Tusaie - Advanced Practice Psychiatric Nursing 2023 with 100% correct questions and answers

Integrative mental health treatment Prospective, relationship-based, client centered, holistic approach that focuses on client's priorities for well-being and preventing, managing, and rehabilitating disease *broad and comprehensive, rather than reductionist and focused on the effects of a specific treatment on a specific symptom *Does not consist of haphazard selection of techniques *Looks beyond confines of a single perspective *Clinicians begin developing a conceptual framework that fits for themselves and their clients - synthesizes several theoretical approaches *Developing an integrated perspective is a lifelong process that is the produce of a great deal of study, clinical practice, and theorizing *Signs and symptoms are interpreted differently across cultures Rationale for integrated treatment *Nursing practice is holistic and the phenomena of interest include not only symptoms but also health risks and promotion *Underlying holistic theory remains as the foundation for any intervention *Scope of practice in PMH-APRN is continually expanding in response to the context of practice, knowledge base evolution, and ongoing need for clients holistic care *The increasing cost of health care is reaching a level where it will soon not be sustainable Recovery After an Initial Schizophrenia Episode (RAISE) project Low-dose medication Family psychoeducation Supported education/employment Individualized resilience training Other interventions to focus on more than psychotic symptoms and medications National Institute of Mental Health Research Domain Criteria (RDoC) project that may lead to revolutionary, integrated diagnostics Psychotherapy and behavior changes Psychophysiological pathways underlying symptoms are increasing understood to be nonlinear and multidimensional - Mechanistic world views chose conventional medical treatments Systems view chose complementary and alternative treatment thinking patterns, genomes and derivatives are being used to make treatment decisions with the expectation of personalized treatment informed by each person's unique information Holistic thinking Conceptualize symptoms across diagnostic categories *No objective test to differentiate one diagnosis from another *signs and symptoms of psychiatric problems overlap Neurotransmitter pathways serotonin, dopamine, norepinephrine, glutamate, gamma-aminobutyric acid Common neurobiological pathways Neurotransmitter pathways Structural abnormalities identified on neuroimaging Genetic predispositions cross diagnostic categories Homeostasis Natural healing powers of the individual Neuroplasticity Process of neuroplasticity, synaptogenesis, dendritic spines, and neurogenesis, or modification of and individuals brain structure may be the central process for therapeutic change Combination of psychotherapy and pharmacotherapy Resulted in more improvement than expected Evidence-based practices Many question the wisdom of evidence *Circular model would involve a multiplicity of methods, using different designs, counterbalancing their individual strengths and weaknesses to arrive at a pragmatic but rigorous evidence base for clinical innovation *Methods should not be viewed as in terms of intrinsic worth but as valuable in relation to the question being asked integrated treatment continuum *Degree of risk is determined *Progression to minimal, moderate, and severe level of symptoms *Interventions begin with health promotion activities - Increasing knowledge, guided self-help including lifestyle changes, and over-the-counter medication or herbs - Professional management with formal interventions *Protocol to ensure safe and effective integration of complementary and alternative approaches Prejudices against complementary and alternative approaches Approaches used only by a few people Clients do not talk about using these approaches Only used when conventional approaches fail They are not effective Complementary approaches are not professionally respected Prejudices in favor of complimentary and alternative approaches The belief that research is not needed Used before safely Effects cannot be proven Natural substances are healthy The placebo effect The physiology of the placebo effect is basically self-healing or nonspecific psychoneuroimmunological stimulation activated by the context of the clinical encounter SSRIs Initially used for depression are now also used for panic disorder, social phobia, OCD, bulemia, impulse control disorders, and fibromyalgia anticonvulsants initially used for seizure disorder are now found to be effective in tx of bipolar mania, substance abuse, impulsivity, treatment-resistant anxiety, depression, and psychosis atypical antipsychotics initially used for schizophrenia are now used for bipolar mania, treatment-resistant depression, OCDs, delirium, and others Psychotherapy starts Believed to enhance the function of the prefrontal cortex (PFC) and then down to the limbic system in a top-down manner Pharmacotherapy starts Starts at the limbic system and works up to the PFC in a bottom-up pattern St John's wort mild to moderate depression (nervous and psychiatric disorders valerian insomnia; relaxation for anxiety (SAMe), inositol depression types of complementary interventions Biologically based practices Mind-body practices Manipulative, body-based practices Energy approaches Others biologically based products include a variety of herbal medicines, vitamins, minerals, food, and other natural products Herb-drug interactions Interactions are based on same pharmacokinetic and pharmacodynamics mechanisms as drug-drug interactions Kava might be effective symptomatic treatment for anxiety but size of effect seems small Ginkgo Neuroprotection and regenerative effects on circulation Ginseng Promote health, increase sexual potency, and longevity rather than cure disease Omega-3 fatty acids selectively concentrated in synaptic neuronal membranes and regulate receptor activity and signal transduction Folate Reduction in depressive symptoms Vitamin D deficiency Individuals with depressive symptoms and low exposure to sunlight should be assessed for vitamin D deficiency Hypnosis Altered state of consciousness; not unconsciousness or sleep *Marked receptiveness to ideas and understandings and increased willingness to respond either positively or negatively to those ideas *Used as part of psychotherapy or medical procedure Meditation Conscious mental process using certain techniques to suspend the stream of thoughts and relax the body and mind *Meditation cals the mind in a natural way *Three main criteria: 1. Defined technique, 2. Relaxation of logical mind, 3. Self-induced state Yoga typically used for health purposes and combines physical postures, breathing techniques, and meditation or relaxation *Each yoga pose has specific physical and mental benefits *Superior to other exercises in decreasing anxiety Tai Chi Chuan described as meditation in motion as it promotes serenity through gently movements *Perform series of postures or movements *Many styles - Health focus, Martial arts aspect Acupuncture Involves stimulation of specific points on the body using a variety of techniques, such as penetrating the skin with needles that are manipulated by hand or electrical stimulation *Acupuncture in mental health treatment has been discussed for depression, anxiety, insomnia, and addictions Emotional freedom technique (tapping) controversial variation of acupressure using the acupoints along meridians Somatic psychotherapy Somatic mental health practitioners tend to bring body, body processes, and body experience into the foreground of therapy practice (Increased use of body-oriented therapeutic techniques in mainstream psychology and mindfulness practices and psychoanalysis has recognized the use for years) Dance therapy considered a study and practice within the field of somatic psychology *based on belief that the body, mind, and spirit are interconnected Aromatherapy *Use of essential oils extracted for plants for treating problems and promoting healing *Minimal research to provide evidence of effectiveness EMDR (eye movement desensitization and reprocessing) form of psychotherapy, were developed to resolve the development of trauma-related disorders Energy work *Manipulation of energy fields to affect health *Traditional healers use approaches based on indigenous theories and beliefs *Ayurvedic medicine is natural health systems based in India *Traditional Chinese Medicine is based on concepts of yin and yang, qi, essence, and spirit (acupuncture, moxibustion, cupping, massage, herbals, and qigong) *Homeopathy and naturopathy stimulate body's ability to heal (Small doses of diluted substances are used to stimulate the body's ability to heal itself) Considerations of complementary and alternative techniques Identify benefit for client Check state and federal regulations to ensure this practice is not constrained Review standards and scope of practice from psychiatric-mental health and advanced practice nursing organizations for compliance Review methods used to gain competence in the technique What is the evidence base? CAM appropriate Patient tried and failed to respond to standard treatments Patient is unable to tolerate standard treatment adverse effects Patient has condition with no effective standard treatment Standard treatments partially relieve symptoms Medications causing adverse effects that CAM may help Patient wants to reduce effects of risk factors Patient wants to explore full range of options Patient is uncomfortable with traditional pharmaceuticals Patient cannot afford traditional pharmaceuticals Training and information Natural products (May be self-taught with recordings, books or trained professional) Hypnosis (Use professionally licensed trainers) Acupuncture (Schools offer certificate or doctorate in acupuncture and take 3 to 4 years to complete coursework and clinical practice; some states offer their own guidelines) Guidelines for the Assessment of Herbal Medications World Health Organization Preparing for interview Self-care (adequate rest, exercise, and time to be relaxed before session) Familiarity with forms and resources available, including emergency numbers Preparing physical environment and making it safe and comfortable Always have the following accessible: Exit door; Ability to see a clock; No large desks between you and the client Common difficulties Countertransference: the desire to fix the client without and appreciation of the client's narrative Clinicians own difficulty in bearing witness to suffering Countertransference Signs: Late for sessions or cutting time short Drowsy during sessions Becoming seductive, cold, arguing, or dreaming about client Strong or lack of emotions Pacing or mirroring Involves assuming a similar body posture as well as language of the client *be alert to language *Having patience to listen without forming a response simple reflections *Use 3 simple reflections without interpretations in first 15 minutes of a session and then one every 20 minutes *Use two reflective statements to each question (the use of reflection builds empathy and avoids the trap of the client being a passive recipient and the clinician doing the work Summarize summarize affect or content without interpretation Nod or use minimal verbalization evaluating empathy Be aware of own reactions at the end of the session Explore client's reactions Ask what he or she thinks about working together Building empathy Creates a sense of safety in the relationship, thus decreasing anxiety and promoting neuronal changes and the ability to learn change Provides emotional proximity or warmth and facilitates engagement in the treatment process Instilling hope *Clarification of information with open-ended statements *Open-ended questions or gentle commands set tone for a nonjudgemental environment where clients can explore problems in more depth *Exploring feelings is another technique to gain information *Broad openings may be followed by some clients who are ready to work, but others may have more ambivalence about sharing *Normalizing situations and reactions are helpful in gathering information without threatening or shutting down interview flow *Giving recognition to positive affirmations is attributing interesting, positive qualities to clients Client resources As clients become less organized, the PMH-APRN becomes more directive PMH-APRN resources Useful to be involved yourself as a client in the psychotherapy process to facilitate self-understanding and clinical skills Benner's stages of clinical skills Novice-No experience, governed by rules, regulations Advanced beginner- recognizes meaningful aspects of situations, able to make judgements Competent - 2-3 years experience, coordinates complex care Proficient - 3-5 years experience, sees situations as whole, uses and sees long-term goals Expert - Performance is fluid, flexible, and efficient; uses intuition beginning, middle and end Beginning very brief and sets the stage for this session (Personal introductions, what to expect) Middle is the work to achieve the goals of the session (work of the session) End is the summary and planning for the next session (Clock placed across the room so the APRN can check the time as the session progresses) Goals for assessment process *Engage self and client in process *Develop empathy and understanding of client *Collect valid database *Identify patterns and develop a diagnosis and case formulation *Instill hope and decrease anxiety Shea's gates Transitioning from one topic to another *Spontaneous gate - client spontaneously moves to a new content area *Natural gate - involves the APRN cueing off the client statement and making a bridge to new content *Referred gate - the return to a new area of discussion by referring back to a previous statement made by the client *Phantom gate - occurs when APRN asks a question totally out of context and this interrupts the information flow *Implied gates - join similar regions and can provide expansion Databases Often preprinted forms or computerized Identifying data Values Chief complaint Strengths Past problems Mini-mental state exam Review of systems Risk formulation Family history DSM-5 diagnosis Personal development Case formulation Adult trauma, self-care ability Initial treatment Plan Yalon's Cruative Factors *Interpersonal learning *Catharsis *Group cohesiveness *Self-understanding *Socializing techniques *Existential factors *Universality *Instillation of hope *Altruism *Corrective family re-enactment *Guidance *Identification of initiative behavior Further testing May include blood work, neuroinaging, and tests of electrophysiology, or psychological testing Acute treatment goals Are to bring about change in the target symptoms and provide safety (Target most distressing symptoms) Therapeutic communication techniques *Interpretation *Gentle confrontation (Medication issues explored, exploring behaviors during sessions Stabilization *Treatment focus moves to potential or actual side effects and strategies to minimize these problems *Cost becomes an issue for many clients and must be addressed *Shifts to groups, more self-help, or extended appointment times are appropriate Termination Usually discussed during first few sessions as part of treatment planning and often in response to client questions (May include time limit or continue indefinitely; Final termination is not really final; Continued use of clinical supervision) Open-ended questions "Tell me about the consequences of your depression" gentle commands set the tone for a nonjudgemental environment where clients can explore their problems in more depth Exploring feelings When client is providing only detailed information as though telling a story, useful to switch to feelings "How did that feel when you were divorced" Altruism Constructive, gratifying service to others Humor Using comedy to express feelings without discomfort to self or others Sublimation Channel instincts to socially acceptable action Dissociation Absence of conscious awareness of behaviors or stimuli; or the coexistence of separate mental systems or identities Reaction formation Transforming an unacceptable impulse into the opposite Rationalization Explaining to justify behavior, beliefs Intellectualization Excessive use of intellectual processes to avoid feelings or experiences Regression Return to an earlier stage of functioning Somatization Converting psychological conflicts into bodily symptoms Blocking Temporarily inhibiting thinking Passive-aggressive behavior Expressing aggression through passivity (failure, illness that affects others) Denial Avoiding some painful aspect of reality Distortion Reshaping external reality (hallucinations, delusions) Projection Reacting to unacceptable impulses or thoughts as if outside oneself behavioral incident technique developed by Pascal and further described by Shea. Asking specific details, "Who is supportive" Values or aspiration Question, "What do you think you will be doing 5 years from now and what would you like to be doing? provides insight into the client's perception of his or her future. Other values may include spirituality, attitudes toward work, money, play, children, family, community, and cultural issues. Mini-Mental State Exam (MMSE) evaluation of client's current status through direct observation. It includes appearance, behavior, speech, affect, thought process, thought content, and cognitive examination cognitive approach Thinking about ways to approach a problem, examining possible solutions, locating evidence Cognitive avoidance Putting off thinking about that until tomorrow Behavioral approach Trying different activities Behavioral avoidance Going dancing to avoid a problem, relocating to avoid a problem neighbor cognitive therapy formulations Focus on maladaptive or illogical thoughts and beliefs about the self and others and the world in general behavioral formulations addresses a person's learning history and an analysis of environmental reinforcers and stimulus-response pairings case formulation a hypothesis or clinical judgement about the causes, precipants, and maintaining influences of a person's psychological, interpersonal, and behavioral problems and his or her strengths Integrated case formulation *Current symptoms and problems *Possible non psychological explanations *Antecedent learning experiences or vulnerabilities *A mechanism explaining the problem plus a possible alternative explanation *Adaptive features of the individual *Application to treatment