characteristics, abilities, accomplishments -Ineffective/unsatisfying relationships -Dissatisfaction with one's place in world
Self-Awareness Issues
-Empowering clients to make their own decisions -Frustration of working with clients having persistent and severe mental illness
Discharge Planning
-Environmental supports: --Housing and transportation --Access to community resources -Impediments to success --Alcohol and drug abuse ----Criminal/violent behavior Noncompliance with medications ...................... -Environmental supports are one of the most important parts of discharge planning: The person has to have housing and transportation The person has to have access to community resources such as outpatient mental health clinics for f/u appts or referrals, medications Impediments to success: Suicidal ideation
Repression:
-Excluding emotionally painful or anxiety-provoking thoughts and feelings from conscious awareness • Woman has no memory of the mugging she suffered yesterday. • Woman has no memory before age 7, when she was removed from abusive parents.
Rationalization:
-Excusing own behavior to avoid guilt, responsibility, conflict, anxiety, or loss of self-respect • Student blames failure on teacher being mean. • Man says he beats his wife because she doesn't listen to him.
-Special Populations: Prisoners:
-Factors for placement in criminal justice system: -Deinstitutionalization -More rigid criteria for civil commitment -Lack of adequate community support -Economization of treatment for mental illness -Attitudes of police, society *13% of those jailed with mental illness*
-Tell whether the following statement is true or false: Board and care homes are an example of a partial hospitalization program.
-False A board and care home is an example of a residential treatment setting. A day treatment program is an example of a partial hospitalization program.
EXC:
-First psychiatric nursing textbook (Nursing Mental Diseases) published in 1920 -Johns Hopkins: first school of nursing to include psychiatric nursing course (1913) -National League for Nursing (1950) requiring schools to include psychiatric nursing experience
Special Populations: Homeless Mentally Ill:
-In comparison to homeless not mentally ill: -Spend more time in jail Are homeless longer -Spend more time in shelters -Have less family contact -Face greater barriers to employment -PATH program: The program Projects for Assistance in Transition from Homelessness (PATH) funds community-based outreach, mental health, substance abuse, case management, and other support services. Some limited housing services are available, but PATH works primarily with existing housing services in the given community -ACCESS demonstration project: The Center for Mental Health Services initiated the Access to Community Care and Effective Services and Support (ACCESS) Demonstration Project in 1994 to assess whether more integrated systems of service delivery enhance the quality of life of homeless people with serious mental disabilities through the use of services and outreach.
Ch.4 -Treatment Settings-
-Inpatient hospital treatment -Rapid assessment, stabilization of symptoms, discharge planning -Client-centered multidisciplinary approach to brief stay -Short inpatient stays -*Safety is first priority*
Homelessness:
-Issues and concerns: Homelessness (⅓ estimated to have serious mental illness; over ½ with substance abuse problems) -Lack of adequate community
Judgment and Insight
-Judgment - ability to interpret environment and situation correctly -Insight - ability to understand true nature of situation, accept responsibility -Judgment - ability to interpret environment and situation correctly and adapt behavior and decisions accordingly. Risky behaviors such as picking up strangers in bars may indicate poor judgment. -Insight - ability to understand true nature of one's situation and accept personal responsibility for that situation. The nurse might ask the client to realistically describe their strengths and weaknesses of their behavior. Poor insight is when a husband blames his drinking and getting into fights on his wife because he says she "nags him all the time". He isn't accepting responsibility for his own drinking and fighting.
-Who are Linda Richards? -The first training of nurses to work with persons with mental illness was in? -Therapies used: -the first school of nursing to include a course in psychiatric nursing?:
-Linda Richards: first American psychiatric nurse. She went on to improve nursing care in psychiatric hospitals and organized educational programs in state mental hospitals in Illinois. Richards is called the first American psychiatric nurse; she believed that "the mentally sick should be at least as well cared for as the physically sick" -McLean Hospital, Belmont MA: site of first training for nurses to work with persons with mental illness -Expansion of role with development of somatic therapies -Therapies such as: Insulin shock therapy, Psychosurgery, and Electroconvulsive therapy required use of med/surg nursing skills -Johns Hopkins was the first school of nursing to include a course in psychiatric nursing in its curriculum. It was not until 1950 that the National League for Nursing, which accredits nursing programs, required schools to include an experience in psychiatric nursing.
-Managed care(1970): -utilization review firms or managed care organizations: - Case management:
-Managed care is a concept designed to purposely control the balance between the quality of care provided and the cost of that care. *Separation of mental health care from physical care for insurance coverage* -In the 1990s, a new form of managed care, was developed by utilization review firms or* managed care organizations* to control the expenditure of insurance funds by requiring providers to seek approval before the delivery of care. *Case management, or management of care on a case-by-case basis*, represented an effort to provide necessary services while containing cost. Case manager coordinates all care for client. -Mental health care management through privately owned behavioral health care firms If no private insurance, reliance on counties of residence for payment HCFA: Medicare, Medicaid Mental health parity, insurance coverage --The Health Care Finance Administration administers two insurance programs: Medicare and Medicaid.
Sensorium/Intellectual Processes
-Orientation -Memory -Ability to concentrate Orientation - refers to client's recognition of person, place, and time. Oriented x 1 means person only, oriented x 2 means person and place. Order is important, when person is disoriented, client first loses track of time, then place, and then finally person. Returns in reverse order: knows person first, then place, and time at the end. Memory - assessed by both recent and past memories, by asking verfiable questions such as: What is the name of the current president? Who was the president before that? In what country do you live? Etc. -Ability to concentrate - the nurse assesses this by asking the client to perform tasks such as: Spell the word world backward Begin with the number 100, subtract 7, subtract 7 again and so on. Called "serial sevens" Repeat the days of the week backward Ask client to perform a 3-part task
-Treatment Settings-
-Partial hospitalization programs: -are designed to help clients make a gradual transition from being inpatients to living independently and to prevent repeat admissions. EXAMPLE: -Day treatment programs-clients return home at night; evening programs are just the reverse. -Eight *broad categories of goals*(Box 4.1) - Stabilizing psychiatric symptoms -Monitoring drug effectiveness -Stabilizing living environment -Improving activities of daily living -Learning to structure time -Developing social skills -Obtaining meaningful work, paid employment, or a volunteer position -Providing follow-up of any health concerns
Psychosocial Nursing in Public Health and Home Care:
-Primary prevention: Ex:stress management education -Secondary prevention: early identification of mental health problems -Tertiary prevention: monitoring, coordinating psychiatric rehabilitation services -Public health nurses work in the community to provide mental health prevention services to help individuals, families, and communities. Primary prevention - there is a certain problem that has been identified (such as stress or parenting problems) and an education program has been developed to help people deal with stress or parenting issues. Secondary prevention - screenings, such as for depression Tertiary prevention - once the problem is identified, dealing with it and trying to prevent other problems through rehab. Important to know what primary, secondary, and tertiary prevention means as well as examples of each.
-Psychiatric rehabilitation:
-Psychiatric rehabilitation, sometimes called psychosocial rehabilitation: -refers to services designed to promote the recovery process for clients with mental illness . -*Emphasis on recovery*, going beyond symptom control and medication management; includes personal growth -Reintegration into community -Empowerment, increased independence -Improved quality of life -Empowerment, increased independence Improved quality of life
-Healthy People 2020 Mental Health objectives:
-Reduce suicide rate/attempts by adolescents -Reduce proportion of adolescents who engage in eating disorder behaviors -Increase employment for those with serious mental illness -Provide more services for incarcerated persons with mental health problems
Roles and Relationships
-Roles in community -Relationships with others -Family relationships -People have various roles in community - mother, wife, son, daughter, teacher, nurse, and volunteer. Assess roles the client occupies, satisfaction with those roles, and whether they are fulfilling them satisfactorily Relationships with others are important to social and emotional health. Mental problems can cause inability to sustain satisfying relationships Assess relationship with family: do you feel close to your family?; are your relationships meeting your needs for companionship or intimacy? If client's source of stress is closely involved with family, may need more in-depth family assessment tool
-Sigmund Freud:
-Sigmund Freud (1856-1939; Figure 3.1) developed *psychoanalytic* theory in the late 19th and early 20th centuries in Vienna, where he spent most of his life. ..................... *-All human behavior is caused, explainable -Repressed sexual impulses, desires as motivation for behavior* ....................... There are many different types of psychosocial theories that attempt to explain human behavior, health, and mental illness. Each theory suggests how normal development occurs based on what the theorist believes, their assumptions, and their view of the world. One of the first theorists was Sigmund Freud and his theory is called the *psychoanalytic theory.* Freud says that all human behavior is caused and can be explained - in other words, there is a specific reason for everything we do He believes that repressed sexual impulses and desires are the motivation for all behavior ... Personality Components: -Id -Ego -Superego Freud says that our personalities have 3 parts: -Id is the part of one's nature that reflects our basic desires such as pleasure-seeking behavior, aggression, and sexual impulses. The id seeks instant gratification, causes impulsive unthinking behavior, and doesn't have any regard for rules or social convention. -Superego is the part of a person's nature that reflect moral and ethical concepts, values, and parental and social expectations - the direct opposite of the id. -Ego is the balancing force between the id and superego. The ego represents the mature and adaptive behavior that allows a person to function successfully in the world. Freud believes that anxiety results from the ego's attempt to balance the impulsive instincts of the id with the stringent rules of the superego. -*Ego defense mechanisms* - methods of attempting to protect the self and cope with basic drives or emotionally painful thoughts, feelings, or events
Sublimation:
-Substituting a socially acceptable activity for an impulse that is unacceptable • Person who has quit smoking sucks on hard candy when the urge to smoke arises. • Person goes for a 15-minute walk when tempted to eat junk food.
-Basic-level functions: --Counseling --Milieu therapy:The psychiatric-mental health registered nurse provides, structures, and maintains a safe and therapeutic environment in collaboration with patients, families, and other health-care clinicians. --Self-care activities --Psychobiologic interventions
-The Basic-level functions are going to be a part of what an LPN would incorporate into their practice Therapeutic milieu is providing and maintaining a beneficial or therapeutic environment. Communication is encouraged between the client and others. Skills are taught to the client. Growth is promoted through role modeling.
Thought Process/Content
-Thought process: inferred from speech/speech patterns -Thought content: what client says -Nurses assesses verbalizations as to whether they make sense, are they related and logical? Focused questions (with short answers) help determine difficulties -Circumstantial thinking: eventually answers question after much unnecessary detail -Delusion: fixed false belief not based in reality -Flight of ideas: excessive amount and rate of speech that doesn't fit or flow together -Ideas of reference: inaccurate interpretation that events are personally directed at them, such as hearing news and thinking the message is only meant for them -Thought broadcasting: a delusional belief that others can ear or know what the client is thinking. - Thought insertion: a delusional belief that others are putting ideas or thoughts into the client's head—that is, the ideas are not those of the client -Thought withdrawal: a delusional belief that others are taking the client's thoughts away and the client is powerless to stop it -Word salad: flow of unconnected words that convey no meaning to the listener.
Who is *Peplau?*
-Two early nursing theorists shaped psychiatric nursing practice: Hildegard Peplau and June Mellow. --Peplau published Interpersonal Relations in Nursing in 1952 and Interpersonal Techniques: The Crux of Psychiatric Nursing in 1962. She described the therapeutic nurse-client relationship with its phases and tasks and wrote extensively about anxiety. EXC: -*H. Peplau: therapeutic nurse-client relationship; *interpersonal dimension (foundation for current practice) -which includes four phases: orientation, identification, exploitation, and resolution --1. The orientation phase is directed by the nurse and involves engaging the client in treatment, providing explanations and information, and answering questions. 2. The identification phase begins when the client works interdependently with the nurse, expresses feelings, and begins to feel stronger. 3. In the exploitation phase, the client makes full use of the services offered. 4. In the resolution phase, the client no longer needs professional services and gives up dependent behavior. The relationship ends. -J. Mellow: focus on client's psychosocial needs, strengths -American Nurses Association and Standards of Care (see Box 1.3)
Projection:
-Unconscious blaming of unacceptable inclinations or thoughts on an external object • Man who has thought about same-gender sexual relationship, but never had one, beats a man who is gay. • Person with many prejudices loudly identifies others as bigots.
Displacement:
-Ventilation of intense feelings toward persons less threatening than the one who aroused those feelings • Person who is mad at the boss yells at his or her spouse.
Self-Concept
-Way person views self - personal worth and dignity Assessment: -Describe self -Emotions -Coping strategies -Self-concept is the way a person views themselves in terms of personal worth and dignity Assessment includes: Ask the client to describe themselves, nurse is looking for what characteristics they like and dislike about themselves. How the person describes their physical characteristics gives info about body image - part of self-concept Emotions - part of self-concept are emotions the client frequently experiences - sadness or anger and how comfortable they are with them Coping strategies - ask what they do when they have a problem. Ask what usually works to help deal with anger or disappointment.
Issues and concerns: "Revolving-door" effect due to what?
-deinstitutionalization Shorter hospital stays, decompensation, rehospitalization, dual diagnoses. -Revolving door means people with severe and persistent mental illness have shorter hospital stays and leave the hospital because they are better, but go out, get bad again and come back to the hospital.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a taxonomy published by _______.
-the American Psychiatric Association and is revised as needed. *Used to diagnose disorders* *-DSM: taxonomy of American Psychiatric Association Purposes: Standardizes nomenclature, language Identifies defining characteristics/ symptoms Assists in identifying causes -Describes all mental disorders, outlining specific diagnostic criteria for each based on clinical experience and research*
Psychiatric Rehabilitation Programs: -Assertive Community Treatment (ACT)
Assertive Community Treatment (ACT): -One of most effective approaches (Box 4.4) !!*multidisciplinary team* -*Problem-solving orientation* No problem is too small -Direct provision of service rather than referral -Services intense; no time constraints
Psychiatric Rehabilitation Programs: -Clubhouse Model
Clubhouse Model: Four guaranteed rights of members: -A place to come to -Meaningful work -Meaningful relationships -A place to return to (lifetime membership) *Physician-client relationship as key Focus on health, not illness*
-Interdisciplinary Team: Core Skills:
Core skills: -Interpersonal skills (tolerance, patience) -Humanity (warmth, acceptance, empathy) -Knowledge base -Communication skills -Personal qualities (consistency, assertiveness, problem-solving) Teamwork skills Risk assessment, risk management
The Interview:
Environment: -Comfortable, private, safe -Quiet with few distractions Input from family, friends (client's permission necessary) -Information about their perceptions of client
Exc.
In 1547, the Hospital of St. Mary of Bethlehem was officially declared a hospital for the insane, the first of its kind
What was the Community mental health movement?
In 1963, the Community Mental Health Centers Construction Act was passed with the idea that mental illness should be treated in the least restrictive environment... -Deinstitutionalization: shift from institutional care in state hospitals to community-based services that has resulted in the 'revolving door effect' -Legislation for disability income: passed to provide income for disabled persons - Supplemental Security Income (SSI) and Social Security Disability Income (SSDI).- allows people with mental illness to be more independent financially and to not rely on family. -Changes in commitment laws: Changes to commitment laws happened in the early 1970's, making it more difficult to commit someone into a mental health treatment center against their will. This decreased the number of patients in state hospitals, saving money for the state.
What is mental health?
In most cases, mental health is a state of emotional, psychological, and social wellness evidenced by satisfying interpersonal relationships, effective behavior and coping, positive self-concept, and emotional stability. ....* -Difficult to define -No single, universal definition -Many components influenced by factors -Dynamic, ever-changing state*
-Treatment Settings- Inpatient hospital treatment:
Inpatient hospital treatment: -Long-stay clients (severe, persistent mental illness requiring acute care services) -Case management -Discharge planning -*Management of symptoms*
Data Analysis
Overall assessment data: -Not isolated bits of information -Patterns or themes in data → nursing diagnoses Nurse doesn't just look at details, look for overall data and patterns or themes to lead to conclusions about client's strengths and needs for nrsg. Dx. ... Data Analysis, con't: Psychological tests Psychiatric diagnoses Mental status exam -Psychological Tests - source of data for care plan. 2 basic types: Psychiatric diagnoses - Mental Status Exam
Treatment Settings:
Residential settings: -long-term treatment provided in a living situation; vary according to structure, level of supervision, and services provided -Vary in structure, level of supervision, services provided -Group homes -Supervised apartments -Board, care homes -Adult foster care Respite/crisis housing
Intellectualization:
Separation of the emotions of a painful event or situation from the facts involved; acknowledging the facts but not the emotions • Person shows no emotional expression when discussing serious car accident.
Standards of care:
Standards of care are authoritative statements by professional organizations that describe the responsibilities for which nurses are accountable.
How does the WHO define health?
World Health Organization defines health as a state of complete physical, mental, and social wellness, not merely the absence of disease or infirmity.
