Mental health exam 1

Projection

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 Excusing own behavior to avoid guilt, responsibility, conflict, anxiety, or loss of self-respect

MAOI administration and client teaching

Monoamine Oxidase Inhibitors the client must be able to follow a tyramine- free diet Foods (Containing Tyramine) to Avoid When Taking Monoamine Oxidase Inhibitors Mature or aged cheeses or dishes made with cheese, such as lasagna or pizza. All cheese is considered aged except cottage cheese, cream cheese, ricotta cheese, and processed cheese slices. Aged meats such as pepperoni, salami, mortadella, summer sausage, beef logs, meat extracts, and similar products. Make sure meat and chicken are fresh and have been properly refrigerated. Italian broad beans (fava), bean curd (tofu), banana peel, overripe fruit, and avocado. All tap beers and microbrewery beer. Drink no more than two cans or bottles of beer (including nonalcoholic beer) or 4 oz of wine per day. Sauerkraut, soy sauce or soybean condiments, or marmite (concentrated yeast). Yogurt, sour cream, peanuts, brewer's yeast, and monosodium glutamate (MSG). ide effects of MAOIs include daytime sedation, insomnia, weight gain, dry mouth, orthostatic hypotension, and sexual dysfunction. The sedation and insomnia are difficult to treat and may necessitate a change in medication. Of particular concern with MAOIs is the potential for a life- threatening hypertensive crisis if the client ingests food that contains tyramine or takes sympathomimetic drugs. Because the enzyme MAO is necessary to break down the tyramine in certain foods, its inhibition results in increased serum tyramine levels, causing severe hypertension, hyperpyrexia, tachycardia, diaphoresis, tremulousness, and cardiac dysrhythmias Clients taking MAOIs need to be aware that a life-threatening hyperadrenergic crisis can occur if they do not observe certain dietary restrictions. They should receive a written list of foods to avoid while taking MAOIs. The nurse should make clients aware of the risk for serious or even fatal drug interactions when taking MAOIs and instruct them not to take any additional medication, including OTC preparations, without checking with the 90 physician or pharmacist.

Medication teaching and mental health medications

• Time of dosage • SSRI first thing in morning • TCAs at night • Actions for missed dose • SSRI up to 8 hours after missed dose • TCAs within 3 hours of missed dose

Group therapy principles

.A group is a number of persons who gather in a face-to-face setting to accomplish tasks that require cooperation, collaboration, or working together. 140 Each person in a group is in a position to influence and to be influenced by other group members. Group content refers to what is said in the context of the group, including educational material, feelings and emotions, or discussions of the project to be completed. Group process refers to the behavior of the group and its individual members, including seating arrangements, tone of voice, who speaks to whom, who is quiet, and so forth. Content and process occur continuously throughout the life of the group. Stages of Group Development A group may be established to serve a particular purpose in a specified period such as a work group to complete an assigned project or a therapy group that meets with the same members to explore ways to deal with depression. These groups develop in observable stages. In the pregroup stages, members are selected, the purpose or work of the group is identified, and group structure is addressed. Group structure includes where and how often the group will meet, identification of a group leader, and the rules of the group—for example, whether individuals can join the group after it begins, how to handle absences, and expectations for group members. The beginning stage of group development, or the initial stage, commences as soon as the group begins to meet. Members introduce themselves, a leader can be selected (if not done previously), the group purpose is discussed, and rules and expectations for group participation are reviewed. Group members begin to "check out" one another and the leader as they determine their levels of comfort in the group setting. The working stage of group development begins as members begin to focus their attention on the purpose or task the group is trying to accomplish. This may happen relatively quickly in a work group with a specific assigned project but may take two or three sessions in a therapy group because members must develop some level of trust before sharing personal feelings or difficult situations. During this phase, several group characteristics may be seen. Group cohesiveness is the degree to which members work together cooperatively to accomplish the purpose. Cohesiveness is a desirable group characteristic and is associated with positive group outcomes. It is evidenced when members value one another's contributions to the group; members think of themselves as "we" and share responsibility for the work of the group. When a group is cohesive, members feel free to express all opinions, positive and negative, with little fear of rejection or retribution. If a group is "overly cohesive," in that uniformity and agreement become the group's implicit 141 goals, there may be a negative effect on the group outcome. In a therapy group, members do not give one another needed feedback if the group is overly cohesive. In a work group, critical thinking and creative problem- solving are unlikely, which may make the work of the group less meaningful. Some groups exhibit competition, or rivalry, among group members. This may positively affect the outcome of the group if the competition leads to compromise, improved group performance, and growth for individual members. Many times, however, competition can be destructive for the group; when conflicts are not resolved, members become hostile, or the group's energy is diverted from accomplishing its purpose to bickering and power struggles. The final stage, or termination, of the group occurs before the group disbands. The work of the group is reviewed, with the focus on group accomplishments or growth of group members or both, depending on the purpose of the group. Observing the stages of group development in groups that are ongoing is difficult with members joining and leaving the group at various times. Rather, the group involvement of new members as they join the group evolves as they feel accepted by the group, take a more active role, and join in the work of the group. An example of this type of group would be Alcoholics Anonymous, a self-help group with stated purposes. Members may attend Alcoholics Anonymous meetings as often or infrequently as they choose; group cohesiveness or competition can still be observed in ongoing groups.

Boundaries

The crucial components of therapeutic communication are confidentiality, privacy, respect for boundaries The therapeutic communication interaction is most comfortable when the nurse and client are 3 to 6 ft apart. If a client invades the nurse's intimate space (0-18 in), the nurse should set limits gradually, depending on how often the client has invaded the nurse's space and the safety of the situation.

Strategies to promote nurse and client safety

The nurse should conduct the psychosocial assessment in an environment that is comfortable, private, and safe for both the client and the nurse. An environment that is fairly quiet with few distractions allows the client to give his or her full attention to the interview. Conducting the interview in a place such as a conference room assures the client that no one will overhear what is being discussed. The nurse should not choose an isolated location for the interview, however, particularly if the client is unknown to the nurse or has a history of any threatening behavior. The nurse must ensure the safety of him or herself and the client even if that means another person is present during the assessment.

Treatment settings (description, goals): residential, inpatient, clubhouse, etc

Today, inpatient units must provide rapid assessment, stabilization of symptoms, and discharge planning, and they must accomplish goals quickly. A client-centered multidisciplinary approach to a brief stay is essential. Clinicians help clients recognize symptoms, identify coping skills, and choose discharge supports. When the client is safe and stable, the clinicians and the client identify long-term issues for the client to pursue in outpatient therapy. Some inpatient units have a locked entrance door, requiring staff with keys to let persons in or out of the unit. This situation has both advantages and disadvantages. Nurses identify the advantages of providing protection against the "outside world" in a safe and secure environment as well as the primary disadvantages of making clients feel confined or dependent and emphasizing the staff members' power over them. residential treatment settings that vary according to structure, level of supervision, and services provided (Box 4.2). Some settings are designed as transitional housing with the expectation that residents will progress to more independent living. Other residential programs serve clients for as long as the need exists, sometimes years. Board and care homes often provide a room, bathroom, laundry facilities, and one common meal each day. Adult foster homes may care for one to three clients in a family-like atmosphere, including meals and social activities with the family. Halfway houses usually serve as temporary placements that provide support as the clients prepare for independence. Group homes house six to 10 residents, who take turns cooking meals and sharing household chores under the supervision of one or two staff persons. Independent living programs are often housed in apartment complexes, where clients share apartments. Staff members are available for crisis intervention, transportation, assistance with daily living tasks, and sometimes drug monitoring. In addition to on-site staff, many residential settings provide case management services for clients and put them in touch with other programs (e.g., vocational rehabilitation; medical, dental, and psychiatric care; and psychosocial rehabilitation programs or services) as needed. Assisted living services are available in many states, but may vary a great deal in regard to services provided. Some agencies provide a broad range of services; others provide shelter but few services.Some agencies provide respite housing, or crisis housing services, for 169 clients in need of short-term temporary shelter. These clients may live in group homes or independently most of the time but have a need for "respite" from their usual residences. This usually occurs when clients experience a crisis, feel overwhelmed, or cannot cope with problems or emotions. Respite services often provide increased emotional support and assistance with problem-solving in a setting away from the source of the clients' distress. A client's living environment affects his or her level of functioning, rate of reinstitutionalization, and duration of remaining in the community setting. In fact, the living environment is often more predictive of the client's success than the characteristics of his or her illness. A client with a poor living environment often leaves the community or is readmitted to the hospital. Finding quality living situations for clients is a difficult task. Many clients live in crime-ridden or commercial, rather than residential, areas. The evolving consumer household is a group living situation in which the residents make the transition from a traditional group home to a residence where they fulfill their own responsibilities and function without on-site supervision from paid staff. One of the problems with housing for people with mental illness is that they may have to move many times, from one type of setting to another, as their independence increases. This continual moving necessitates readjustment in each setting, making it difficult for clients to sustain their gains in independence. Because the evolving consumer household is a permanent living arrangement, it eliminates the problem of relocation. Frequently, residents oppose plans to establish a group home or residential facility in their neighborhood. They argue that having a group home will decrease their property values, and they may believe that people with mental illness are violent, will act bizarrely in public, or will be a menace to their children. These people have strongly ingrained stereotypes and a great deal of misinformation. Local residents must be given the facts so that safe, affordable, and desirable housing can be established for persons needing residential care. Nurses are in a position to advocate for clients by educating members of the community. The essence of membership in the clubhouse is based on the following four guaranteed rights of members: A place to come to Meaningful work 173 • Meaningful relationships• A place to return to (lifetime membership) The clubhouse model provides members with many opportunities, including daytime work activities focused on the care, maintenance, and productivity of the clubhouse; evening, weekend, and holiday leisure activities; transitional and independent employment support and efforts; and housing options. Members are encouraged and assisted to use psychiatric services, which are usually local clinics or private practitioners. The clubhouse model recognizes the physician-client relationship as a key to successful treatment and rehabilitation while acknowledging that brief encounters that focus on symptom management are not sufficient to promote rehabilitation efforts. The "rehabilitation alliance" refers to the network of relationships that must develop over time to support people with psychiatric disabilities and includes the client, family, friends, clinicians, and even landlords, employers, and neighbors. The rehabilitation alliance needs community support, opportunities for success, coordination of service providers, and member involvement to maintain a positive focus on life goals, strengths, creativity, and hope as the members pursue recovery. The clubhouse model exists to promote the rehabilitation alliance as a positive force in the members' lives. The clubhouse focus is on health, not illness. Taking prescribed drugs, for example, is not a condition of participation in the clubhouse. Members, not staff, must ultimately make decisions about treatment, such as whether or not they need hospital admission. Clubhouse staff supports members, helps them obtain needed assistance, and, most of all, allows them to make the decisions that ultimately affect all aspects of their lives. This approach to psychiatric rehabilitation is the cornerstone and the strength of the clubhouse model.

1. Erikson's stages and examples of each

starts on page 122

Displacement

the ego defense mechanism that involves unconsciously shifting the target of an emotional urge to a substitute target that is less threatening or dangerous • Person who is mad at the boss yells at his or her spouse• Child who is harassed by a bully at school mistreats a younger sibling Dealing with emotional conflict by a temporary alteration in consciousness or identity

Regression

• A 5-year-old asks for a bottle when new baby brother is being fed• Man pouts like a 4-year-old if he is not the center of his girlfriend's attention Excluding emotionally painful or anxiety-provoking thoughts and feelings from conscious awareness

Nurse-client relationship

page 211-220( tables and phases)

Symptoms of an adventitious crisis

Adventitious crises, sometimes called social crises, include natural disasters like floods, earthquakes, or hurricanes; war; terrorist attacks; riots; and violent crimes such as rape or murder.

Describe the crisis experience

A crisis is a turning point in an individual's life that produces an overwhelming emotional response. Individuals experience a crisis when they confront some life circumstance or stressor that they cannot effectively manage through use of their customary coping skills. (1) the person is exposed to a stressor, experiences anxiety, and tries to cope in a customary manner; (2) anxiety increases when customary coping skills are ineffective; (3) the person makes all possible efforts to deal with the stressor, including attempts at new methods of coping; and (4) when coping attempts fail, the person experiences disequilibrium and significant distress. Crisis is described as self-limiting; that is, the crisis does not last indefinitely but usually exists for 4 to 6 weeks. At the end of that time, the crisis is resolved in one of three ways. In the first two, the person either returns to his or her precrisis level of functioning or begins to function at a higher level; both are positive outcomes for the individual. The third resolution is that the person's functioning stabilizes at a level lower than precrisis functioning, which is a negative outcome for the individual. Positive outcomes are more likely when the problem (crisis response and precipitating event or issue) is clearly and thoroughly defined. Likewise, early intervention is associated with better outcomes. Persons experiencing a crisis are usually distressed and likely to seek help for their distress. They are ready to learn and even eager to try new coping skills as a way to relieve their distress. This is an ideal time for intervention that is likely to be successful.

Advocacy

Advocate In the advocate role, the nurse informs the client and then supports him or her in whatever decision he or she makes. In psychiatric-mental health nursing, advocacy is a bit different from medical-surgical settings because of the nature of the client's illness. For example, the nurse cannot support a client's decision to hurt him or herself or another person. Advocacy is the process of 224 acting on the client's behalf when he or she cannot do so. This includes ensuring privacy and dignity, promoting informed consent, preventing unnecessary examinations and procedures, accessing needed services and benefits, and ensuring safety from abuse and exploitation by a health professional or authority figure. For example, if a physician begins to examine a client without closing the curtains and the nurse steps in and properly drapes the client and closes the curtains, the nurse has just acted as the client's advocate. Being an advocate has risks. In the previous example, the physician may be embarrassed and angry and make a comment to the nurse. The nurse needs to stay focused on the appropriateness of his or her behavior and not be intimidated. The role of advocate also requires the nurse to be observant of other health care professionals. At times, staff members may be reluctant to see what is happening or become involved when a colleague violates the boundaries of a professional relationship. Nurses must take action by talking to the colleague or a supervisor when they observe boundary violations. State nurse practice acts include the nurse's legal responsibility to report boundary violations and unethical conduct on the part of other health care providers. There is a full discussion of ethical conduct in Chapter 9. There is debate about the role of nurse as advocate. There are times when the nurse does not advocate for the client's autonomy or right to self- determination, such as by supporting involuntary hospitalization for a suicidal client. At these times, acting in the client's best interest (keeping the client safe) is in direct opposition to the client's wishes. Some critics view this as paternalism and interference with the true role of advocacy. In addition, they do not only see advocacy as a role exclusive to nursing but also relevant to the domains of physicians, social workers, and other health care professionals.

The purpose of the DSM

All mental health clinicians who diagnose psychiatric disorders use this diagnostic taxonomy. The DSM-5 has three purposes: To provide a standardized nomenclature and language for all mental health professionals To present defining characteristics or symptoms that differentiate specific diagnoses To assist in identifying the underlying causes of disorders The classification system allows the practitioner to identify all the factors that relate to a person's condition: All major psychiatric disorders such as depression, schizophrenia, anxiety, and substance-related disorders Medical conditions that are potentially relevant to understanding or managing the person's mental disorder as well as medical conditions that might contribute to understanding the person Psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of mental disorders. Included are problems with the primary support group, the social environment, education, occupation, housing, economics, access to health care, and the legal system.

Operant Conditioning

B.F. Skinner: Operant Conditioning One of the most influential behaviorists was B.F. Skinner (1904-1990), an American psychologist. He developed the theory of operant conditioning, which says people learn their behaviors from their history or past experiences, particularly those experiences that were repeatedly reinforced. Although some criticize his theories for not considering the role that thoughts, feelings, or needs play in motivating behavior, his work has provided several important principles still used today. Skinner did not deny the existence of feelings and needs in motivation; however, he viewed behavior as only that which could be observed, studied, and learned or unlearned. He maintained that if the behavior could be changed, then so could the accompanying thoughts or feelings. Changing the behavior was what was important. The following principles of operant conditioning described by Skinner (1974) form the basis for behavior techniques in use today:1. All behavior is learned. 2. Consequences result from behavior—broadly speaking, reward and punishment. 3. Behavior that is rewarded with reinforcers tends to recur. 4. Positive reinforcers that follow a behavior increase the likelihood that the behavior will recur. 5. Negative reinforcers that are removed after a behavior increase the likelihood that the behavior will recur. 6. Continuous reinforcement (a reward every time the behavior occurs) is the fastest way to increase that behavior, but the behavior will not last long after the reward ceases. 7. Random intermittent reinforcement (an occasional reward for the desired behavior) is slower to produce an increase in behavior, but the behavior continues after the reward ceases.

Therapeutic communication

pg 244-248 also briefly 275

Denial

Diabetic person eating chocolate candy• Spending money freely when broke• Waiting 3 days to seek help for severe abdominal pain Ventilation of intense feelings toward persons less threatening than the one who aroused those feelings

Therapeutic lithium levels and nursing actions

Dosage Lithium is available in tablet, capsule, liquid, and sustained-release forms; no parenteral forms are available. The effective dosage of lithium is determined by monitoring serum lithium levels and assessing the client's clinical response to the drug. Daily dosages generally range from 900 to 3,600 mg; more importantly, the serum lithium level should be about 1 mEq/L. Serum lithium levels of less than 0.5 mEq/L are rarely therapeutic, and levels of more than 1.5 mEq/L are usually considered toxic. The lithium level should be monitored every 2 to 3 days while the therapeutic dosage is being determined; then, it should be monitored weekly. When the client's condition is stable, the level may need to be checked once a month or less frequently. ➔ WARNING - Lithium Toxicity is closely related to serum lithium levels and can occur at therapeutic doses. Facilities for serum lithium determinations are required tomonitor therapy. Lithium and selected anticonvulsants are used to stabilize mood, particularly in bipolar affective disorder. ► The nurse must monitor serum lithium levels regularly to ensure the level is in the therapeutic range and to avoid lithium toxicity. Symptoms of toxicity include severe diarrhea and vomiting, drowsiness, muscle weakness, and loss of coordination. Untreated, lithium toxicity leads to coma and death.

Empathy

Empathy is the ability of the nurse to perceive the meanings and feelings of the client and to communicate that understanding to the client. It is considered one of the essential skills a nurse must develop to provide high-quality, compassionate care. Being able to put him or herself in the client's shoes does not mean that the nurse has had the exact experiences as that of the client. Nevertheless, by listening and sensing the importance of the situation to the client, the nurse can imagine the client's feelings about the experience. Both the client and the nurse give a "gift of self" when empathy occurs—the client by feeling safe enough to share feelings and the nurse by listening closely enough to understand. Empathy has been shown to positively influence client outcomes. Clients tend to feel better about themselves and more understood when the nurse is empathetic. Several therapeutic communication techniques, such as reflection, 198 restatement, and clarification, help the nurse send empathetic messages to the client

Individual factors influencing mental health

Factors influencing a person's mental health can be categorized as individual, interpersonal, and social/cultural. Individual, or personal, factors include a person's biologic makeup, autonomy and independence, self-esteem, capacity for growth, vitality, ability to find meaning in life, emotional resilience or hardiness, sense of belonging, reality orientation, and coping or stress management abilities. Interpersonal, or relationship, factors include effective communication, ability to help others, intimacy, and a balance of separateness and connectedness. Social/cultural, or environmental, factors include a sense of community, access to adequate resources, intolerance of violence, support of diversity among people, mastery of the environment, and a positive, yet realistic, view of one's world. Individual, interpersonal, and social/cultural factors are discussed further in

Transference

Freud developed the concepts of transference and countertransference. Transference occurs when the client displaces onto the therapist attitudes and feelings that the client originally experienced in other relationships (Freud, 1923, 1962). Transference patterns are automatic and unconscious in the therapeutic relationship. For example, an adolescent female client working with a nurse who is about the same age as the teen's parents might react to the nurse like she reacts to her parents. She 120 might experience intense feelings of rebellion or make sarcastic remarks; these reactions are actually based on her experiences with her parents, not with the nurse.

Transitional residential treatment

Group homes Supervised apartments Board and care homes Assisted living Adult foster care Respite/crisis housing Transitional Care In Canada and Scotland, the transitional relationship model, formerly called the transitional discharge model, has proved successful. Patients who were discharged to the community after long hospitalizations received intensive services to facilitate their transition to successful community living and 170 functioning. Two essential components of this model are peer support and bridging staff. Peer support is provided by a consumer now living successfully in the community. Bridging staff refers to an overlap between hospital and community care; hospital staff do not terminate their therapeutic relationship with the client until a therapeutic relationship has been established with the community care provider. This model requires collaboration, administrative support, and adequate funding to effectively promote the patient's health and well-being and prevent relapse and rehospitalization. Poverty among people with mental illness is a significant barrier to maintaining housing. Residents often rely on government entitlements, such as Social Security Insurance or Social Security Disability Insurance, for their income, which averages $400 to $450 per month. Although many clients express the desire to work, many cannot do so consistently. Even with vocational services, the jobs available tend to be unskilled and part-time, resulting in income that is inadequate to maintain independent living. In addition, the Social Security Insurance system is often a disincentive to making the transition to paid employment; the client would have to trade a reliable source of income and much-needed health insurance for a poorly paying, relatively insecure job that is unlikely to include fringe benefits. Both psychiatric rehabilitation programs and society must address poverty among people with mental illness to remove this barrier to independent living and self-sufficiency.

Mental disorders linked to genetics

Heredity and biologic factors are not under voluntary control. We cannot change these factors. Research has identified genetic links to several disorders. For example, some people are born with a gene associated with one type of Alzheimer disease. Although specific genetic links have not been identified for several mental disorders (e.g., bipolar disorder, major depression, alcoholism), research has shown that these disorders tend to appear more frequently in families. Genetic makeup tremendously influences a person's response to illness and perhaps even to treatment (see Chapter 2, Cultural Considerations on page 34). Hence, family history and background are essential parts of the nursing assessment.

Classical conditioning

Ivan Pavlov's theory of classical conditioning: Behavior can be changed through conditioning with external or environmental conditions or stimuli. Pavlov's experiment with dogs involved his observation that dogs naturally began to salivate (response) when they saw or smelled food (stimulus). Pavlov (1849-1936) set out to change this salivating response or behavior through conditioning. He would ring a bell (new stimulus), then produce the food, and the dogs would salivate (the desired response). Pavlov repeated this ringing of the bell along with the presentation of food many times. Eventually, he could ring the bell, and the dogs would salivate without seeing or smelling food. The dogs had been "conditioned," or had learned a new response, to salivate when they heard the bell. Their behavior had been modified through classical 132 conditioning, or a conditioned response.

Lithium efficacy

Lithium is the most established mood stabilizer; Lithium normalizes the reuptake of certain neurotransmitters such as serotonin, norepinephrine, acetylcholine, and dopamine. It also reduces the release of norepinephrine through competition with calcium and produces its effects intracellularly rather than within neuronal synapses; it acts directly on G-proteins and certain enzyme subsystems such as cyclic adenosine monophosphates and phosphatidylinositol. Lithium is considered a first-line agent in the treatment of bipolar disorder (Stahl, 2017). Common side effects of lithium therapy include mild nausea or diarrhea, anorexia, fine hand tremor, polydipsia, polyuria, a metallic taste in the mouth, 92 and fatigue or lethargy. Weight gain and acne are side effects that occur later in lithium therapy; both are distressing for clients. Taking the medication with food may help with nausea, and the use of propranolol often improves the fine tremor. Lethargy and weight gain are difficult to manage or minimize and frequently lead to noncompliance. Toxic effects of lithium are severe diarrhea, vomiting, drowsiness, muscle weakness, and lack of coordination. Untreated, these symptoms worsen and can lead to renal failure, coma, and death. When toxic signs occur, the drug should be discontinued immediately. If lithium levels exceed 3 mEq/L, dialysis may be indicated.

Definition of mental illness

Mental health and mental illness are difficult to define precisely. People who can carry out their roles in society and whose behavior is appropriate and adaptive are viewed as healthy. Conversely, those who fail to fulfill roles and carry out responsibilities or whose behavior is inappropriate are viewed as ill. The culture of any society strongly influences its values and beliefs, and this, in turn, affects how that society defines health and illness. What one society may view as acceptable and appropriate, another society may see as maladaptive and inappropriate.

Resistance

Nurse is too busy with tasks to spend time talking to a dying patient.• Person attends court-ordered treatment for alcoholism but refuses to participate Substituting a socially acceptable activity for an impulse that is unacceptable

Revolving door effect

One result of deinstitutionalization is the revolving door of repetitive hospital admission without adequate community follow-up. Shorter unplanned hospital stays further complicate frequent repeated hospital admissions. People with severe and persistent mental illness may show signs of improvement in a few days but are not stabilized. Thus, they are discharged into the community without being able to cope with community living. However, planned or scheduled short hospital stays do not contribute to the revolving door phenomenon and may show promise in dealing with this issue (see Chapter 4). The result frequently is decompensation and rehospitalization. In addition, many people have a dual problem of both severe mental illness and substance abuse. Use of alcohol and drugs exacerbates symptoms of mental illness, again making rehospitalization more likely. Substance abuse issues cannot be dealt within the 3 to 5 days typical for admissions in the current managed care environment. Homelessness is a major problem in the United States today with 610,000 people, including 140,000 children, homeless on any given night. Approximately 257,300 of the homeless population (33%) have a severe mental illness of a chronic substance use disorder. The segment of the homeless population considered to be chronically homeless numbers 110,000, and 30% of this group has a psychiatric illness and two-thirds have a primary substance abuse disorder or other chronic health condition (Treatment Advocacy Center, 2019). Those who are homeless and mentally ill are found in parks, airport and bus terminals, alleys and stairwells, jails, and other public places. Some use shelters, halfway houses, or board-and-care rooms; others rent cheap hotel rooms when they can afford it. Homelessness worsens psychiatric problems for many people with mental illness who end up on the streets, contributing to a vicious cycle. Many of the problems of the homeless mentally ill, as well as of those who pass through the revolving door of psychiatric care, stem from the lack of adequate community resources. Money saved by states when state hospitals were closed has not been transferred to community programs and support. Inpatient psychiatric treatment still accounts for most of the spending for mental health in the United States, so community mental health has never been given the financial base it needs to be effective. In addition, mental health services provided in the community must be individualized, available, and culturally relevant to be effective.

Role of the mental health nurse and interdisciplinary teams

Pharmacist: The registered pharmacist is a member of the interdisciplinary team when medications, management of side effects, and/or interactions with nonpsychiatric medications are complex. Clients with refractory symptoms may also benefit from the pharmacist's knowledge of chemical structure and actions of medications. Psychiatrist: The psychiatrist is a physician certified in psychiatry by the American Board of Psychiatry and Neurology, which requires a 3- year residency, 2 years of clinical practice, and completion of an examination. The primary function of the psychiatrist is diagnosis of mental disorders and prescription of medical treatments. Psychologist: The clinical psychologist has a doctorate (Ph.D.) in clinical psychology and is prepared to practice therapy, conduct research, and interpret psychological tests. Psychologists may also participate in the design of therapy programs for groups of individuals. Psychiatric nurse: The registered nurse gains experience in working with clients with psychiatric disorders after graduation from an accredited program of nursing and completion of the licensure examination. The nurse has a solid foundation in health promotion, illness prevention, and rehabilitation in all areas, allowing him or her to view the client holistically. The nurse is also an essential team member in evaluating the effectiveness of medical treatment, particularly medications. Registered nurses who obtain master's degrees in mental health may be certified as clinical specialists or licensed as advanced practitioners, depending on individual state nurse practice acts. Advanced practice nurses are certified to prescribe drugs in many states. Psychiatric social worker: Most psychiatric social workers are prepared at the master's level and are licensed in some states. Social workers may practice therapy and often have the primary BOX 4.6 Interdisciplinary Team Primary Roles 181 responsibility for working with families, community support, and referral. Occupational therapist: Occupational therapists may have an associate degree (certified occupational therapy assistant) or a baccalaureate degree (certified occupational therapist). Occupational therapy focuses on the functional abilities of the client and ways to improve client functioning, such as working with arts and crafts and focusing on psychomotor skills. Recreation therapist: Many recreation therapists complete a baccalaureate degree, but in some instances, persons with experience fulfill these roles. The recreation therapist helps the client to achieve a balance of work and play in his or her life and provides activities that promote constructive use of leisure or unstructured time. Vocational rehabilitation specialist: Vocational rehabilitation includes determining clients' interests and abilities and matching them with vocational choices. Clients are also assisted in job-seeking and job retention skills as well as in pursuit of further education, if that is needed and desired. Vocational rehabilitation specialists can be prepared at the baccalaureate or master's level and may have different levels of autonomy and program supervision based on their educatio

Healthy People 2020 objectives for mental health

Reduce the suicide rate. Reduce suicide attempts by adolescents. Reduce the proportion of adolescents who engage in disordered eating behaviors in an attempt to control their weight. Reduce the proportion of persons who experience major depressive episode. Increase the proportion of primary care facilities that provide mental health treatment onsite or by paid referral. Increase the proportion of juvenile residential facilities that screen admissions for mental health problems. Increase the proportion of persons with serious mental illness who are employed. Increase the proportion of adults with mental health disorders who receive treatment. Increase the proportions of persons with co-occurring substance abuse and mental disorders who receive treatment for both disorders. Increase depression screening by primary care providers. Increase the number of homeless adults with mental health problems who receive mental health services.

Role of neurotransmitters in mental health

pg 62-63 table 2.1.••Chemical substances to facilitate neurotransmission (see Figure 2.3) •Important in right proportions to relay messages (see Figure 2.4) •Play role in psychiatric illness and psychotropic medications, including their actions and side effects.Excitatory •Dopamine: complex movements, motivation, cognition, regulation of emotional response •Norepinephrine: attention, learning, memory, sleep, wakefulness, mood regulation •Epinephrine: flight-or-fight response •Glutamate: major neurotoxic effects at high levels

coping strategies

Two categories of coping strategies are important for clients to learn and to practice: emotion-focused coping strategies, which help clients relax and reduce feelings of stress, and problem-focused coping strategies, which help resolve or change a client's behavior or situation or manage life stressors. Emotion-focused strategies include progressive relaxation, deep breathing, guided imagery, and distractions such as music or other activities. Many approaches to stress relief are available for clients to try. The nurse should help clients learn and practice these techniques, emphasizing that their effectiveness usually improves with routine use. Clients must not expect such techniques to eliminate their pain or physical symptoms; rather, the focus is helping them manage or diminish the intensity of the symptoms. Problem-focused coping strategies include learning problem-solving methods, applying the process to identified problems, and role-playing interactions with others. For example, a client may complain that no one comes to visit or that she has no friends. The nurse can help the client plan social contact with others, can role-play what to talk about (other than the client's complaints), and can improve the client's confidence in making relationships. The nurse can also help clients identify stressful life situations and plan strategies to deal with them. For example, if a client finds it difficult to accomplish daily household tasks, the nurse can help him to plan a schedule with difficult tasks followed by something the client may enjoy.

Ways of knowing: Aesthetic, ethical, personal, empirical

empirical knowing (derived from the science of nursing), ex.The client with panic disorder begins to have an attack. Panic attacks will raise pulse rate. personal knowing (derived from life experiences), ethical knowing (derived from moral knowledge of nursing), ex, The client's face shows the panic. aesthetic knowing (derived from the art of nursing). ex.Although the client shows outward signals now, the nurse has sensed Ethical knowing (obtained from the moral knowledge of nursing) ex.Although the nurse's shift has ended, he or she remains with the client. These patterns provide the nurse with a clear method of observing and understanding every client interaction. Understanding where knowledge comes from and how it affects behavior helps the nurse become more self-aware

Efficacy of SSRIs

selective serotonin reuptake inhibitors (SSRIs) first choice in treating depression because they are equal in efficacy and produce fewer troublesome side effects. but much is known about their action on the CNS. The major interaction is with the monoamine neurotransmitter systems in the brain, particularly norepinephrine and serotonin. Both of these neurotransmitters are released throughout the brain and help regulate arousal, vigilance, attention, mood, sensory processing, and appetite. Norepinephrine, serotonin, and dopamine are removed from the synapses after release by reuptake into presynaptic neurons. After reuptake, these three neurotransmitters are reloaded for subsequent release or metabolized by the enzyme MAO. The SSRIs block the reuptake of serotonin, the cyclic antidepressants and venlafaxine block the reuptake of norepinephrine primarily and block serotonin to some degree, and the MAOIs interfere with enzyme metabolism. This is not the complete explanation, however; the blockade of serotonin and norepinephrine reuptake and the inhibition of MAO occur in a matter of hours, while antidepressants are rarely effective until taken for several weeks. The cyclic compounds may take 4 to 6 weeks to be effective, MAOIs need 2 to 4 weeks for effectiveness, and SSRIs may be effective in 2 to 3 weeks. Researchers believe that the actions of these drugs are an "initiating event" and that eventual therapeutic effectiveness results when neurons respond more slowly, making serotonin available at the synapses (Burchum & Rosenthal, 2018). SSRIs have fewer side effects compared to the cyclic compounds. Enhanced serotonin transmission can lead to several common side effects such as anxiety, agitation, akathisia (motor restlessness), nausea, insomnia, and sexual dysfunction, specifically diminished sexual drive or difficulty achieving an erection or orgasm. In addition, weight gain is both an initial and ongoing problem during antidepressant therapy, although SSRIs cause less weight gain than other antidepressants. Taking medications with food usually can minimize nausea. Akathisia is usually treated with a beta-blocker, such as propranolol (Inderal) or a benzodiazepine. Insomnia may continue to be a problem even if the client takes the medication in the morning; a sedative- hypnotic or low-dosage trazodone may be needed. Less common side effects include sedation (particularly with paroxetine [Paxil]), sweating, diarrhea, hand tremor, and headaches. Diarrhea and headaches can usually be managed with symptomatic treatment. Sweating and continued sedation most likely indicate the need for a change to another 87 antidepressant.

Reality Therapy

therapeutic focus is need for identity through responsible behavior; individuals are challenged to examine ways in which their behavior thwarts their attempts to achieve life goals William Glasser devised an approach called reality therapy that focuses on the person's behavior and how that behavior keeps him or her from achieving life goals. He developed this approach while working with persons with delinquent behavior, unsuccessful school performance, and emotional problems. He believed that persons who were unsuccessful often blamed their problems on other people, the system, or the society. He believed they needed to find their own identities through responsible behavior. Reality therapy challenges clients to examine the ways in which their own behavior thwarts their attempts to achieve life goals.

Rationalization

• Student blames failure on teacher being mean• Man says he beats his wife because she does not listen to him Acting the opposite of what one thinks or feels