NURS 3554: Exam 1

Main neurotransmitters affected by psychotropic drugs

-Antidepressant: serotonin -Antianxiety: GABA -Sedative hypnotic: histamine -Mood stabilizer: norepinephrine -Antipsychotic: dopamine -Anticholinesterase: acetylcholine

Areas inherent in the art of nursing

-Caring -Attending -Patient advocacy

PMH nursing is an art

"Arts" of psychiatric mental health nursing: -Intuition -Interpersonal skills -Employ purposeful use of self Recovery: empowering those with mental illness to find meaning and satisfaction, realize potential and function at maximum level of independence

Introduction to theories and therapies for nursing practice

-Psychological theories help us to explain behavior -Psychological therapies are treatments based on these theories -An overview of theories and therapies and their relevance to nursing and psychiatric mental health nursing

Barriers to quality mental health services

-Communication barriers: may not speak English, may struggle accessing healthcare, navigating to find a PCP due to language barrier -Stigma of mental illness: may feel stigmatized for seeking mental healthcare, interference with jobs (ex. military personnel often don't seek help do to concern of being seen as weak, not fit for the military) -Misdiagnosis: Culture-bound syndromes, interferes with patient's ability to get best treatment possible -Ethnic variation in pharmacodynamics: not everyone responds to psychiatric medications the same way, be willing to work with patient to find a medication that helps them best

Western tradition

-Identity found in individuality Values: -Autonomy -Independence -Self-reliance Mind and body separate entities Disease has a cause, and treatment is aimed at the cause Time is linear Success is obtained in preparing for the future: having a job, making money, possession of material things, importance placed on title, position, place in society

Populations at risk of mental illness and inadequate care

-Immigrants -Refugees -Cultural "minorities" May find it hard to understand language, assimilate to Western culture, go through enculturation process, which is time-consuming and difficult, may not know the best way to find and receive care

According to Freud, experiences during early stages of life determine:

-Individual's lifetime adjustment patterns -Personality traits

Freud's psychoanalytic theory

-An Austrian neurologist (1856-1939) -Majority of mental disorders due to unresolved issues during childhood -Experiences in early stages development determine life adjustment patterns and personality traits (birth to 5 years of age, interactions with parents/caregivers, bonding) -Theory about personality structures and traits, levels of awareness, anxiety, role of defense mechanisms -Ego, superego, and id (conscious, preconscious, and unconscious level)

Buspirone

-Antianxiety medication -Effective in reducing anxiety without dependency or sedation -Not a CNS depressant -MOA unknown: blocks feedback inhibition by serotonin, leading to increased release of serotonin by the presynaptic cell (5-HT1 Serotonin), parital serotonin-1A agonist

Benzodiazepines

-Antianxiety/ hypnotic drugs -Affect GABA: Diazepam (Valium), Clonazepam (Klonopin), and alprazolam (Xanax) -Insomnia treatment (hypnotics): flurazepam (Dalmane), temazepam (Restoril), triazolam (Halcion), estazolam (ProSom), and quazepam (Doral) -Quick acting, long half lives (up to 6 hours) -Problem with dependency -Can cause sedation (fall risk) -Need to be tapered off -Use cautiously with elderly *END IN -AM

Psychotropic drug interactions

-Antianxiety/ hypnotics -Anti-depressants -Mood stabilizers -Anti-convulsants -Anti-psychotics -ADHD agents -Alzhemier agents -Herbal treatments Always important to have full medication reconciliation, including herbal and OTC treatments (Saint Johns wart can be used for mild depression but can interact with antidepressants such as SSRI, SNRI, SNDI, Kava Kava can produce calmness as an herbal remedy but interacts with antipsychotics, benzodiazepines because both affect GABA in brain

Social influences on psychiatric care settings

-1950s: Thorazine, first antipsychotic, viewing mental health illness as a biological/genetic cause -1960s: Community Mental Health Centers Act— deinstitutionalization, attempting to discharge individuals to get them back into the community, participating in social lives, however, discharged prior to CMHC availability for continuity of care and follow up, leaving many patients homeless or using negative coping skills such as self-medication with drugs or alcohol, ending them up in correctional settings -1980s: Carter's Commission on Mental Health— recommended more community-based care -George W. Bush's New Freedom Commission on Mental Health -2010—Affordable Care Act: hope that treatment will become available for everyone, yet to see full impact

Accessing mental health care

-Access to mental health care more difficult than accessing care for physical problems -Factors leading to problems obtaining care: stigmatized, discriminated against for seeking help, embarrassment, emotional components of feeling flawed, not being mentally capable of realizing the need for help -Symptomatology of mental illnesses can mimic physical issues (ex. panic attack manifesting as MI symptoms) -Mental health symptoms can cause physical problems, need to assess for both mental and physical illnesses/symptoms -Treatment options based on severity of symptoms, look for least restrictive setting first, give most freedom and the ability to care for themselves

Nursing care in PMNH

-Admission assessment: initiation of therapeutic relationship -Physical health assessment: as needed, always do vital signs, overall observation -Therapeutic groups: structured, specific activities with goals, outcomes, coping, psychosocial, med management, stress management -Documentation: if it is not documented, it is not done, important to keep care plan going, keeping patient-centered care consistent -Medication management -Medical emergencies -Preparation for discharge to community

Rational-Emotive Behavior Therapy (Ellis)

-Aims to eradicate irrational beliefs -Recognize thoughts that are not accurate -Activating event, Belief, Consequence/Behaviors (ABC) -Need to identify irrational belief about situation, then change belief to change actions

Transmission of neurotransmitters

-All activities of the brain involve actions of neurons, neurotransmitters, and receptors. These are the targets of pharmacologic intervention. -Most psychotropic drugs act by either increasing or decreasing the activity of certain neurotransmitter-receptor systems -May inhibit synapse sites so the neurotransmitter doesn't get reabsorbed at presynaptic cell in order that more neurotransmitter is available or may decrease number of neurotransmitters in the synapse -Thought disorders such as schizophrenia are physiologically associated with the excess transmission of the neurotransmitter dopamine.

Sullivan's interpersonal theory

-An American born psychiatrist -Personality: can be observed within interpersonal relationships -Purpose of all behavior is to get needs met through interpersonal interactions and to decrease or avoid anxiety -Security operations: interpersonal relationship activities designed to relieve anxiety (similar to Freud's defense mechanisms) -Behaviors are observable unlike defense mechanisms that are unconscious and automatic -Therapist is very invovled in treatment for patients, as opposed to psychoanalysis which focuses less on engagement and interaction

Erikson's ego theory

-An American psychoanalyst (1902-1994) -Felt Freud was too restrictive in his psychoanalysis approach -Believed culture and society influenced personality -Eight stages of development, psychosocial crises at each stage have positive or negative outcomes, affects ability to mature and go through other stages -Failures at one stage can be rectified at another -Personality continues to develop through old age -Helps guide nursing internveitonsa based on clinical presentation and what are most likely to be effective

Emergency care and crisis stabilization

-Comprehensive emergency service model: ER, triage, stabilize and send home -Hospital-based consultant model: ER, triage and stabilize, admission to psych unit from psych section of ER -Mobile crisis team model: lead by social workers, PMNH, APRNs, psychiatrists, includes psych assessment and recommended based on assessment -Crisis stabilization/observation units: can hold for 72 hours on obs unit for rapid stabilization (ex. patient comes in for suicidal ideation/attempt, can't give safety promise if they left during assessment, past hx doesn't warrant them to be definitely admitted to psych unit, they are held overnight for uptimes 72 hours to determine if able to be discharged or admitted to unit)

Discharge procedures

-Conditional release: patient required to continue treatment in an outpatient setting for a determined amount of time -Unconditional release: patient is discharged without any sort of requirement for outpatient services, institutional relationship ends -Release against medical advice (AMA): disagreement by HCPs that patient is ready for discharge, however patient makes the decision to discharge themselves, released from admission

Case Study: Ms. B is admitted to your unit. In your assessment you identify some cultural patterns that may support or interfere with her health and recovery process. What can you do?

-Desire to help her incorporate her culture and educate her on her recovery process -Empathy -Awareness, gain knowledge, develop cultural skill

Cultural encounters PMNH

-Deter nurses from stereotyping -Help nurses gain confidence in cross-cultural interactions -Help nurses avoid or reduce cultural pain

Anticholinergic effects

-Dry mouth -Blurred vision -Urinary retention -Constipation -Tachycardia Paroxetine (Paxil) has the most anticholinergic effects

Five elements to prove negligence

-Duty -Breach of duty: do not meet standard of care that any other nurse would be expected to meet -Cause in fact: if the breach did not occur, would this injury have resulted -Proximate cause -Damages: patient, property, medical damage

Cognitive theory

-Dynamic interplay between individuals and the environment -Thoughts come before feelings and actions -Thoughts about the world and our place in it are based on our own unique perspectives, which may or may not be based on reality -Many of our behaviors are due to how you think how you think about a situation, which affects our actions -Schematas: our views on the world, clouds how we view different situations, interplay between our world view, perceptions, and the environment -Rational-emotive behavior therapy (Ellis) -Cognitive-Behavioral Therapy (Beck)

Culture and mental health

-Enculturation: learning world views, beliefs, values, and practices of the culture a person is immersed within, then beginning to practice this way of life and adopt the culture one is immersed within -Deviance from cultural expectations can be defined as illness by other members of the group, not fitting into the culture a person is surrounded by -Ethnocentrism: belief by individuals that their culture and beliefs are the only right, best way to do things and others are wrong compared to what they believe -Nurses influenced by their own professional and ethnic cultures -Cultural imposition does not promote client health and wellbeing -Nurses must be aware of patient's culture and help them along integrate their beliefs and practices into their care, helping along a continuum of health and wellbeing (ex. Individual may want people to come in and lay hands on them, pray with them, we may push antibiotics, rest, but in that person's mind, laying hands and prayer is what will promote healing, need to be culturally aware and work with them to incorporate this into care plan)

Ethical concepts

-Ethics -Bioethics -Ethical dilemma

Cultural awareness PMNH

-Examine beliefs, values, and practices of own culture -Recognize that during a cultural encounter, three cultures are intersecting: Culture of the patient, nurse, and setting

Eastern tradition

-Family basis for identity -Body-mind-spirit one entity -Disease caused by fluctuations in opposing forces -Time is circular and recurring -Born into a fate; duty to comply with traditions and values of culture

Freud's Psychoanalytic Theory: Implications for Mental Health Nursing

-Formation of personality -Conscious and unconscious influences -Importance of individual talk sessions -Attentive listening -Transference -Countertransference

Theory of Interpersonal Relationships (Peplau)

-Foundation of PMHN professional practice -Worked under Sullivan -Essential for nurses to observe behaviors in themselves as well as patients -Concerned with the processes by which nurses help patients make positive changes -Operationalized levels of anxiety and nursing interventions (mild, moderate, severe, and panic) -Identified many roles PMHN assume: educator, counselor, supporter -Stages of nurse patient relationship -Developed first advanced nursing program

Cultural desire PMNH

-Genuine concern for patient's welfare -Willingness to listen until patient's viewpoint is understood -Patience, consideration, and empathy

Patients' Rights

-Hospitalized patients retain their rights as citizens -Patient's need for safety must be balanced against patient's rights as a citizen: possession of belongings, can refuse medications even if psychotic/delusional/manic unless risk to self or others, if suicidal or homicidal, staff remains in arms' length for their safety without violating their rights -Mental health facilities have written statements of patient's rights and applicable state laws

Case Study: You are working with a patient who will be discharged into the community soon. What are some problems that may affect the success of treatment?

-Housing adequacy and stability: If a patient faces daily fears of homelessness, it is not possible to focus on other treatment issues. -Income and source of income: A patient must have a basic income—whether from an entitlement, a relative, or other sources—to obtain necessary medication and meet daily needs for food and clothing. -Family and support system: The presence of a family member, friend, or neighbor supports the patient's recovery and gives the nurse a contact person, with the patient's consent. -Substance abuse history and current use: Often hidden or minimized during hospitalization, substance abuse can be a destructive force, undermining medication effectiveness and interfering with community acceptance and procurement of housing. -Physical well-being: Factors that increase health risks and decrease life span for individuals with mental illnesses include decreased physical activity, smoking, medication side effects, and lack of routine health exams.

Admission procedures

-Informal admission: sought by patient, least restrictive of all admissions, free to stay or leave, even against medical advice -Voluntary admission: sought by patient or guardian, need for treatment, willing to be admitted -Temporary admission: person confused or demented, so ill he or she needs emergency admission, holding for 72 hours to perform assessment, determine best treatment intervention -Involuntary admission: without patient's consent, court order admission to facility (mental ill, gravely disabled, treatment and mental illness prevents them from seeking help, danger to self or others) -Long term involuntary admission: medical certification, judicial review, administrative action (not as common, ex. CVH) -Involuntary outpatient admission: can be discharged but must continue with outpatient treatment

ICD-10-CM

-International Classification of Disease for all diseases -United States reimbursement traditionally based on ICD codes -Clinical descriptions of mental and behavioral disorders: 2 broad classification, subclassifications -The DSM V aligns with the ICD-10 to facilitate common use of diagnoses across disorders -Important for healthcare coverage to facilitate treatment interventions

Accessing 'best evidence' practice

-Internet mental health resources -Clinical practice guidelines -Clinical algorithms -Clinical/critical pathways

Cultural knowledge PMNH

-Learn by attending cultural events and programs -Forge friendships with diverse cultural groups -Learn by studying -Learning cultural differences helps nurse: Establish rapport, Ask culturally relevant questions, Identify cultural variables to be considered

Treatment settings

-Levels of intensity in treatment based on least restrictive environment** -Principle of least restrictive intervention** -Rights of the hospitalized patient -Criteria for admission to inpatient: danger to self, others, not able to take care of day to day activities -PHP vs. inpatient: PHP can still maintain work, school, however in need of intensive therapy, but not 24/7 care -Assertive community treatment settings: open 24/7, case manager can do triage -Can refuse medication even if delusional, psychotic (unless danger to self and others, acute situation, or deemed incompetent and court order or power of attorney, advance directive, DCF involvement) -Therapeutic milieu: overall environment and interactions need to be therapeutic; SAFETY

Functions of the brain

-Maintenance of homeostasis: keeping body in balance -Regulation of autonomic nervous system (ANS) and hormones: fight or flight -Control of biological drives and behavior -Cycle of sleep and wakefulness -Circadian rhythms -Conscious mental activity -Memory -Social skills

Therapeutic milieu: surroundings and physical environment

-Managing behavioral crises -Safety -Suicide risk

Multidisciplinary treatment team

-Members of each discipline are responsible for gathering data and participating in the planning of care (PMNH: behavioral health assessment, mental health status assessment every time meeting with patient, may need physical exam as well) -Treatment plan or clinical pathway provides a guideline for patient's care during hospital stay: standardized treatments and guidelines to patient care, based on evidence and tools, suggestions of how to treat patient during hospitalization and beyond)

Behavioral therapy

-Modeling -Operant conditioning -Systematic desensitization -Aversion therapy -Biofeedback

Antidepressant drugs

-Monoamine Oxidase Inhibitors -Tricyclic antidepressants -Selective serotonin reuptake inhibitors (SSRI's) -Serotonin-norepineprhine reuptake inhibitors (SNRIs) -Serotonin-norepinephrine disinhibiitors (SNDIs) -Norepinephrine-dopamine reuptake inhibitors (NDRIs) -Serotonin antagonist/reuptake inhibitors (SARIs) -Selective norepinephrine reuptake inhibitors (NRIs)

Continuum of psychiatric treatment

-Most acute treatment (short-term) -Intensive outpatient treatment (usually short-term) -Transitional outpatient treatment (usually long-term) -Ongoing outpatient treatment (long-term)

Off-label mood stabilizers

-Oxcarbazepine (Trileptal) -Gabapentin (Neurontin): also treatment of individuals with neuropathic pain -Topiramate (Topamax)

Defense mechanisms and anxiety (Freud)

-Part of Freud's psychoanalytic theory -Operate on unconscious level -Deny, falsify, or distort reality to make it less threatening -Maladaptive or adaptive -Automatic response

Indigenous culture

-Place significance on place of humans in natural world -Basis of identity is the tribe -Person an entity only in relation to others, self esteem based on relationship with others -Disease - lack of harmony of individual with environment

Outpatient psychiatric mental health care

-Primary care providers: often first place for seeking mental health treatment, can prescribe medications, but often limited in knowledge, often first entry to psych care -Specialty psychiatric care providers -Patient-centered health/medical homes -Community clinics -Psychiatric home care -Assertive community treatment (ACT): effective for those with repeat hospitalizations, intensive case management with a multidisciplinary team who work together to keep patient in the community and prevent them from continued inpatient treatment and visits to the ER, available 24/7, ready to intervene at any time of the day -Partial hospitalization programs (PHPs): great in-between program between outpatient and inpatient setting, similar services, groups and activities in inpatient setting, but available during times so the patient can maintain work/school and/or ease back into work environment part time Other outpatient venues for psychiatric care: -Telephone crisis counseling -Telephone outreach -Internet -Telepsychiatry

Second generation (SGA) Atypical Antipsychotic Drugs

-Produce fewer extrapyramidal side effects (EPS) -Target negative and positive symptoms of schizophrenia Drugs: -Clozapine (Clozaril) -Risperadone (Risperdal) -Quetiapine (Seroquel) -Olanzapine (Zyprexa) -Iloperidone (Fanapt) -Lurasidone HCl (Latuda) -Ziprasidone HCl (Geodon) -Aripiprazole (Abilify) -Paliperidone (Invega)

Psychotropic drugs

-Psychiatric illness is related to a number of factors (e.g., genetics, neurodevelopmental factors, drugs, infection, psychosocial experience). -Psychiatric illness results in an alteration in neurotransmitters. -These alterations are the targets of psychotropic drugs. -All mental activity has its locus in the brain. The primary goals of psychiatric mental health nursing is to: -Understand the biological basis of both normal and abnormal brain functions. -Apply this understanding to the care of individuals treated with psychotropic drugs.

Patient's rights under the law

-Right to treatment -Right to refuse treatment -Right to informed consent -Right to privacy and dignity -Right to least restrictive environment -Right to attorney -Right to clergy -Right to consent to treatment and being informed of treatment prior to consent -Right to be free of unnecessary and excessive use of medication -Right for psychiatric advance directives: expression of treatment preferences prior to admission, document prepared by attorney presenting their wishes and desires for treatment -Rights regarding restraint and seclusion: always consider deescalation techniques first -Right to confidentiality

Patient Advocate

-SPeaks up for another's cause -Helps another by defending and comforting -Can be a lawyer who is often viewed as an advocate for our clients Advocacy in nursing: -Committing to patient's health -Alleviating suffering -Promoting a peaceful, comfortable, and dignified death Nurses advocate for patients when they: -Advise patients of their rights -Provide accurate and current information

Interpersonal theory (Sullivan)

-Security operations: measures individuals employ to reduce anxiety and enhance security (all of the security operations and invidious uses to defend against anxiety and ensure self-esteem make up the self-system) -Human beings driven by need for interaction -Reduce psychiatric symptoms by improving interpersonal relationships -More interactive approach than Freud, short term therapy, goal is to reduce or eliminate psychiatric symptoms (particularly depression) by improving interpersonal functioning and satisfaction with social relationships

Attributes of mental health

-Self care -Meaningful relationships -Learning -Productivity -Contentment

Herbal therapy

-St. Johns Wort -Kava kava

Barriers to mental health treatment

-Stigma associated with mental disorders (ex. autistic child is often bullied in school, given labels by schools) -Scarcity of care in rural areas -Inability to afford health insurance (improvement with ACA) -Fragmented care for children and adults with serious mental illness (improvement with treatments like ACTs or intensive case management)

Psychiatric nursing in outpatient and community settings

-Strong problem-solving and clinical skills: working independently outside acute care setting -Cultural competence -Flexibility: work with equipment that you have in community settings -Knowledge of community resources: ex. patient is newly diagnosed diabetic, direct them to group on nutrition) -Autonomy: not surrounded by nurses in hospital setting, involved in home environment of individual -Biopsychosocial assessment: biological, psychological, and social needs, determine best plan for that individual and to implement effective treatment -Case management: coordinating mental health care for client, coordinating physical, spiritual, social, and emotional care -Promoting continuation of treatment: identifying factors for noncompliance and working to use patient-centered care to help them succeed in community -Teamwork and collaboration: inter-professional collaboration, nurse acts as leader in integrating care for the patient

Protective factors of mental health

-Temperament -Resilience -Cultural influences -Positive social support

Traits of Mental Wellness

-Think rationally -Communicate appropriately -See oneself as able to reach ideals, goals -Learn -Grow emotionally -Be resilient: meet the demands of life -Have a healthy self-esteem -Individual is able to realize his/her own potential -Cope with the normal stresses of life -Work productively -Make a contribution to the community

Psychoanalysis (Freud)

-Transference/ countertransference -Dream analysis -Talk therapy -Defense mechanism

PMH nursing is a science

-Use of nursing, psychosocial, and neurobiological theories and research -Evidence-based practice (EBP): use of scientific evidence for psychological, sociological, and psychopharmacological decision making regarding treatment -Work with people throughout the life span -Employed in a variety of settings

Medical records

-Used by the facility for quality improvement -Used as evidence -Electronic documentation

Five principles of bioethics

1. Beneficence 2. Autonomy 3. Justice 4. Fidelity (nonmaleficence) 5. Veracity

Duty to Warn and Protect Third Parties

1976: California Supreme Court issued a second ruling in the Tarasoff case. It now includes the duty to protect. -Most states have similar laws. Duty to warn usually includes the following: -Assessing and predicting a patient's danger of violence toward another -Identifying specific individual(s) being threatened -Identifying appropriate actions to protect victim(s) Nursing implications: In jurisdictions that have adopted the Tarasoff doctrine: -Duty to warn third parties is applied to advanced practice registered nurses (APRNs) and psychiatric mental health nurses. -Staff nurses and members of the mental health team should report threats of harm. Failure to communicate and record relevant information from police and relatives, may deem patient's old records as negligent.

Cultural competence for PMNH

5 constructs: -Cultural awareness -Cultural knowledge -Cultural encounters -Cultural skill -Cultural desire

Kohlberg's stages of moral development

6 identifiable developmental stages of moral reasoning which form the basis of ethical behavior, the pre-conventional (level 1) contains the first stage (obedience and punishment orientation and second stage (self-interest orientation)), the conventional (level 2) contains the third stage (interpersonal accord and conformity) and fourth stage (authority and social-order maintaining orientation) the post-convential (level 3) contains the 5th stage (social contract orientation) and 6th stage (universal ethical principles)

Aversion therapy

A behavior therapy in which an aversive stimulus is paired with a stimulus that elicits an undesirable response, needs to be agreed upon by patient Ex. picking at cuticles, put bitter tasting things on cuticles, avoiding behavior due to taste Ex. Taking anabuse medication for substance abuse with alcohol, if were to drink alcohol, become violently ill

Unconscious level

A level of mental activity that influences consciousness but is not conscious, often repressed memories, passions, desires, impulses -Defense mechanisms (manage and deal with anxiety) -Includes the "id"

Preconscious level

A level of mental activity that is not currently conscious but of which we can easily become conscious, just below the surface -Values -Morals -Includes the "superego"

Amygdala

A limbic system structure involved in memory and emotion, particularly fear and aggression Processing fear and anxiety

Diathesis-Stress model

A generally theory that explains psychopathology using a multi-causational systems approach -Diathesis: biological predisposition -Stress: environmental stress or trauma Most accepted explanation for mental illness Combination of genetic vulnerability and negative environmental stressors Other factors: resilience, optimism, view of world, protective factors

Hippocampus

A neural center located in the limbic system that helps process explicit memories for storage

Cultural skill PMNH

Ability to perform a cultural assessment in a sensitive way -Use professional medical interpreter to ensure meaningful communication -Use culturally sensitive assessment tools Goal -A mutually agreeable therapeutic plan: Culturally acceptable, Capable of producing positive outcomes

Documentation of care

A record's usefulness is determined by evaluating—when the record is read later—how accurately and completely it portrays the patient's behavioral status at the time it was written. If it is not documented, it is not done Document the facts, not opinions or extreme detail, be clear and factual Used in court, can protect the nurse in court of law

Psychogenetics may one day lead to which of the following? (Select all that apply.) A. Personalized medications B. Safer drugs C. Targeted pharmacologic therapies determined by genetically inherited factors D. Increased number of receptors

A. Personalized medications B. Safer drugs C. Targeted pharmacologic therapies determined by genetically inherited factors

A client plans to have electroconvulsive therapy (ECT). Which member of the team is responsible for obtaining the client's informed consent? A. Physician B. Psychologist C. Case manager D. Registered nurse

A. Physician

Determination of standard of care

ANA has established standards for psychiatric-mental health nursing practice and credentialing for psychiatric-mental health RN and the advanced practice RN (ANA, 2007) -Standards differ from minimal state requirements Nurses are held to standards of care provided by other nurses possessing the same degree of skill or knowledge in same or similar circumstances -Hospital policies and procedures set up institutional criteria for care -Substandard institutional policies do not absolve nurse of responsibility to practice on basis of professional standards of care

An occupational health nurse screens factory workers for depression. Which level of prevention is applicable to this activity? A. Primary B. Secondary C. Tertiary D. Not sure

ANS: B Secondary prevention is aimed at reducing the prevalence, or number of new and old cases at any point in time, of psychiatric disorders. Early identification of problems, screening, and prompt, effective treatment are hallmarks of this level.

A hospitalized client diagnosed with major depression tells the nurse, "I need my belt to keep my pants up. They keep falling down." Which response should the nurse provide? A. "Your belt is locked in the business office for safekeeping, along with all your other valuables." B. "For safety reasons, hospitalized clients are not allowed to keep certain personal possessions." C. "I cannot provide your belt, but I will help you get some pants with an elastic waistband." C. "I will ask the psychiatric technician to get your belt for you."

ANS: C Clients' rights allow them to keep personal possessions except those that might prove dangerous. A belt is potentially dangerous; so, the client should be prohibited from having it. It is important however for the nurse to respond to the client's need. Elastic banded pants are safe and the client would not need a belt.

Resilience

Ability and capacity to secure resources needed to support well-being Characterized by: -Optimism -Sense of mastery -Competence Essential to recovery

Neurotransmitters: cholinergics

Acetylcholine: major role in ability to learn, memory, regulate mood, sexual aggression, aggressive types of behavior -Increase: depression -Decrease: Alzheimers disease, Huntington chorea, Parkinson disease (dysregulation in moods, sexually inappropriate, sundowning and aggression at night)

Inpatient psychiatric care

Admission reserved for individuals who are -Suicidal -Homicidal -Extremely disabled and in need of short-term acute care Admission options: -Direct admission -Hospital emergency department Criteria to justify admissions: -Danger to self or others or -Unable to fulfill basic needs Voluntary or involuntary (legal status of patient)

Involuntary admission

Admission to a psychiatric facility without the patient's consent because they are deemed unsafe to be outpatient/ discharged, not able to leave freely, patient still has rights, must petition in court for release

DSM-V

American Psychiatric Association Board of Trustees approved and released May 2013 Tool used to make mental illness diagnoses Substantive changes: -Chapter order: organized in three sections -Removal of multaxial system Section 1: introduction Section 2: outline categorical diagnoses/disorders Section 3: conditions that require further research before being considered as formal disorders (ex. internet use gaming disorder, suicidal behavior disorder, non-suicidal self-injury, attenuated psychosis syndrome)

Intuition

An effortless, immediate, automatic feeling or thought, as contrasted with explicit, conscious reasoning Sense you get that something is not right before knowing the details (ex. if feeling uncomfortable or that a patient is not safe, remove yourself or get additional data through assessment)

Tricyclic (cyclic) antidepressants (TCAs)

Antidepressant, increase norepinephrine -Amitriptylene (Elavil) -Nortriptyline (Pamelor) Side effects: -Anticholinergic effects: blurred vision, constipation, dry mouth, urinary retention, tachycardia -Such side effects make these drugs less desirable and impact compliance -Blockage of histamine receptors: can cause sedation and weight gain, be fatal in overdoses (highly lipid soluble and rapidly absorbed, which can lead to cardiotoxicity and death), if highly suicidal, less likely to be prescribed this anti-depressant or only given a week's supply to prevent suicide by overdose

Serotonin-norepinephrine disinhibitors (SNDIs)

Antidepressant, increase serotonin and norepinephrine -Mirtazapine (Remeron) Combined with SSRIs to augment efficacy or counteract serotonergic side effects

Serotonin-norepinephrine reuptake inhibitors (SNRIs)

Antidepressant, increase serotonin and norepinephrine, affect serotonin levels in spinal cord, therapeutic with neuropathic pain -Venlafaxine (Effexor) -Duloxetine (Cymbalta) Side effects include fewer anticholinergic effects

MAOIs

Antidepressants -Phenelzine (Nardil) -Tranylcypromine (Parnate) -ENSAM (selegiline transdermal system)

Norepinephrine-dopamine reuptake inhibitors (NDRIs)

Antidepressants, do not act on serotonin system, focuses more on norepinephrine and dopamine, inhibit nicotine acetylcholine receptors to reduce addictive effects, also effective in helping with smoking cessation due to inhibition of nicotinic receptors -Bupropion (Wellbutrin)

Peplau's Interpersonal Relations Theory

Basis for developing a therapeutic relationship with a patient (especially useful for working with adult or child psychiatric patients)

Biological theories and therapies

Assumes that abnormal behavior seen in mental illness has a biological cause (neurological, chemical, biological, and genetic) Medications as an intervention

Which term refers to individuals' belief that their cultural values and practices are correct and superior to those of others? A. Assimilation B. Enculturation C. Ethnocentrism D. Somaticization

C. Ethnocentrism

Extrapyramidal side effects are the result of which one of the following? A. Too much serotonin B. Dopamine blocking C. Too little serotonin D. Too few receptors

B. Dopamine blocking

Legal and clients' rights are suspended when a client is hospitalized involuntarily. A. True B. False

B. False Involuntary admission requires that the client retain freedom from unreasonable bodily restraints, the right to informed consent, and the right to refuse medications, including psychotropic or antipsychotic medications. Other rights are preserved as well.

A nurse was the case manager for a client with serious mental illness for 6 years. The client died by suicide 1 week ago. Today, the client's spouse asks, "I always wondered if my spouse was a victim of sexual abuse in childhood. What can you tell me about that?" Can the nurse disclose information to the surviving spouse? A. Yes B. No

B. No

Which worldview would the nurse anticipate from a client who says, "It is important to save enough money to take care of yourself in your old age. We should not rely on anyone else to take care of us." A. Eastern (balance) B. Western (science) C. Indigenous (harmony)

B. Western (science) Western culture focuses on fostering independence, autonomy, being able to take care of yourself

Social learning theory

Bandura: the theory that we learn social behavior by observing and imitating and by being rewarded or punished, concepts of modeling and self-efficacy

Id

Basic impulses (sex and aggression): seeking immediate gratification, irrational and impulsive, operates at unconscious level

Antianxiety and hypnotic drugs: nonbenzodiazepines

Buspirone (Buspar): an anxiolytic agent with less potential for dependence -Effective for individuals with GAD -Used for long term, less potential for dependence "Z-hypnotics" (nonbenzodiazepine agents): short-acting sedative and hypnotic sleep agents -Provide sedative effects without anxtianxiety, anticonvulsant, or muscle relaxant effects of benzodiazepines -Zolpidem (Ambien): duration of 5 hours -Zaleplon (Sonata) -Eszopiclone (Lunesta): duration of 8 hours Melatonin-receptor agonist: -Remalteon (Rozerem): a hypnotic drug that acts similar to melatonin; is thought to regulate circadian rhythms

Which individual with mental illness may need involuntary hospitalization? A. A person with alcoholism who has been sober for 6 months but begins drinking again B. An individual with schizophrenia who stops taking prescribed antipsychotic drugs C. An individual with bipolar disorder, manic phase, who has not eaten in 4 days D. Someone who repeatedly phones a national TV broadcasting service with news tips

C. An individual with bipolar disorder, manic phase, who has not eaten in 4 days

Blocking muscarinic cholinergic receptors may result in which one of the following? A. Sedation B. Weight gain C. Blurred vision D. Orthostatic hypotension

C. Blurred vision Blocking muscarinic cholinergic receptors can result in blurred vision, dry mouth, constipation, and urinary hesitancy. Antagonism of the histamine1 receptors causes sedation and weight gain. Blockage at the α1 receptors for norepinephrine can affect vasodilation and a consequent drop in blood pressure, or orthostatic hypotension. Antagonism of either α1 receptors or 5-HT2 receptors may result in ejaculatory dysfunction.

Genetics play which role in response to psychotropic drugs? A. Different ethnic groups have different responses. B. Genetics are not associated with drug response. C. Response to psychotropic drugs may be related to genetics. D. Genetics are related to the disease process and not the drug response.

C. Response to psychotropic drugs may be related to genetics.

Child and elder abuse reporting

Child abuse reporting statutes: -Established in all 50 states and Washington, D.C. -Statutes differ from state to state. -Most statutes include civil penalties for the failure to report. -Many states require nurses to report cases of suspected abuse. Signs of abuse: -Injuries that do not match explanation -Bruising over body, different stages of healing -Malnourished -Dehydrated -Repeated hospital visits -Frequent broken bones

Alzheimers treatment

Cholinesterase inhibitors

Countertransference

Circumstances in which a psychoanalyst develops personal feelings about a client because of perceived similarity of the client to significant people in the therapist's life Therapist puts unconscious feelings onto the patient Negative interaction, not therapeutic (ex. patient reminds you of someone negative in your life, you place unconscious negative thoughts on them, place restrictions on them)

Monoamine Oxidase Inhibitors (MAOIs)

Class of antidepressant drugs, which increases the levels of monoamine neurotransmitters in the synapse by decreasing the enzyme MAO -Need to be on a tyramine diet (no aged cheeses, pickled or smoked fish, wine): hypertensive crisis risk -Other antidepressants and sympathomimetic drugs taken together can result in serious reactions (serotonin syndrome)

Cognitive Behavioral Therapy (Beck)

Cognitive theory/therapy Active, directive, time limited -Process of challenging pattern of negative and self-critical thinking (unique assumptions about themselves, the world, and others) -Automatic thoughts/cognitive distortions Ex. automatically thinking someone doesn't like you when they don't say hi back, challenging distorted thinking by checking the facts

Rational Emotive Therapy (Ellis)

Cognitive theory/therapy Remove core irrational beliefs by helping patient recognize thoughts are irrational beliefs and are not sensible (A-B-C process) -A: antecedent-> what was thought, what happened prior to behavior -B: behavior -C: consequence

Levels of awareness (Freud)

Conscious, preconscious, unconscious

Mental health is a:

Continuum

What is psychiatric mental health nursing?

Core mental health profession that employs purposeful use of self as its art and a wide range of nursing, psychosocial, and neurogiological theories and research as evidence as a science Different tools: therapeutic use of self, communication skills with patients, active listening, recognition of defense mechanisms and behaviors

Importance of culturally relevant care

Culture ➢Groups with shared beliefs, values, and practices ➢Influences their thinking and behavior Cultural norms ➢Define what is normal or abnormal within a culture, defines normal behavior according to their beliefs, values and practices Ethnic groups ➢Common heritage and history ➢Share worldview for thinking

Antidepressant effects of receptor binding

DA reuptake inhibition: -Decrease depression -Psychomotor activation -Antiparkinsonian effects 5-HT2 block: -Reduce depression -Reduce suicidal behavior -Antipsychotic effects -Hypotension -Ejaculatory dysfunction 5-HT reuptake inhibition: -Reduce depression -Antianxiety effects -GI disturbances -Sexual dysfunction NE reuptake inhibition: -Reduce depression -Tremors -Tachycardia -Erectile/ejaculatory dysfunction a1 (norepinephrine) block: -Postural hypotension -Dizziness -Reflex tachycardia -Memory dysfunction a2 (norepinephrine) block: -Priapism ACh block: -Blurred vision -Dry mouth -Constipation -Sinus tachycardia -Urinary retention H1 block: -Sedation/drowsiness -Hypotension -WEight gain

Basil ganglia

Deep in cerebrum, major role in extrapyramidal motor system, ability to move, movements, walking, strength, ability to grab things When taking different meds, particularly first generation antipsychotics: movement disturbances, acute extrapyramidal disturbances, tardive dyskinesia, this part of the brain is greatly affected by certain psychotropic drugs that are used, problems with movement, any drugs that affect extrapyramidal pathway can also affect diaphragm and breathing

Hildegard Peplau

Developed the art and science of nursing Peplau influenced by Sullivan's work The art of nursing: -Provide care, compassion, and advocacy -Enhance comfort and wellbeing -Nurses as advocates, educators, teachers, helping patients learn, understand, find resources to take care of themselves, communication The science of nursing: -Application of science to nursing knowledge Application: Peplau's many contributions to PMHN is therapeutic relationships, therapeutic use of self, therapeutic communication techniques, and levels of anxiety Peplau was the mother of psychiatric nursing, strong believer in EBP in PMHN Developed levels of anxiety: mild, moderate, severe, and panic -Provided evidence of symptoms and behaviors at each stage and interventions for each level of anxiety Developed masters of nursing programs, psych NP

Cognitive development (Piaget)

Developmental theory Cognitive development is a dynamic progression from primitive awareness and simple reflexes to complex thought and responses Stages: -Sensorimotor (birth to 2) -Preoperational (2-7) -Concrete operational (7-11) -Formal operational (11+)

Theory of psychosocial development (Erikson)

Developmental theory Developed 8 predetermined and consecutive life stages each resulting in a positive or negative outcome Stages: -Trust vs. mistrust (0-1.5): being able to trust other peopole, environment, future -Autonomy vs. shame and doubt (1.5-3): potty training, sense of self-control and adequacy, independence/fear conflict if not achieved -Initiative vs. guilt (3-6): becoming purposeful and directive, ability to initiate one's own activities, sense of purpose, aggression/fear conflict, sense of inadequacy or guilt if not achieved -Industry vs. inferiority (6-12): developing social, physical, and school skills, competence, ability to work, or sense of inferiority, difficulty learning and working if not achieved -Identify vs. role confusion (12-20): making transition from childhood to adulthood, developing sense of identity, sense of personal identity, fidelity, or confusion about who one is, weak sense of self if not achieved -Intimacy v. isolation (20-35): establishing intimate bonds of love and friendship, ability to love deeply and commit oneself, or emotional isolation, egocentricity if not achieved -Generativity vs. self-absorption (35-65): fulfilling life goals that involve family, career, and society, developing concerns that embrace future generations, ability to give and to care for others, or self-absorption, inability to grow and a person if not achieved -Integrity vs. despair (65+): looking back over one's life and accepting its meeting, sense of integrity and fulfillment, willingness to face death, wisdom, or dissatisfaction with life, denial of or despair over prospect of death if not achieved

Theory of object relations (Mahler)

Developmental theory Psychological problems are the result of separation issues with mother during the first three years of life -"Good parenting" see successful separation-individuation -Dependency with caregiver in nurturing, caring relationship, then learn to separate identity with caregiver, see themselves as an individual *This theory is important when studying borderline personality disorder

Diathesis-stress model (nurture vs. nature)

Diathesis represents biological predisposition and stress represents environmental stress or trauma Most accepted explanation for mental illness Most psychiatric disorders result form a combination of genetic vulnerability and negative environmental stressors

Mental illness

Disorders with definable diagnosis Significant dysfunction in mental functioning related to: -Developmental -Biological -Physiological disturbances Culturally defined Needs to meet specific criteria Behaviors that significantly cause individual to be dysfunctional occupationally, socially, personally, disrupting ability to function in day to day world

Beneficence

Doing good or causing good to be done; kindly action

Antipsychotics: SGA

Dopamine and serotonin blockers -Produce fewer EPS -Target both negative and positive symptoms of schizophrenia -Clozapine (Clozaril): agranulocytosis (routine blood count), potential for inducing convulsions

Antipsychotic drugs: first-generation agents (FGA)

Dopamine receptor agonists (DRAs) -Bind to dopamine type 2 (D2) receptors -Reduce dopamine transmission -Schizophrenia result of excessive dopamine, alleviates symptoms such as delusions, hallucinations, bizarre thinking, by decreasing amount of dopamine Drugs: positive symptoms schizophrenia -Chlorpromazine (Thorazine): first antipsychotic, high potency, hypotension risk -Fluphenazine (Prolixin): less sedation and anticholinergic effects, given by injection -Haloperidol (Haldol): often used with injections *Can have extrapyramidal side effects due to affect on basil ganglia and adverse reactions: -Dystonia: muscle stiffness, appears to be pulling head back or to side -Akathisia (restlessness) -Tardive dyskinesia (TD): umbrella of symptoms, such as lip smacking, tongue protrusion, eyes blinking and moving, irregular movements of arms and gait -Drug-induced parkinsonism: stiff gait, tilted forward, rigid walk -Neuroleptic malignant syndrome (NMS): rare but life-threatening -Orthostatic hypotension: instruct patient to get up slowly Specific adverse reactions: -Blocking muscarinic cholinergic receptors: blurred vision, dry mouth, constipation, and urinary hesitancy -Antagonism of histamine receptors: sedation and weight gain, slow in movements, thinking -Blocking alpha1 receptors for norepinephrine: drop in BP, orthostatic hypotension -Antagonism of either a1 receptors or 5-HT2 receptors, ejaculatory dysfunction

Monoamines

Dopamine: involved in fine muscle movements, helps to integrate emotions, thoughts, and decision making -Decrease: Parkinson disease, depression -Increase: schizophrenia, mania Norepinephrine: affects mood, attention, arousal, fight or flight response when dealing with stress -Decrease: depression -Increase: anxiety states Serotonin: -Decrease: depression -Increase: anxiety states Histamine: high levels associated with anxiety and depression, stimulates inflammatory response, rash, itchiness, affects alertness -Benadryl is an antihistamine

Justice

Duty to use resources equally regardless of individual differences Ex. patient bedtime is at 10pm, must make sure we don't make exceptions for any patients in order to be fair to everyone

Limbic system

Emotional brain Consists of hippocampus, amygdala, hypothalamus, thalamus, and basil ganglia

Maslow's Theory: Application for Mental Health Nursing

Emphasis on human potential and the client's strengths Prioritizing nursing actions - recognizing that lower needs, unless met, will interfere with meeting higher level needs Ex: A depressed patient has loss of appetite, lack of energy, poor concentration. If the patient's intake is inadequate, providing nutrition takes precedence over joining groups

Recovery

Empowering those with mental illness to find meaning and satisfaction, realize potential and function at maximum level of independence

Chapter 6 highlights

Ethical concepts: -Beneficence -Autonomy -Justice: unit bedtime example -Fidelity -Veracity Criteria for admission Admission procedures: voluntary, involuntary, 72 hour hold, PEC (physician emergency certificate, determine require hospitalization, 15 day paper, still maintain patient rights, right to appeal with a judge if needed), PEER (police emergency examination request) Patient's rights Ex. right to refuse medications (informed consent, implied consent) Restraints and seclusionL -Importance of de-escalation techniques -Least restrictive principle -Once restrained or secluded FIRST and MOST important is for nurse to get an order for the intervention -DOCUMENTATION is critical as well -MUST know hospital policy and procedures Confidentiality: -Staff are obliged to report a patient's threat to harm against specific victim -Report child and elder abuse -Report harm to self Assault and battery: threaten (verbal) harm or physical harm Ex. if you don't take this medication I will give it to you against your will by injection False imprisonment: unless court ordered or on PEC/PEER/72 hour hold, cannot hold patient in hospital against they wishes ADHERE TO YOUR STANDARDS OF PRACTICE AND INSTITUTIONAL POLICIES AND PROCEDURES

Operant conditioning

Ex. use of a token system with patient to reward positive behaviors or taking away a privilege in order to see a behavior change

Ego

Executive mediating between id impulses and superego inhibitions; testing reality, rational Operates mainly at conscious level but also at preconscious level

Activities of neurons

Once an electrical impulse reaches the end of a neuron, a neurotransmitter is released, crossing the synapse to attach to receptors on the postsynaptic cell to inhibit or excite it. Interaction between neurotransmitters and synapse is the major target of psychotropic drugs.

Cognitive development

Piaget: the development of thinking, problem solving, and memory -Operational stages

Contrasting side effects of FGAs and SGAs

FGA: -EPS: dystonic reaction, akathisia, drug-induced Parkinsonism, tar dive dyskinesia -Orthostatic hypotension -NMS SGA: -Risk of metabolic syndrome: increased weight, increased blood glucose, increased triglyceride levels, insulin resistance -Lower risk of EPS -If already diagnosed with diabetes, SGA may not be the best choice due to disruption in blood sugar and need for more insulin

Selective serotonin reuptake inhibitors (SSRIs)

FIRST LINE CHOICE antidepressant, most commonly prescribed, increase serotonin -Fluoxetine (Prozac) -Sertraline (Zoloft) -Paroxetine (Paxil) Side effects: -Fewer anticholinergic effects than TCAs -N/V -Interaction with MAOIs, if switching to SSRI from MAOI, need to have 2 week drug holiday because both affect serotonin levels and can cause excess increase leading to serotonin syndrome and toxicity -Discontinuation syndrome if stop taking drug too quickly, adverse events

Guidelines for nurses who suspect negligence

Follow channels of communication 1. Legal duty is to report risks of harm to the patient 2. Document evidence clearly and accurately 3. Communicate concerns directly to the person involved 4. If risky behavior continues, inform a supervisor 5. If chemical impairment or irresponsible practice is suspected, protecting the rights of peers and patients who could be harmed is an obligation 6. If danger persists, report the concern to the next level of authority 7. If a dangerous situation persists, report the behavior to the appropriate authority, such as the state board of nursing

Systematic desensitization

Form of behavior modification that helps the patient to deal with very specific fears by using learned relaxation techniques as we slowly systematically expose them to their fear Ex. Professor has a severe fear of elevators after multiple incidents of getting stuck, chose to walk up the stairs instead of take the elevator for a long time after, began to slowly expose herself to elevators, taking a step in, taking deep breaths, going up one floor, then going up another floor, using relaxation techniques while in the elevator, now able to go in elevator most times

Structure of the brain

Frontal lobe: executive functioing, decision making, problem solving, figuring out what is going on in environment -Not fully developed until around age 25 Limbic system: crucial role in emotional status and psychological unction using norepinephrine, serotonin, and dopamine as their transmitters -Amygdala: processing fear and anxiety, emotional brain -Hippocampus: storage of memories Cellular composition of brain: -Neurons: respond to stimuli, conduct electrical impulses, release chemicals called neurotransmitters -Neurotransmitter: chemical substance that functions as a neuromessenger -Synapse: space between neurons where neurotransmitters cross -Receptors: place on postsynaptic neuron where neurotransmitters attach to neuron's surface -Reuptake: process by which neurotransmitters are taken back into the presynaptic cell from which they were originally released, which are then either reused or destroyed by intracellular enzymes (MAO and monoamines)

Neurotransmitters: amino acids

Gamma-amino butyric acid (GABA): reduces anxiety, depression, may impair cognition, motor function, if not enough, more anxiety and mania occurs -Decrease: anxiety disorders, schizophrenia, mania, Huntington chorea -Increase: reduction of anxiety, schizophrenia, mania Glutamate: -Major mediator of excitatory signals in the central nervous system -Is involved in most aspects of normal brain function, including condition, memory, and learning

Genes and culture and psychotropic medication

Genes and culture affect an individual's response to psychotropic medication Cultural and ethnic beliefs: -Mental illness and pharmacotherapy Cross-cultural psychopharmacology: -Effects and responses that exist among ethnic groups Pharmacogenetics: -How genes influence drug metabolism Individualize ability to determine medications that work best for individuals, with less symptoms and greater compliance

Systematic desensitization (behavioral therapy)

Gradual exposure to patient's specific fear

Civil rights of persons with mental illness

Guaranteed the same rights under: -Federal laws -State Laws

Direct admission

Hospitalization of a patient from home or physician office -Deemed not safe to self or others by PCP, psychiatrist, outpatient provider (admission from ER has first priority over direct admit)

Biological theories

How the body and brain interacts to create -Emotions -Memories -Perceptual experiences -Also influence the body, all connected -Taking care of the WHOLE PERSON Discovery of chlorpromazine (phenathiazine or antipsychotic) - demonstrated the strong correlation between the brain functioning and psychiatric disease Consider other influences that play a role in the development and treatment of mental disorders -Social, environmental, cultural, economic

Hierarchy of Needs (Maslow)

Humanistic theory Emphasis on human potential and helps establish most important of nursing actions Ex. patient has major depressive episode, not eating, drinking sleeping, socially withdrawn, no motivation, priority goal is to have them take care of themselves first before having them increase their level of participation and interaction in groups, assist them to eat, drink, sleep before asking them to attend groups

Maslow's hierarchy of needs

Humanistic theory, motivated by looking at unmet needs, helps nurses prioritize interventions to be more successful with the patient Physiological - Depressed patient may need to monitor eating and drinking as depression may interfere with both Safety -Adhering to limit setting or asking for prn Belonging - Participation in group therapy Self-esteem - Feel valued by others; confidence in their abilities; happy with achievements Self-actualization - Contentment at what you achieved in life

Due Process in Involuntary Commitment

Humphrey vs. Cady, 1972: "Involuntary civil commitment to a mental hospital is a 'massive curtailment of liberty' requiring due process protections" Writ of habeas corpus: is a "formal written order" to "free the person", patient has right to request evaluation of case by external psychiatrist and court to be judged as a free person Least restrictive alternative doctrine: mandates that the least drastic means be taken to achieve a specific purpose

Future of psychiatric nursing

IOM 2013: Future of Nursing Future challenges and roles: -Aging population -Increasing cultural diversity -Expanding technology -Patient advocacy -Legislative involvement 2020-2030: -Nursesp lay a key role in the health of Americans -It is important to tap into their unique combination of skills, knowledge, and dedication to address health inequities and improve the health and well-being for all -The Committee on the Future of Nursing 2020-2030 will explore how nurses can work to reduce health disparities and promote quite, while keeping costs at bay, utilizing technology, and maintaining patient and family-focused care into 2030

Superego

Ideals and morals; striving for perfection, incorporate from parents, becoming a person's conscious, operates mostly at preconscious level

Admission to the hospital

Illness must present an IMMEDIATE crisis: -Other less restrictive alternatives are inadequate or unavailable -The expectation exists that hospitalization and treatment will improve the immediate problem -Danger to self -Danger to others -Unable to take care of themselves

Transference

In psychoanalysis, the patient's transfer to the analyst of emotions linked with other relationships (such as love or hatred for a parent) Unconscious feeling that a patient transfers to other person in relationship (ex. the actions of the therapist remind the patient of their mother, can use this to explore the feelings more, therapeutically discover greater depth and understanding, identify unconscious feelings and behaviors)

Voluntary admission

Inpatient care sought by a patient or patient's guardian through a written application to the facility

Operant conditioning (Skinner)

Learning through rewards and punishments for voluntary behavior or behavior modification -Reinforcement: causes a behavior to occur more frequently 0Positive reinforcement: add stimulus to increase behavior -Negative reinforcement: remove stimulus to increase behavior -Punishment: unpleasant consequence to make behavior occur less frequently Ex. token systems

Patient confidentiality

Legal considerations - Health Insurance Portability and Accountability Act (HIPAA) - Confidentiality after death - Confidentiality of professional communications - Confidentiality and human immunodeficiency virus (HIV) status Exceptions: -Duty to Warn and Protect Third Parties: Tarasoff v. Regents of University of California (1974) ruled that psychotherapist has duty to warn patient's potential victim of potential harm -Child and elder abuse reporting statutes -Staff nurse reports threats by patient to the treatment team -Ex. adolescent patient treating to harm parents, when patient went AWOL, nurse obligated to notify parents and police of potential danger to parents if he were to reach home

Neurotransmitters

Monoamines: -Dopamine -Norepinephrine -Serotonin -Histamine Amino acids: -Gamma-amino butyric acid (GABA) -Glutamate Cholinergic: -Acetylcholine Peptides-neuromodulators: -Substance P -Somatostatin -Neurotensin

Neurotransmitters (chapter 3 highlights)

Monoamines: -Dopamine -Norepinephrine (NE) -Serotonin (5-HT) -Histamine Amino acids: -GABA -Glutamate Cholinergics: -Acetylcholine (ACh) Peptides (neuromodulators) -Substance P -Somatostatin -Neurotensin

Mood stabilizers (chapter 3 highlights)

Lithium (Eskalith, Lithobid): -Narrow therapeutic index -Treatment of bipolar disorder -Maintain normal fluid and sodium intake -Pay attention to situations that would deplete fluid and electrolyte balance

Mood stabilizers

Lithium (Eskalith, Lithobid): -Stabilizes depression and mania (bipolar disorder) -Works by interacting with sodium and potassium at cellular level to stabilize electrical activity, works at excitatory neurotransmitter glutamate -Narrows the therapeutic index: can reach lethal level very quickly, patient must have frequent blood values drawn to stay in therapeutic range -Has a potential for toxicity -Toxic effects can include tremor, ataxia, confusion, convulsions, and N/V

Monamine Oxidase Inhibitors (MAOIs)

Monoamines: organic compound including neurotransmitters that are further divided into subgroups -Catecholamines (e.g. norepinephrine, epinephrine, dopamine) -Indolamines (e.g. serotonin) -Many drugs and food substances Monoamine oxidase (MAO): enzyme that destroys monoamines Monoamine oxidase inhibitors (MAOIs): drugs that increase concentrations of monoamines by inhibiting the action of MAO, stops action of enzyme for more availability of neurotransmitter -Phenelzine (Nardil) -Tranylcypromine (Parnate) -ENSAM (selegiline transdermal system): delivers MAOIs through the skin Adverse effects: *Hypertensive crisis (vasopressor reaction, severe headache, extremely high BP): occurs if patient ingests tyramine found in some OTC medications, beef, wine, aged cheese, organ meats, avocados, and other foods -Dietary restriction of tyramine must be maintained for 2 weeks after stopping MAOIs -Strict diet, extensive food restriction, caution when eating out, restrictions make MAOIs less appealing as drug of choice

Restraint and seclusion

Most state laws prohibit the use of unnecessary physical restraint or isolation. Behavioral restraint and seclusion are authorized as interventions if: -Behavior is physically harmful to the patient or a third party. -Alternative, less-restrictive measures are insufficient in protecting the patient and others from harm. -Decrease in sensory overstimulation is needed (seclusion only). -Patient requests seclusion. Guidelines to follow: -Least restrictive intervention -Deescalation techniques prior -Clear documentation of all interventions used prior, procedures used -Adults 18 and over: limited to 4 hours -Children and adolescents ages 9-17: up to 2 hours -Children under 9: up to 1 hour

Adverse effects of receptor blockage of antipsychotic agents

Muscarinic cholinergic block: -Dry mouth -Blurred vision -Urinary retention -Constipation -Tachycardia Histamine block: -Sedation -Substantial weight gain -Orthostasis Serotonin (5-HT2): -Antipsychotic effects -Eight gain -Hypotension -Ejaculatory dysfunction GABA: -Lowers seizure threshold Alpha2 block: -Sexual dysfunction -Priapism Alpha1 block: -Orthostatic hypotension -Antipsychotic effect -Reflux tachycardia -Failure to ejaculate D2 block (dopaminergic): -Antipsychotic effect -EPS -Increased prolactin: gynecomastia (men), galactorrhea -Amenorrhea (women)

Chapter 5 highlights

Stigma of mental illness: has improved but is still existent and affects individuals with mental illness, particularly in their ability to receive care Cultural competence: -Cultural awareness -Cultural knowledge -Cultural encounters -Cultural skill -Cultural desire

Bupropion (Wellbutrin)

NDRI antidepressant also used for smoking cessation (Zyban) *Contraindicated in patients with seizure dirodr

Behavioral theories

No concern with inner conflicts of personality, focused on behaviors that can be seen and changed John B. Watson's: -Father of behaviorism theory -Made a loud noise when a baby saw their white rat resulting in a fear response Ivan Pavlov's classical conditioning theory -Conditioned response -Used a metronome to condition a response in dogs to salivate; connected the sound with presence of food and eventually removed food using only metronome -INVOLUNTARY RESPONSES B.F. Skinner's operant conditioning theory -Skinner believed that it wasn't what comes before a behavior that influences it, but what comes after; positive or negative reinforcements -VOLUNTARY responses -Learning how to change and modify behaviors by using positive and negative reinforcements -Ex. token and reward systems Implications for nursing: -Modifying or replacing behaviors -Behavior management

Fidelity

Not doing wrong to a person, no harm to patient

Serotonin antagonist/reuptake inhibitors (SARIs)

Not the first choice for antidepressant treatment, but useful for insomnia -Trazodone (Desyrel) Can cause priapism

Countertransference (Freud)

Not therapeutic, nurse transferring emotions onto patient Ex. Nursing student recognized that the individual patient reminded them of their little brother, was annoyed with them the whole day, couldn't figure out why Treat patient either very positively or very negatively

Safety in PMNH

Number one concern -Monitoring medication side effects (ex. hypotension and fall risk) -Keeping patients safe that are harm to themselves or others -Codes: violence, rapid response, suicidal, overdose -Check patient's clothing, body exam on admission for hidden meds, weapons, tools for self-harm -15 minutes checks for those at risk of harm -Keep door open when patient is using bathroom -Monitoring visitations, can be potential hazards -Patients should not engage in developing intense relationships with other patients or staff members, need to focus on their own treatment

Modeling

Nurses serve as a role model for patients by the types of behaviors they display, attempt to teach patients through demonstration, based on how we interact with other patients and staff on the unit, we serve as models of therapeutic, kind, caring, accepting, respectful behavior

Transference (Freud)

Occurs in the aptient Ex. you remind me of my mother, she says the same thing, I can't stand when she does that Use this to understand the underlying issues (can you tell me what it is that reminded you of your mother, how did it make you feel, how often does it happen?

Prefrontal cortex

Part of frontal lobe responsible for thinking, planning, and language Key functions include executive functioing, problem solving, decision making Affected particularly with schizophrenia, depression

Antipsychotics: FGA

Strong dopamine blocking agent in basil ganglia -Targets positive symptoms of schizophrenia -Can lead to motor abnormalities (EPS) -Increase secretion of prolactin: women galactorrhea and amenorrhea, men gynecomastia and galactorrhea -AIMS test

Attending in nursing

Pay attention to person we are talking to, make eye contact, observe behaviors, being there in the moment to help patient

Future of mental health care

President's New Freedom Commission on Mental Health (2003) recommendations -Mental health is essential to overall health -Care is consumer and family driven -Disparities in mental health services are eliminated -Early screening, assessment, and referral are common -Excellent mental health care is delivered; research is accelerated -Technology is used to access mental health care and information

Prevention strategies

Primary prevention: delaying onset of symptoms, identifying individuals who are vulnerable, helping them cope with tools such as pharmacotherapy or CBT prior to them developing a mental illness Secondary prevention: screening for symptoms of mental illness, reducing number of cases of mental illness, earlier identification, promptly intervene and provide effective care Tertiary prevention: treatment of disease, preventing progression of disease before it becomes severe or disabling, treatment such as rehab to help them be able to function in their day to day activities

Funding psychiatric mental health care

Private pay insurance Managed care plans -Health maintenance organizations (HMOs) -Preferred provider organizations (PPOs) -Managed behavioral health care organizations (MBHOs) Medicaid Medicare

Tort Law Applied to Psychiatric Settings

Protection of patients: legal issues common in psychiatric nursing are related to failure to protect safety of patients Protection of self -Nurses must protect themselves in both institutional and community settings -Important for nurses to participate in setting policies that create safe environment -Adhering to standards of practice, staying within boundaries of practice, following and having knowledge of institutional practice, abiding by the law -Ex. nurses cannot assist in physician assisted suicide, not acceptable in CT and standards of practice

ADHD treatment

Psychostimulants: -Methylphenidate -Dextroampehtamine Non-stimulants: -Atomoxetine -Guanfacine -Clonidine

What is PMHN?

Purposeful use of self and therapeutic communication to promote mental health through nursing process

PET scans

Records biochemical changes in the brain as they occur by detecting radioactive material which has been injected or inhaled. Looks at brain function. Examination of identical twin studies can show comparisons and alterations in brain function for those with mental illness. Reduced brain activity can be seen in frontal lobe in patients with schizophrenia, provides evidence that psychiatric illnesses are a disease of the brain

Autonomy

Respecting the rights of others to make their own decisions Ex. allowing a patient with schizophrenia who is hallucinating to refuse medication

Classical conditioning (Pavlov)

Response is involuntary -Neutral stimulus is repeatedly parted with another stimulus to elect an involuntary response Ex. Go out to dinner, ate food, food poisoning, violently ill, next time go out and see food that made you sick, involuntarily feel sick

Resolving ethical dilemmas

Role of nurse -Act in the best interests of the patient and society to the degree possible Resources for consultation -Hospital ethics committee -Agency ethics consultant -Professional nursing organizations -State board of nursing

What is the first line of defense in treating depression and anxiety disorders?

SSRIs

Antidepressants

Serotonin and epinephrine are key in regulating mood -SSRIs: *FIRST LINE OF TREATING DEPRESSION AND ANXIETY DISORDERS -NaSSA -NDRI -SARI -SNRI -TCAs

Trazodone (Desyrel)

Serotonin antagonist and reuptake inhibitor Used more for treatment of insomnia

Mental health is a _____________________________

State of wellbeing

Neurotransmitters: Peptides-Neuromodulators

Substance P: -Regulation of mood and anxiety -Role in pain management Somatostatin: relates to cognitive disease -Decrease: Alzheimer disease -Increase: Huntington disease Neurotensin: -Decreased levels in spinal fluid of patients with schizophrenia -Role in psychotic tendencies

Cognitive-Behavioral Therapy (Beck)

Test distorted beliefs and change way of thinking; reduce symptoms Reframe how you think about something to change behavior, consequences, symptoms

Psychotropic medications cross:

The blood brain barrier and alter transmission or availability of neurotransmitters

Defense mechanisms

The ego develops defenses to ward off anxiety by preventing conscious awareness of threatening feelings 2 common features: 1. They all operate on an unconscious level 2. They deny, falsify, or distort reality to make it less threatening Protect ourselves from overwhelming anxiety, majority unconscious, can be adaptive or maladaptive Affect an individual, try to avoid anxiety and dealing with the situation, interferes with therapy, healing, recovery

Psychiatric theories

The evidence for PMNH interventions: the why we do what we do (not just because it makes sense and how I respond in social situations)

Conscious level

The level at which mental activities that people are normally aware of occur, includes the "ego" -Executive functioning -Rational decisions -Problem solving

Biofeedback

The process of learning to control bodily states by monitoring the states to be controlled Connected to electronic monitoring to monitor vital signs such as HR, BP, breathing Learn how to practice relaxation skills to control physiological responses to stress, feedback

Milieu therapy

Therapeutic community defined as "a scientific structuring of the environment to effect behavioral changes and to improve the psychological health and functioning of the individual" Within the therapeutic community setting, the client is expected to learn adaptive coping, interaction, and relationship skills that can be generalized to other aspects of his or her life

Modeling (behavioral therapy)

Therapist provides role model for identified maladaptive behaviors to gain insight to underlying cause and how to change

Tort law

Tort: a civil wrong for which money damages may be collected by the injured party (plaintiff) from the responsible party (the defendant) Intentional tort: willful or intentional acts that violate another person's rights or property -Battery -Assault -False imprisonment -Invasion of privacy -Defamation of character (slander or libel) Unintentional tort: unintended acts against another that produce injury or harm -Negligence: ex. med to give but nurse forgets to give it, nurse fails to remember to put side rail up and results in patient injury, nurse was supposed to provide med education but did not -Malpractice: breach of duty, did not do what would have been done by other nurses

Selective norepinephrine reuptake inhibitors (NRIs)

Treat ADHD when stimulants are not tolerated but no significant antidepressant benefits -Atomoxetine (Strattera)

Anticonvulsant drugs

Treatment of bipolar disorders Valproate (Depakote, Depakene): -Mixed episodes -serious side effects: thrombocytopenia, need CBC and blood values taken frequently -Other side effects: tremor, weight gain, sedation Carbamazepine (Tegretol): -Acute mania -Blood values taken to avoid toxicity -Anticholinergic effects common Lamotrogine (Lamictal): -Maintenance therapy for bipolar disorder, not effective in acute mania -Treating depression of bipolar disorder -Monitor for Stevens Johnson Syndrome

Erikson's eight stages of development

Trust vs. mistrust: -Ages 0-1.5 -Attachment to mother or caregiver, attachment disorders can occur due to lack of bonding when young, did not know how to form trusting relationship Autonomy vs. shame and doubt: -Ages 1.5-3 -Gaining some control over behaviors and own bodies (ex. toilet training) Initiative vs. guilt: -Ages 3-6 - More independent and skillful, developing ability to do tasks and be purposeful and directive with what they do Industry vs. inferiority: -Ages 6-12 -Learning how to be social, physical development, educational development, learning skills and knowledge to be successful in teenage years Identity vs. role confusion: -Ages 12-20 -Trying out different groups, personas, forming a sense of belonging and identity Intimacy vs. isolation: -Ages 20-35 -Development of long term, love relationships, establishing families and getting settled Generation vs. self-absorption: -Ages 35-65 -Established, developing career, involvement in different things, looking at giving back to future generations Integrity vs. despair: -Ages 65+ -Looking back over life at what you have accomplished and forming a sense of accomplishment or despair

Veracity

Truthfulness, honesty Ex. not crushing up medication and putting in applesauce to trick patient into taking medication

Tricyclic antidepressants (TCAs)

Used before development of SSRIs, have more side effects and take longer to reach effectiveness -Overdose with this drug is fatal secondary to cardiac disturbances, not used as much primarily due to this toxicity risk -Anticholinergic effects -Sedation and drowsiness Ex. nortriptyline (Pamelor), amitriptyline, imipramine (Tofranil)

Nursing applications of cognitive theories

Using a cognitive strategy for a patient's struggling with problematic patterns of behaviors would be to examine automatic thoughts (no one likes me) and challenge these thoughts by considering other possibilities

Aversion (behavioral therapy)

Using a negative stimulus to stop behavior

Biofeedback (behavioral therapy)

Using biological monitoring to learn to control body's physical reaction to stress and anxiety

Interpersonal skills

Using ourselves and experiences as who we are to help treat a person and their mental illness

A psychiatric client is to be discharged with orders for haloperidol (Haldol) therapy. When developing a teaching plan for discharge, the nurse should include cautioning the client against: a. Driving at night b. Staying in the sun c. Ingesting wines and cheeses d. Taking medications containing aspirin

b. Staying in the sun

Anticonvulsant mood stabilizers

Valproate (Depakote/ Depakene): -Is very effective in managing impulsive aggression Carbamazepine (Tegretol): -Is administered for acute mania -Needs to be monitored closely, can lead to blood dycrasias such as aplastic anemia, agranulocytosis, need to check CBC's Iamotrogine (Lamictal) -Is administered for maintenance therapy for bipolar disorder -Watch for rash, may indicate Stevens-Johnson syndrome *Need to monitor blood values and for rash: If rash on any patient taking an anticonvulsant, HOLD medication and consult with HCP

Antianxiety or anxiolytic drugs: Benzodiazepines

Work by increasing the presence of GABA, attach to receptor sites where GABA would attach at postsynaptic neurons, making more available -Can reach level of tolerance, needing more medication to produce desired effect -Effective for short term treatment, work quickly and eliminate anxiety very quickly, often used for panic attacks Anxiety: -Diazepam (Valium) -Clonazepam (Klonopin) -Alprazolam (Xanax) Insomnia: -Flurazepam (Dalmane) -Triazolam (Halcion) Lorazepam (Ativan) and alprazolam (Xanax) reduce anxiety without being as soporific (sleep producing) at lower therapeutic doses *End in -am

Several nurses are concerned that agency policies related to restraint and seclusion practices are inadequate. Which understanding about the relationship of substandard institutional policies and individual nursing practice should guide nursing practice? a. The policies do not absolve an individual nurse of the responsibility to practice according to professional standards of nursing care b. Agency policies are considered the legal standard by which a professional nurse must act and therefore override other standards of care. c. In an institution with substandard policies, the nurse has a responsibility to inform the supervisor and leave the premises without delay. d. Interpretation of policies by the judicial system is rendered on an individual basis and therefore cannot be predicted.

a. The policies do not absolve an individual nurse of the responsibility to practice according to professional standards of nursing care

A student nurse says, "I don't need to interact with my patients. I learn what I need to know by observation." An instructor can best interpret the nursing implications of Sullivan's theory to this student by responding: a. "Interactions are required in order to help you develop therapeutic communication skills." b. "Nurses cannot be isolated. We must interact to provide patients with opportunities to practice interpersonal skills." c. "Observing patient interactions will help you formulate priority nursing diagnoses and appropriate interventions." d. "It is important to note patients' behavioral changes, because these signify adjustments in personality."

b. "Nurses cannot be isolated. We must interact to provide patients with opportunities to practice interpersonal skills."

Select the example of a tort. a. The plan of care for a patient is not completed within 24 hours of the patient's admission. b. A nurse gives a PRN dose of an antipsychotic drug to an agitated patient because the unit is short staffed. c. An advanced practice nurse recommends hospitalization for a patient who is dangerous to self and others. d. A patient's admission status changed from involuntary to voluntary after the patient's hallucinations subside.

b. A nurse gives a PRN dose of an antipsychotic drug to an agitated patient because the unit is short staffed.

Mental health is defined as: a. The ability to distinguish what is real from what is not. b. A state of well-being where a person can realize his own abilities can cope with normal stresses of life and work productively. c. Is the promotion of mental health, prevention of mental disorders, nursing care of patients during illness and rehabilitation d. Absence of mental illness

b. A state of well-being where a person can realize his own abilities can cope with normal stresses of life and work productively.

A nurse is putting together an educational seminar on advance directives. What information would be included in the materials? a.A patient may change a treatment decision in an advance directive if the patient's health care agent approves the change. b.When admitted to the hospital, a patient must appoint a Durable Power of Attorney for health care decisions. c.A health care facility must provide a patient informational material advising them of their rights to declare their desires concerning treatment decisions. d.A health care facility is required to provide a patient an attorney when the patient is signing a living will.

c.A health care facility must provide a patient informational material advising them of their rights to declare their desires concerning treatment decisions. Under Federal law, all healthcare facilities are required to provide patients with information on how to make medical decisions under Federal and State law, including accepting or refusing treatments and creation of an Advance Directive. The patient has the right to change a treatment decision in an advance directive, regardless of whether the patient's healthcare agent approves or denies the change. It is the patient's right to appoint a Durable Power of Attorney at the time and place of his choosing. It is not required for entry to a hospital. The healthcare facility is not required to provide an attorney to a patient to sign a living will. The patient needs to determine which attorney they want to hire or if they want to hire an attorney.

A 26-month-old displays negative behavior, refuses toilet training, and often says, "No!" Which psychosocial crisis is evident? a. Trust versus mistrust b. Initiative versus guilt c. Industry versus inferiority d. Autonomy versus shame and doubt

d. Autonomy versus shame and doubt

A patient is to be discharged on a regimen of lithium carbonate. In the teaching plan for discharge the nurse should include: a. Advising the client to watch the diet carefully b. Suggesting that the client take the pills with milk c. Reminding the client that a CBC must be done once a month. d. Encouraging the client to have blood levels checked as ordered.

d. Encouraging the client to have blood levels checked as ordered.

In a team meeting a nurse says, "I'm concerned about whether we are behaving ethically in using restraint to prevent one patient from engaging in self-mutilating behavior while the care plan for another self-mutilating patient calls for one-on-one supervision." Which ethical principle most clearly applies to this situation? a. Beneficence b. Autonomy c. Fidelity d. Justice

d. Justice

Your patient has taken amitriptyline HCL (Elavil) for 3 days, but now complains that it "doesn't help" and refuses to take it. What should the nurse say or do? a.Withhold the drug. b.Record the client's response. c.Encourage the client to tell the doctor. d.Suggest that it takes awhile before seeing the results.

d.Suggest that it takes awhile before seeing the results.