mental health
Generalized anxiety disorder (GAD)
The client exhibits uncontrollable, excessive worry for more than 3 months. ■GAD causes significant impairment in one or more areas of functioning, such as work-related duties. ■Manifestations of GAD include the following: ☐Restlessness ☐Muscle tension ☐Avoidance of stressful activities or events ☐Increased time and effort required to prepare for stressful activities or events ☐Procrastination in decision-making ☐Seeks repeated reassurance
Hallucinations
are sensory perceptions that do not have any apparent external stimulus. Examples include the following: ☐Auditory - hearing voices or sounds. X-Command - the voice instructs the client to perform an action, such as to hurt self or others. ☐Visual - seeing persons or things. ☐Olfactory - smelling odors. ☐Gustatory - experiencing tastes. ☐Tactile - feeling bodily sensations. Nursing Care ◯Milieu therapy is used for clients who have a psychotic disorder both in acute mental health facilities and in community facilities, such as residential crisis centers, halfway houses, and day treatment programs. ■Provide a structured, safe environment (milieu) for the client in order to decrease anxiety and to distract the client from constant thinking about hallucinations. ■Assertive community treatment (ACT) - intensive case management and interprofessional team approach to assist clients with community-living needs. ◯Promote therapeutic communication to lower anxiety, decrease defensive patterns, and encourage participation in the milieu. ◯Establish a trusting relationship with the client. ◯Encourage the development of social skills and friendships. ◯Encourage participation in group work and psychoeducation. ◯Use appropriate communication to address hallucinations and delusions. ■Ask the client directly about hallucinations. The nurse should not argue or agree with the client's view of the situation, but may offer a comment, such as, "I don't hear anything, but you seem to be feeling frightened." ■Do not argue with a client's delusions, but focus on the client's feelings and possibly offer reasonable explanations, such as, "I can't imagine that the president of the United States would have a reason to kill a citizen, but it must be frightening for you to believe that." ■Assess the client for paranoid delusions, which can increase the risk for violence against others. ■Provide for safety if the client is experiencing command hallucinations due to the increased risk for harm to self or others. ■attempt to focus conversations on reality-based subjects. ■Identify symptom triggers, such as loud noises (may trigger auditory hallucinations in certain clients) and situations that seem to trigger conversations about the client's delusions. ■Be genuine and empathetic in all dealings with the client. ◯Assess discharge needs, such as ability to perform activities of daily living. ◯Promote self-care by modeling and teaching self-care activities within the mental health facility. ◯Relate wellness to the elements of symptom management. ◯Collaborate with the client to use symptom management techniques to cope with depressive symptoms and anxiety. Symptom management techniques include such strategies as using music to distract from "voices," attending activities, walking, talking to a trusted person when hallucinations are most bothersome, and interacting with an auditory or visual hallucination by telling it to stop or go away. ◯Encourage medication compliance. ◯Provide teaching regarding medications. ◯Whenever possible, incorporate family in all aspects of care.
Defense Mechanisms Used in Cognitive Disorders
◯Assess for defense mechanisms used by the client to preserve self-esteem and to compensate when cognitive changes are progressive: ■Denial - Both the client and family members may refuse to believe that changes, such as loss of memory, are taking place, even when those changes are obvious to others. ■Confabulation - The client may make up stories when questioned about events or activities that she does not remember. This may seem like lying, but it is actually an unconscious attempt to save self-esteem and prevent admitting that she does not remember the occasion. ■Perseveration - The client avoids answering questions by repeating phrases or behavior. This is another unconscious attempt to maintain self-esteem when memory has failed.
Obsessive-compulsive and related disorders
OCD - Persistent thoughts or urges that the client attempts to suppress through compulsive or obsessive behaviors. Obsessions or compulsions are time consuming and result in impaired social and occupational functioning. ■Hoarding disorder - Client has obsessive desire to save items regardless of value. Experiences extreme stress with thoughts of discarding or getting rid of items. Client's hoarding behavior results in social and occupational impairment and often leads to an unsafe living environment.
cognitive disorders (Alzheimers and delerium)
Nursing Care ◯Perform self-assessment regarding possible feelings of frustration, anger, or fear when performing daily care for clients who have progressive cognitive decline. ◯Nursing interventions are focused on protecting the client from injury, as well as promoting client dignity and quality of life. ◯Provide for a safe and therapeutic environment ■Assign the client to a room close to the nurse's station for close observation. ■Provide a room with a low level of visual and auditory stimuli. ■Provide for a well-lit environment, minimizing contrasts and shadows. ■Have the client sit in a room with windows to help with time orientation. ■Have the client wear an identification bracelet; use monitors and bed alarm devices as needed. ■Use restraints only as an intervention of last resort. ■Monitor client's level of comfort and assess for non-verbal indications of discomfort. ■Use caution when administering medications PRN for agitation or anxiety. ■ Assess client's risk for injury and ensure safety in the physical environment, such as a lowered bed and removal of scatter rugs to prevent falls. ■Provide compensatory memory aids, such as clocks, calendars, photographs, memorabilia, seasonal decorations, and familiar objects. Reorient as necessary. ■Provide eyeglasses and assistive hearing devices as needed. ■Keep a consistent daily routine. ■Maintain consistent caregivers. ■Ensure adequate food and fluid intake. ■Allow for safe pacing and wandering. ■Cover or remove mirrors to decrease fear and agitation. ◯Communication ■Communicate in a calm, reassuring tone. ■Speak in positive rather than negatively worded phrases. Do not argue or question hallucinations or delusions. ■Reinforce reality. ■Reinforce orientation to time, place, and person. ■Introduce self to client with each new contact. ■Establish eye contact and use short, simple sentences when speaking to the client. Focus on one item of information at a time. ■Encourage reminiscence about happy times; talk about familiar things. ■Break instructions and activities into short timeframes. ■Limit the number of choices when dressing or eating. ■Minimize the need for decision making and abstract thinking to avoid frustration. ■Avoid confrontation. ■Encourage family visitation as appropriate Home safety measures to be implemented may include: ■Removing scatter rugs ■Installing door locks that cannot be easily opened ■Locking water heater thermostat and turning water temperature down to a safe level ■Providing good lighting, especially on stairs ■Installing a handrail on stairs, and marking step edges with colored tape. ■Placing mattresses on the floor ■Removing clutter, keeping clear, wide pathways for walking through a room ■Securing electrical cords to baseboards ■Storing cleaning supplies in locked cupboards ■Installing handrails in bathrooms
Pharmacological therapy for drug use
◯Medications ■Alcohol withdrawal - Diazepam (Valium), lorazepam (Ativan), carbamazepine (Tegretol), clonidine (Catapres), chlordiazepoxide (Librium) ■Alcohol abstinence - Disulfiram (Antuse), naltrexone (Revia), acamprosate (Campral) Opioid withdrawal - methadone (Dolophine) substitution, clonidine (Catapres), buprenorphine (Subutex) ■Nicotine withdrawal from tobacco use - Bupropion (Zyban), nicotine replacement therapy (nicotine gum [Nicorette] and nicotine patch [Nicotrol])
Alterations in behavior
☐Extreme agitation, including pacing and rocking ☐Stereotyped behaviors - motor patterns that had meaning to client (sweeping the floor) but now are mechanical and lack purpose ☐Automatic obedience - responding in a robotlike manner ☐Wavy flexibility - excessive maintenance of position ☐Stupor - motionless for long periods of time, comalike ☐Negativism - doing the opposite of what is requested ☐Echopraxia - purposeful imitation of movements made by others
alterations in speeCh
Flight of ideas ›Associative looseness ›The client may say sentence after sentence, but each sentence may relate to another topic, and the listener is unable to follow the client's thoughts. Neologisms ›Made-up words that have meaning only to the client, such as, "I tranged and flittled."echolalia ›The client repeats the words spoken to him. clang association ›Meaningless rhyming of words, often forceful, such as, "Oh fox, box, and lox." Word salad ›Words jumbled together with little meaning or significance to the listener, such as, "Hip hooray, the flip is cast and wide-sprinting in the forest."
psychotic disorders
Schizophrenia - The client has psychotic thinking or behavior present for at least 6 months. Areas of functioning, including school or work, self-care, and interpersonal relationships, are significantly impaired. ◯Schizotypal personality disorder - The client has impairments of personality (self and interpersonal) functioning. However, impairment is not as severe as with schizophrenia. ◯Delusional disorder - The client experiences delusional thinking for at least 1 month. Self or interpersonal functioning is not markedly impaired. ◯Brief psychotic disorder - The client has psychotic manifestations that last between 1 day to 1 month in duration. ◯Schizophreniform disorder - The client has manifestations similar to those of schizophrenia, but the duration is from 1 to 6 months, and social/occupational dysfunction may or may not be present. ◯Schizoaffective disorder - The client's disorder meets both the criteria for schizophrenia and depressive or bipolar disorder. ◯Substance-induced psychotic disorder - The client experiences psychosis within 1 month of substance intoxication or withdrawal. May be caused by medications intended for therapeutic use.
Suicide
Sense of hopelessness ■Intense emotions, such as rage, anger, or guilt ■Poor interpersonal relationships at home, school, and work ■Developmental stressors, such as those experienced by adolescents *Subjective Data ◯Assess carefully for verbal and nonverbal clues. It is essential to ask the client if he is thinking of suicide. This will not give the client the idea to commit suicide. ◯Suicidal comments usually are made to someone that the client perceives as supportive. ◯Comments or signals may be overt or covert. ■Overt comment - "There is just no reason for me to go on living." ■Covert comment - "Everything is looking pretty grim for me." ◯Assess the client's suicide plan: ■Does the client have a plan? ■How lethal is the plan? ■Can the client describe the plan exactly? ■Does the client have access to the intended method? ■Has the client's mood changed? A sudden change in mood from sad and depressed to happy and peaceful may indicate a client's intention to commit suicide. ●Objective Data ◯Lacerations, scratches, and scars that could indicate previous attempts at self-harm Suicide precautions include milieu therapy within the facility. ■Initiate one-on-one constant supervision around the clock, always having the client in sight and close. ■Document the client's location, mood, quoted statements, and behavior every 15 min or per facility protocol. ■Remove all glass, metal silverware, electrical cords, vases, belts, shoelaces, metal nail files, tweezers, matches, razors, perfume, shampoo, and plastic bags from the client's room and vicinity. ■Allow the client to use only plastic eating utensils. ■Check the environment for possible hazards (such as windows that open, overhead pipes that are easily accessible.) ■During observation periods, always check the client's hands, especially if they are hidden from sight. ■Do not assign to a private room if possible and keep door open at all times. ■Ensure that the client swallows all medications. ■Identify whether or not the client's current medications can be lethal with overdose. If so, collaborate with the provider to have less dangerous medications substituted if possible. ■Restrict the visitors from bringing possibly harmful items to the client.
Phobias
Social phobia - The client has a fear of embarrassment, is unable to perform in front of others, has a dread of social situations, believes that others are judging him negatively, and has impaired relationships. ■Agoraphobia - The client avoids being outside and has an impaired ability to work or perform duties. ■Specific phobias ☐The client has a fear of specific objects, such as spiders, snakes, strangers. ☐The client has a fear of specific experiences, such as flying, being in the dark, riding in an elevator, being in an enclosed space.
Anger/ aggression
Subjective and Objective Data ◯Hyperactivity such as pacing, restlessness ◯Defensive response when criticized, easily offended ◯Eye contact that is intense, or no eye contact at all ◯Facial expressions, such as frowning or grimacing ◯Body language, such as clenching fists, waving arms ◯Rapid breathing ◯Aggressive postures, such as leaning forward, appearing tense ◯Verbal clues, such as loud, rapid talking ◯Drug or alcohol intoxication Nursing Care ◯Provide a safe environment for the client who is aggressive, as well as for the other clients and staff on the unit. ◯Follow policies of the mental health setting when working with clients who demonstrate aggression. ◯Assess for triggers or preconditions that escalate client emotion. ◯Steps to handle aggressive and/or escalating behavior in a mental health setting include the following: ■Responding quickly ■Remaining calm and in control ■Encouraging the client to express feelings verbally, using therapeutic communication techniques (reflective techniques, silence, active listening) ■Allowing the client as much personal space as possible ■Maintaining eye contact and sitting or standing at the same level as the client ■Communicating with honesty, sincerity, and nonaggressive stance ■Avoiding accusatory or threatening statements ■Describing options clearly and offering the client choices ■Reassuring the client that staff are present to help prevent loss of control Setting limits for the client: ☐Tell the client calmly and directly what he must do in a particular situation, such as, "I need you to stop yelling and walk with me to the day room where we can talk." ☐Use physical activity, such as walking, to deescalate anger and behaviors. ☐Inform the client of the consequences of his behavior, such as loss of privileges. ■Use pharmacological interventions if the client does not respond to calm limit setting. ■Plan for four to six staff members to be available and in sight of the client as a "show of force" if appropriate.
tRaNscRaNial MagNetic stiMulatioN (tMs)
TMS is a noninvasive therapy that uses magnetic pulsations to stimulate specific areas of the brain. Educate the client about TMS. ◯TMS is commonly prescribed daily for a period of 4 to 6 weeks. ◯TMS can be performed as an outpatient procedure. ◯The TMS procedure lasts 30 to 40 min. ◯A noninvasive electromagnet is placed on the client's scalp, allowing the magnetic pulsations to pass through. ◯The client is alert during the procedure.
12-step program
X-Abstinence is necessary for recovery. X-A higher power is needed to assist in recovery. X-They are not responsible for their disease but are responsible for their recovery. X-Others cannot be blamed for their addictions, and they must acknowledge their feelings and problems.
CoUntertransferenCe
description ›Countertransference occurs when a health care team member displaces characteristics of people in her past onto a client. example ›A nurse may feel defensive and angry with a client for no apparent reason if the client reminds her of a friend who often elicited those feelings. Nursing implications ›A nurse should be aware that clients who induce very strong personal feelings may become objects of countertransference.
Personal boundary difficulties
disenfranchisement with one's own body, identity, and perceptions. This includes the following: ☐ Depersonalization - nonspecific feeling that a person has lost her identity; self is different or unreal. ☐ Derealization - perception that environment has changed.
SEDATIVES/HYPNOTICS
general information ›Such as benzodiazepines like diazepam (Valium) or barbiturates like pentobarbital (Nembutal) can be taken orally or injected. intended effects ›Decreased anxiety, sedationeffects of intoxication ›Increased drowsiness and sedation, agitation, slurred speech, uncoordinated motor activity, nystagmus, disorientation, nausea, vomiting ›Respiratory depression and decreased level of consciousness, which may be fatal ›An antidote, flumazenil (Romazicon), available for IV use for benzodiazepine toxicity ›No antidote to reverse barbiturate toxicity Withdrawal Manifestations ›Anxiety, insomnia, diaphoresis, hypertension, possible psychotic reactions, hand tremors, nausea or vomiting, hallucinations or illusions, psychomotor agitation, and sometimes seizure activity
opioiDs
general information ›Such as heroin, morphine, hydromorphone (Dilaudid) can be injected, smoked, and inhaled intended effects ›A rush of euphoria (extreme well-being), relief from pain effects of intoxication ›Slurred speech, impaired memory, pupillary changes, and decreased respirations and level of consciousness, which may cause death ›Maladaptive behavioral or psychological changes, including impaired judgment or social functioning ›An antidote, naloxone (Narcan), available for IV use to relieve effects of overdoseWithdrawal Manifestations ›Abstinence syndrome begins with sweating and rhinorrhea progressing to piloerection (gooseflesh), tremors, and irritability followed by severe weakness, diarrhea, fever, insomnia, pupil dilation, nausea and vomiting, pain in the muscles and bones, and muscle spasms. ›Withdrawal is very unpleasant but not life-threatening, and it is self-limiting to 7 to 10 days.
hallUCinogens
general information ›Such as lysergic acid diethylamide (LSD), mescaline (peyote), and phencyclidine piperidine (PCP) are usually ingested orally, can be injected or smoked intended effects ›Heightened sense of self and altered perceptions (colors being more vivid while under the influence) effects of intoxication ›Anxiety, depression, paranoia, impaired judgment, impaired social functioning, pupil dilation, tachycardia, diaphoresis, palpitations, blurred vision, tremors, incoordination, and panic attacks Withdrawal Manifestations ›Hallucinogen Persisting Perception Disorder - Visual disturbances or flashback hallucinations can occur intermittently for years
delusions
ideas of reference ›Misconstrues trivial events and attaches personal significance to them, such as believing that others, who are discussing the next meal, are talking about him. persecution ›Feels singled out for harm by others (e.g., being hunted down by the FBI). grandeur ›Believes that she is all powerful and important, like a god. somatic delusions ›Believes that his body is changing in an unusual way, such as growing a third arm. Jealousy ›May feel that her spouse is sexually involved with another individual. being controlled ›Believes that a force outside his body is controlling him. thought broadcasting ›Believes that her thoughts are heard by others. thought insertion ›Believes that others' thoughts are being inserted into his mind. thought withdrawal ›Believes that her thoughts have been removed from her mind by an outside agency. Religiosity ›Is obsessed with religious beliefs.
electRocoNvulsive tHeRapy (ect)
nursing actions ●Preparation of the Client ◯The typical course of ECT treatment is three times a week for a total of six to 12 treatments. ◯The provider obtains informed consent. ■If ECT is involuntary, consent may be obtained from next of kin or a court order. ◯Medication management ■Any medications that affect the client's seizure threshold must be decreased or discontinued several days before the ECT procedure. ■MAOIs and lithium should be discontinued 2 weeks before the ECT procedure. ◯Severe hypertension should be controlled because a short period of hypertension occurs immediately after the ECT procedure. ◯Any cardiac conditions, such as dysrhythmias, should be monitored and treated before the procedure. ◯The nurse monitors the client's vital signs and mental status before and after the ECT procedure. ◯The nurse also assesses the client's and family's understanding and knowledge of the procedure and provides teaching as necessary. ◯thirty minutes prior to the beginning of the procedure, an IM injection of atropine sulfate or glycopyrrolate (Robinul) is given to decrease secretions and counteract any vagal stimulation. ◯An IV line is inserted and maintained until full recovery Ongoing Care ◯ECT is administered early in the morning after the client has fasted for a prescribed period of time. ◯A bite guard should be used to prevent trauma to the oral cavity. ◯Electrodes are applied to the scalp, either unilaterally or bilaterally for encephalogram (EEG) monitoring. ◯The client is mechanically ventilated during the procedure and receives 100% oxygen. ◯Ongoing cardiac monitoring is provided, including blood pressure, electrocardiogram (ECG), and oxygen saturation. ◯An anesthesia provider administers a short-acting anesthetic, such as methohexital (Brevital), via IV bolus. ◯A muscle relaxant, such as succinylcholine (Anectine), is then administered. ◯A cuff is placed on one leg or arm to block the muscle relaxant so that seizure activity can be monitored in the limb distal to the cuff. ◯The electrical stimulus is typically applied for 0.2 to 0.8 seconds. Seizure activity is monitored, and the duration of the seizure, which is usually 25 to 60 seconds, is documented. ◯After seizure activity has ceased, the anesthetic is discontinued. ◯The client is extubated and assisted to breathe voluntarily. ●Postprocedure Care ◯When stable, the client is transferred to a recovery area where level of consciousness, cardiac status, vital signs, and oxygen saturation continue to be monitored. ◯The client is positioned on his side to facilitate drainage and prevent aspiration. ◯The client is monitored for ability to swallow and return of the gag reflex. ◯The client is usually awake and ready for transfer back to the mental health unit or other facility within 30 to 60 min after the procedure.
transferenCe
›Transference occurs when the client views a member of the health care team as having characteristics of another person who has been significant to the client's personal life. example ›A client may see a nurse as being like his mother, and thus may demonstrate some of the same behaviors with the nurse as he demonstrated with his mother. Nursing implications ›A nurse should be aware that transference by a client is more likely to occur with a person in authority.
Specific therapies
■Cognitive behavioral therapy - The anxiety response can be decreased by changing cognitive distortions. This therapy uses cognitive reframing to help the client identify negative thoughts that produce anxiety, examine the cause, and develop supportive ideas that replace negative self-talk. ■Behavioral therapies teach clients ways to decrease anxiety or avoidant behavior and allow an opportunity to practice techniques. ☐Relaxation training is used to control pain, tension, and anxiety. Refer to the chapter on Stress Management, which covers relaxation training techniques. ☐Modeling allows a client to see a demonstration of appropriate behavior in a stressful situation. The goal of therapy is that the client will imitate the behavior. ☐Systematic desensitization begins with mastering of relaxation techniques. Then, a client is exposed to increasing levels of an anxiety-producing stimulus (either imagined or real) and uses relaxation to overcome the resulting anxiety. The goal of therapy is that the client is able to tolerate a greater and greater level of the stimulus until anxiety no longer interferes with functioning. This form of therapy is especially effective for clients who have phobias. ☐Flooding involves exposing the client to a great deal of an undesirable stimulus in an attempt to turn off the anxiety response. This therapy is most useful for clients who have phobias. ☐Response prevention focuses on preventing the client from performing a compulsive behavior with the intent that anxiety will diminish. ☐Thought stopping teaches a client to say "stop" when negative thoughts or compulsive behaviors arise, and substitute a positive thought. The goal of therapy is that with time, the client uses the command silently. ■Group and family therapy is beneficial, especially for clients who have trauma- and stressor-related disorders. ■Eye movement desensitization and reprocessing (EMDR) is a therapy for clients who have PTSD. EMDR encourages eye focus on a separate stimuli while thinking of or talking about the traumatic event.
impaired Coworkers
●Impaired health care providers pose a significant risk to client safety. ●A nurse who suspects a coworker of using alcohol or drugs while working has a duty to report the coworker to appropriate management personnel as specified by institutional policy. At the time of the infraction, the report may need to be made to the immediate supervisor, such as the charge nurse, to ensure client safety. ●Health care facility policies should provide guidelines for handling employees who have a chemical dependency issue, and many provide peer assistance programs that facilitate the health care provider's entry into a treatment program. ●Each state board of nursing has laws and regulations that govern the disposition of nurses who have been reported secondary to chemical dependency. Depending on the individual case, the boards may have the option to require the nurse to enter a treatment program, during which time the nurse's license may be retained, suspended, or revoked. If a nurse is allowed to maintain licensure, there usually are work restrictions put in place, such as working in noncritical care areas and being restricted from administering controlled medications. ●Health care providers who are found guilty of misappropriation of controlled substances also can be charged with a criminal offense consistent with the infraction. ●Behaviors consistent with chemical dependency that should be considered suspicious include: ◯Smell of alcohol on breath or frequent use of strong mouthwash or mints ◯Impaired coordination, sleepiness, shakiness, and/or slurred speech ◯Bloodshot eyes ◯Mood swings and memory loss ◯Neglect of personal appearance ◯Excessive use of sick leave, tardiness, or absences after a weekend off, holiday, or payday ◯Frequent requests to leave the unit for short periods of time or to leave the shift early ◯Frequently "forgetting" to have another nurse witness wasting of a controlled substance ◯Frequent involvement in incidences where a client assigned to the nurse reports not receiving pain medication or adequate pain relief (impaired nurse provides questionable explanations) ◯Documenting administration of pain medication to a client who did not receive it or documenting a higher dosage than has been given by other nurses ◯Preferring to work the night shift where supervision is less or on units where controlled substances are more frequently given Behaviors may be difficult to detect if the impaired nurse is experienced at masking the addiction.
Ethical principles are standards of what is right or wrong with regard to important social values and norms. Ethical principles pertaining to the treatment of clients include:
◯Autonomy - the ability of the client to make personal decisions, even when those decisions may not be in the client's own best interest ◯Beneficence - the care that is in the best interest of the client ◯Fidelity - keeping one's promise to the client about care that was offered ◯Justice - fair treatment in matters related to physical and psycho social care and use of resources ◯Nonmaleficence - the nurse's obligation to avoid causing harm to the client ◯Veracity - the nurse's duty to tell the truth