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Mental Health

Nursing
by

Alicia Rennaker

on 28 October 2013

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Transcript of Mental Health

The Forgotten Genius
Helping Hand
Chinese Massage
Tui Na Massage
Poor and Misfortunate
Comfort
Mental Health
Alicia Rennaker
Kara Harbauer
Stormie Robinson
Ashlie LaRue
Sarah Lanning


Objectives:
1. Understand the foundation of mental health, and be able to explain the proper way of interacting with mental health patients.
2. Understand the models of care that are used with mental health patients and how to apply them.
3. Understand the interventions that are taken when patient present with mental health problems.
4. Be able to identify different disorders associated with mental health and the symptoms patients display.
5. Understand different addictions, and the effects they have on patients.
6. Know psychiatric medications used for the treatment of mental health disorders.

What are the Rights of Mentally Ill Patients?
The right...
to be treated with dignity/respect
to Communicate with people outside of the hospital
to keep clothing and personal effects
to religious freedom
to be employed
to manage property
to execute wills
to enter into agreements
to make purchases

to make purchases
to education
to hebeas corpus
to an independent psychiatric examination
to civil service status, including the right to vote
to retain licenses, privileges, and permits
to sue/be sued
to marry/divorce
to treatment in the least restrictive setting
no to be subjected to unnecessary restraints
informed consent
to treatment/refused treatment
Although Mental Health Nursing can be a challenging profession...

All nurses are called upon by God...
Because we all have the...
Objectives:
Suicidal Behavior
What are Suicidal Clues?
Can you name a few?

Assessment of Suicidal Patients
Plan?
Patient history of suicide attempts
Psychosocial factors?


Interventions for Suicidal Behavior
Suicide precautions
Create a contract that indicates alternative behavior at time of suicidal thoughts.
Encourage patient to talk about their feelings
Encourage self care
Make sure visitors do not leave harmful objects behind
ID support groups
Do not let patient leave unit unless with a staff member
Continue assessment of suicidal potential

Abusive Behavior
Anger that is used to avoid anxiety.

Gives feelings of power in situation where person feels out of control.
Assessment of Abusive Behavior
History?
Poor impulse control
Defiant/Argumentative
Raising of voice, verbal threats
Pacing/Agitation
Muscle rigidity/flushed face/glaring.

Interventions of Abusive Behavior
Safety
Calm approach
Large personal space
Listen actively
Acknowledge that they are angry.
Determine what patient feels their need is.
Set limits on behavior
Talk about restraints/seclusion if they are unable to control their behavior.
Assist with problem solving/decision making.
Restraints/Seclusion
REQUIRE a written prescription
Renewed q 24 hrs
Specify type of restraint
Duration
Criteria for release
When are Restraints used?
When behavior is physically harmful to patient or others.
Last resort
Important
Document behavior leading up to restraints.
In an emergency: a qualified nurse may place restrains/seclusion and obtain prescription soon after.
Within 1 hr. there must be a psychiatrist face-to-face.
1-on-1 observation
Assess physical, safety, and comfort needs every 15-30 minutes/document.
Foundations of Mental Health
All Information Provided to you by....
for the NCLEX-RN examination (5th ed). St. Louis: Elsevier Saunders.
Silvestri, L. (2011). Saunders comprehensive review
Therapeutic Interaction
1. Preinteraction phase:

2.Orientation/Introductory phase:

3.Working phase:

4.Termination phase:
Establish trust, acceptance, and boundaries. Set expectations.
Before the nurse/client meet. Go without bias, erase all preconceived ideas.
Determine client concerns, allow patient to determine recovery.
Discuss improvement, successful goals, ask client thoughts, give references, and determine needs.
Therapeutic Communication
Mental Health
"A lifelong process of successful adaptation to changing internal and external environments" *
Psychiatric Mental Health Illness
"The loss of the ability to respond to the internal and external environment in ways that are in harmony with oneself or the expectations of society."*
Thoughts/Behaviors will affect function...

Stress?
Relationships?
Perception of self/others is distorted.
Focused on thoughts or actions of self/others.
Impaired ability to complete tasks and find meaning in life.
Possible inability to meet own needs.
Loss/decreased self-control.
The way surroundings are perceived is skewed.
Decreased/no coping mechanisms.
May not exist or be reduced.
Impaired ability to enjoy long term intimacy.
Coping:
"any effort to decrease anxiety"*
Defense Mechanism:
"coping mechanism used in an effort to protect the individual from feeling anxiety."*
Displacement
Dissociation
Intellectualization
Rationalization
Sublimation

Types of Defense Mechanisms:
Interventions
1. Encourage pt. to pinpoint source of stress.
2. Determine appropriate methods to cope.
3. Assess effectiveness to coping methods.
Diagnostic & Statistical Manual of Mental Health Disorders
Gives criteria to determine and categorize mental health disorders
Published by American Psychiatric Association
Guidelines for treatment plans and evaluations
Admissions:
Voluntary:
Involuntary:
Clients admit themselves freely.
Can discharge themselves, HOWEVER the physician can order the client to be held...
When a person needs psychiatric treatment, is dangerous to themselves/others, or if they are mentally ill.
HOWEVER, they still have the right to refuse treatment until they are in immediate danger to themselves or others.
Discharge:
Instructions and follow up are important.

Case managers help the client to adapt back into society and give an early referral if the client is unsuccessful with treatment plan.
Models of Care:
Milieu Therapy:
Deals with the environment/physical factors involved in the patient's treatment.
Activity groups, exercise programs, community meeting, and social skills groups.
RN's
Exercise Therapist
Social Worker
Psychiatrist
Psychologist
Nurse Practitioner
Personality Disorders
"Various inflexible maladaptive behavior patterns/traits that impair functioning and relationships."*
Addiction
Just a review, we all know these!
Eating Disorders:
Substance Disorders:
Alcohol Abuse & Withdrawal
Drug Dependency:
Compulsive overeating, Anorexia, Bulimia
Dependence, tolerance, abuse, withdrawal
CNS stimulants/depressants, Opioids, Hallucinogens, Inhalants, Marijuana
Patient is in touch with reality, but lacks insight into their behavior.

Stress exacerbates manifestations.

In severe cases it may deteriorate to psychotic state.
Poor Impulse Control

Physical/verbal attacks
Self-inflicted injuries
Substance abuse
Suicide Attempts
Acting Out...
Preoccupied with self, religion, or sex
Mood Characteristics
Abandonment
Depression
Rage
Guilt
Fear
Emptiness
Impaired Judgement
Inability to perceive consequences of behavior.
Impaired Reality Testing
Distortion of reality, project feelings onto others
Impaired Relationships
Rigid/inflexible, difficulty with intimate relationships.
Impaired Self Perception & Thought Process
Impaired Stimulus Barrier
Inability to regulate incoming sensory stimuli, increased excitability, excessive response to noise/light, poor attention span, agitation, insomnia.
Cluster A
Cluster B
Cluster C
Schizoid
Schizotypal
Paranoid
Histonic
Narcissistic
Antisocial
Borderline
Obsessive Compulsive
Avoidant
Dependent
Cluster A Personality:

Odd,eccentric types
Schizoid
Inability to form close relationships
Social detachment
Solitary activities
Aloof/indifferent
Restricted expressions
Schizotypal
Display of abnormal or highly unusual thoughts, perceptions, speech, and behavior patterns.
Paranoia
Magical thinking
Paranoid
Suspiciousness/mistrust of others
Argumentative
Hostile, rigid
Critical/controlling of others
Thoughts of grandiosity

Cluster B Personality:
Histrionic
Narcissistic
Antisocial
Borderline
Overly dramatic
Enjoy being center of attention
Poor/shallow relationships
Sexually seductive/provocative
Theatrical/drama
Overly concerned with appearance
Easily bored
Overemotional & Erratic
Increased sense of self importance
Preoccupation with fantasies and unlimited success.
Pattern of irresponsible behavior
Failure to accept social norms
Perceive world as hostile
No shame/guilt, impulsive
self centered, unreliable
Easily bored, poor work history
View others as objects to be manipulated
Unstable relationships
Impulsive behavior
Unclear identity
Mood shifts, argumentative, depressed
Self-destructive behavior
Manipulation
Splitting (other are all good/all bad)

Cluster C Personality:
Obsessive Compulsive:
Avoidant:
Dependent:
Difficulty expressing warm/tender emotions
Need to control others
Feelings of inadequacy
Hypersensitive to reactions of others
Poor reaction to criticism
Social isolation
Lack of support system

Intense lack of self confidence
Inability to function independently
Difficulty making decisions
Interventions:
Maintain safety
Allow pt. to be independent
Discuss feelings rather than act on them
Provide consistency
Discuss expectations & consequences of actions
Assist with dealing with anger
Develop written safety/behavioral contract
Have pt. journal daily about feelings
Group activities
Praise good behavior, realistic praise
Electroconvulsive Therapy:
Electrical current that causes tonic-clonic seizures.
Severe depression, bipolar depressive disorders, depression with psychomotor stupor & retardation, mania when the patient doesn't respond to lithium/antipsychotic medicines, schizophrenia & schizo affective patients.
Treatment:
6-12 tx give 2-3x/week
Not a permanent solution
Contraindicated:
Increased risk in patients with recent stroke, intracranial mass lesions, or MI.
Nursing Responsibility Before ECT:

Explain procedure/effects [common complications: confusion/disorientation right after, memory problems occur but usually go back to normal, but could last 6 months]

Discuss the pt feelings/encourage questions

Teach pt about NPO after midnight or 4 hours before ECT

Informed consent [voluntary pt], consent from next of kin [involuntary pt]

Obtain vital signs to determine baseline

Can give medications to prevent aspiration/bradydysrhythmias/muscle relaxant to decrease the intensity of seizures [prevents injury to bones/vertebrae]
Nursing Responsibilities before/during ECT:
Apply blood pressure cuff/pulse oximeter/mask with 100% oxygen

Insert IV and apply electroencephalographic and electrocardiograph electrodes.

Short acting anesthetic administered

Observe electrical current affect of pt vitals, seizures will last 30=60 sec.
After the ECT:
Transfer the pt to recovery room

As pt wakes, take vitals and do a brief neuro assessment

Orient the client if needed

Assure vitals are stable and gag reflex is returned.
Anxiety:
A response to stress
Different experience for everyone, entails feeling uncertain, uneasy, apprehensive, and dread..
Types:
Normal
Acute
Chronic
Levels of Anxiety
Mild:
Moderate:
Severe:
Panic:
Related to tension of everyday life, perceptual field is increased.
Focus on immediate concerns, perceptual field is decreased, selective attentiveness takes place.
When one feels like something terrible is about to happen, a major decrease in the perceptual field happens, all behavior is focused on alleviating anxiety.
Panic attack, associated with fear/horror/sense of impending doom. Have disorganized personality, unable to function/communicate effectively.
Exhaustion/Death can occur!
What are the Priority Nursing Actions for a Client with Anxiety?
 1. The priority nursing action for a client with anxiety is to provide a calm and quiet environment and decrease stimuli.

 2. Ask the client to say what and how he or she is feeling.

 3. Support and prompt the client to give details about his or her feelings

 4. Assist the client in identifying the causes of the feelings he or she is having.

 5. Watch and listen for expressions of helplessness and hopelessness from the client.

Scenario:
“I returned to my hometown in Michigan on June 9th, after being gone for two years. I have a nightmare almost every night; I even have them when I take naps sometimes. Every time I hear a loud noise I have a flashback. Man, the fireworks around Independence Day had me jumping out of my seat every time I heard one. I often think everything would have been better if I would have just died along with my friends. It’s not fair that I’m still alive and they died. It’s just no fair.”
What do I have?
PTSD
What is PTSD?
Post Traumatic Stress Disorder
After experiencing a psychologically traumatic event, the individual is prone to re-experience the event and have recurrent and intrusive dreams or flashbacks
.
What did you pick up out of my story that is associated with PTSD?
Flashbacks
Nightmares
Recently returned from war
Hypervigilance
Guilt for surviving event when others did not
What is this...?
What causes PTSD?
Combat experience
Natural disaster
Terrorist attack
Accidents
Rape
Crime/violence
Sexual/physical/emotional abuse
Re-experiencing the event as a flashback
Stressors:
What kind of qualities do people with PTSD express and experience?
Emotional numbness
Detachment
Depression
Anxiety
Sleep disturbances/Nightmares
Flashbacks
Hypervigilance
Guilt
Poor ability to concentrate
Avoidance of events that trigger memories
What can be done?
What can we do to help the patient?
Be nonjudgmental/supportive
Assure client that his/her behaviors are normal reactions.
Help the client to recognize the association between his/her feelings and behaviors and the trauma experience.
Encourage the client to
and provide the client with individual therapy.
Help the client develop adaptive coping, use relaxation
Facilitate a progressive review of the trauma experience
Encourage client to [re] establish relationships.

express feelings
***
***
***
***
Phobias:
"An irrational fear of a situation or object that does not go away even if the client sees it as unreasonable."*
Obsessive-Compulsive Disorder OCD
Somatoform Disorders
Dissociative Disorder:
Therapeutic:
Non-Therapeutic:
Clarifying/validating
Encouraging formation of plan
Focusing
Listening
Maintain neutral responses
Maintain silence
Provide acknowledgment & feedback
Provide information
Present reality
Providing non-verbal encouragement
Reflecting
Restating
Sharing perceptions

Asking the client "why?"
Being defensive/challenging
Changing the subject
Giving advice/approval/disapproval
Making stereotypical comments
Making value judgments
Placing the client's feelings on hold
Providing false reassurance
Bipolar Disorder:
Characterized by episodes of mania and depression
Mania:
Depression:
Becomes angry quickly
Delusional self-confidence
Distracted by environmental stimuli
Flight of ideas
Unlimited energy
Increased/decreased appetite
Decrease in ADL's
Decreased emotion/physical activity
Easily fatigued
Lack of energy
Interventions for Mania:
Remove hazardous objects
Assess for fatigue
Provide private room if possible
Provide high calorie finger foods
Avoid competitive games
Provide gross motor activities
Interventions for Depressed Clients:
Assess for suicidal ideation
Provide safety
Assist with ADLs
Do not push decision making
Monitor sleep patterns
Schizophrenia:
Psychotic features (hallucinations & delusions), disordered thought process, and disrupted interpersonal relationships.
Assessment:
Physical Characteristics...

Motor Activity...

Emotional Characteristics...

Abnormal Thought Processes...
Unkempt appearance
Preoccupied with somatic complaints.
Neglects hygiene, sleeping, and elimination.

Catatonic posturing
Catatonic excitement
Immobilization
Echolalia and echopraxia
Waxy flexibility
Mistrust
Views world as threatening
Flat/inappropriate affect
Emotional responses to hallucinations

Fragmentation of thoughts
Thought blocking
Distorted perception of environment
Neolgisms
Word salad
Types of Delusions:
Loss of reference

Persecution

Grandeur

Somatic
Types of Schizophrenia:
*Photo retrieved from Google images
Catatonic:
Disorganized:
Paranoid:
Residual:
Undifferentiated:
Psychomotor disturbances
Immobility
Stupor
Waxy flexibility
Social withdrawal
Disorganized speech/behavior
Flat affect
Grimacing Mannerisms
Suspicious
Hostile
Delusions
Violence
Auditory hallucinations
Diagnosed with schizophrenia in the past
Time limited between attacks
Social isolation
Does not meet criteria for other types
Delusions
Hallucinations
Disorganized speech
Interventions:
Maintain safety
Assess physical needs
Start with 1 on 1 interactions, then small groups
Spend time with them
Do not go along with their hallucinations

Interventions for Active Hallucinations:
1 to 1
Decrease stimuli
Avoid touching
Encourage to express feelings.
Monitor for increasing fear and anxiety.
SAFETY IS THE #1 PRIORITY! ENSURE THEY ARE NOT HAVING COMMAND HALLUCINATIONS.
Paranoid Disorders:
Persecutory and grandiose beliefs
Types of Paranoid Disorders:
Paranoid Personality Disorder..

Paranoia-induced state..

Paranoia..

Paranoid Schizophrenia..
Paranoid Personality Disorder:
Suspicious
Nonpsychotic
No hallucination or delusions
Paranoia-induced State:
Quick onset in response to stress, lessens as stress lessens
No hallucinations
Paranoid delusions
Paranoia:
Organized delusional system
No hallucinations
Paranoid delusions
Paranoid Schizophrenia:
Before onset, they become cold, withdrawn, distrustful, resentful, argumentative
Interventions:
No whispering or laughing in front of this client!
Assess for suicidal ideation
Avoid direct eye contact
Establish trusting relationship
Honesty
Noncompetitive tasks
Obsessions are preoccupations with constant invasive thoughts & ideas.

A compulsion is performing repetitive behaviors or rituals.
If obsessions or compulsions are resisted, anxiety often occurs.
Conversion disorder

Somatization disorder

Hypochondriasis
Conversion Disorder
 "Conversion disorder is a physical symptom or a deficit resulting in loss or distorted body function related to a neurological disorder or psychological conflict."*
The most common are: deafness, blindness, paralysis, and the inability to talk.
 The symptoms happen subconsciously and are beyond control.

Physical limitation or disability, feel guilt, frustration, or anxiety, experience low self-esteem and feelings of inadequacy, unexpressed conflict or anger, and secondary gain.

Symptoms
Assessment
Hypochondriasis
 "Hypochondriasis is the preoccupation with the fear of having a serious health problem or disorder."*
Assessment
 Hypochondriasis majorly interferes with and impairs social and occupational functioning.
Preoccupation with fears of having a health problem, frequent somatic complaints, frequent insomnia and fatigue, anxiety, difficulty in expressing what one is feeling, extensive use of nonprescription medications and home remedies, repeated doctor visits even after being reassured tests are normal, and secondary gain.
Somatization Disorder
Assessment
Interventions
 The client will have many physical complaints involving multiple body systems.
Physical complaints of pain, deny emotional problems, show signs of anxiety, fear, and low self-esteem.
 The client may unconsciously be getting secondary gain.
Help the client identify alternative ways to meet needs.
Help the client relate feelings and conflicts to the physical symptoms.
Show that you as the nurse understand that the physical symptoms the client is experiencing are real to the client
Encourage relaxation techniques
Report and assess any new physical complaint

"Disruption in memory, consciousness, or identity."* It is associated with an extremely traumatic event.
Multiple Personality
Assessment
 "Multiple personality/dissociative identity disorder is when one person has two or more fully developed unique and distinctive personalities."*

 The host is the primary personality and the other personality or personalities are called alters.

 The alter personalities sometimes take complete control of the client and at times are not aware of each other.

 The alters can be aware of the host but the host is not always aware of the alters.

The client may not be able to recall important information.

The transition from one personality into another happens from stress or a sudden traumatic event.

Dissociation is used to distance one’s self from anxiety and traumatizing events.

References
*
*Picture retrieved from Google images.
BREAK!
Full transcript