NR320: Mental Health: Exam 1 / NR 320 Exam 1 Study Guide: Mental Health (2020) Chamberlain College of Nursing

NR320: Mental Health: Exam 1 / NR 320 Exam 1 Study Guide: Mental Health Chapter 7: Therapeutic Relationships • Therapeutic Relationship: An interaction between two people (usually a caregiver and a care receiver) in which input from both participants contributes to a climate of healing, growth promotion, and/or illness prevention o Therapeutic Nurse-Patient Relationships  Goal-oriented, Facilitates communication  Use the problem-solving model to bring about some type of change in the pts life • Roles of the Psychiatric Nurse o Peplau (1991) identified several subroles within the role of the RN:  Stranger: RN is at first a stranger to the pt  Resource: RN explains, in a language the pt can understand, information r/t the pts health care  Educator: RN identifies learning needs & provides information required to improve health situation  Leader: democratic leadership allows pt to be an active participant in their health  Surrogate: pts perceive RN as symbols of other people, such as mother figure, sibling, teacher, another RN  Counselor: help the pt to remember & understand fully what is happening in the present situation • Dynamics of a Therapeutic Nurse-Client Relationship o The goal of a therapeutic relationship may be based on a problem solving model  Directed at learning & growth promotion  to bring about some type of change in the pts life o Therapeutic Use of Self  Require the RN to have a great deal of self-awareness & self-understanding  Strongly influenced by an internal value system  a combination of intellect & emotions o Gaining Self-Awareness  RN needs self-awareness: know own biases  Values Clarification  Beliefs: an idea that one holds to be true  Rational beliefs: objective evidence exists  Irrational beliefs: delusions, no objective evidence exists  Faith: an ideal held true even though no objective evidence exists  Stereotypes: a socially shared belief that describes a concept in an oversimplified matter  Attitudes: a frame of reference around which an individual organizes knowledge about their world  Values: abstract standards, or -, that represent an individual’s ideal mode of conduct & ideal goals  Action oriented or action producing (different from beliefs & attitudes) • The Johari Window(PG 138) o A representation of self & a tool that can be used to  self-awareness o The goal of using this window is to increase the size of the open or public self o Divided into four quadrants:  Open or Public Self: aspects of self that are known to the individual and others  Unknowing Self: blind self: known to others but remains hidden from the awareness of the individual  Private Self: hidden self: known to individual but is deliberately & consciously concealed from others  Unknown Self: part of self that is unknown both to the individual and to others • Characteristics that Enhance the Achievement of a Therapeutic Relationship o Rapport:  Primary task in relationship development  Implies special feelings based on acceptance, warmth, friendliness, common interest, a sense of trust & nonjudgmental attitude  May be accomplished by discussing non-health related topics o Trust:  Basis of a therapeutic relationship  Feeling of confidence in a person’s presence, reliability, integrity, veracity  RN interventions that promote trust: providing a blanket when cold, keeping promises, being honest o Respect:  To show respect is to believe in the dignity and worth of an individual regardless of their unacceptable behavior  Unconditional positive regard – the attitude is non-judgmental  RN conveys respect by: calling pt by name, spending time with pt, always being open & honest o Genuineness:  RNs ability to be open, honest & “real” in interactions with pt  There is congruence between what is felt and what is being expressed o Empathy:  Ability to see beyond outward behavior & to understand the situation from the pts point of view  RN accurately perceives or understands pts feelings & encourages of exploration of feelings  Not sympathy (sharing the pts feelings and feels need to alleviate distress) • Phases of a Therapeutic Nurse-Patient Relationship(PG 141) o Preinteraction: explore self-perceptions  Involves preparation for the 1st encounter with the pt  Tasks include:  Obtain information about pt, family, other health team members  Initial assessment is begun  Examine personal response to knowledge about pt feelings, fears, anxieties o Orientation: introductory phase, establish trust, formulate contract for intervention  RN and pt become acquainted  Tasks include:  Create an environment for trust and rapport to grow  Establish a contract for intervention  Gather assessment information, Formulating nursing Dx, Developing a plan o Working: promote client change through therapeutic work  Tasks include:  Maintain trust and rapport  Promote pts insight and perception of reality  Problem solve  Overcome resistant behaviors and Continuously evaluate progress  Transference: occurs when pt unconsciously displaces to the RN feelings formed toward a pp from their past  Countertransference: RNs behavioral and emotional response to the pt  Related to unresolved feelings towards significant others from the RNs past  Generated in response to transference feelings on the part of the pt o Termination: evaluate goal attainment, ensure therapeutic closure  Bringing a therapeutic conclusion to the relationship r/t:  Goals have been accomplished  Discharge from hospital  End of a clinical rotation for student nurse  For therapeutic closure, the RN must establish the reality of the separation and resist being manipulated into repeated delays by the pt • Boundaries in the Nurse-Patient Relationship o Types of boundaries: material, social, personal and professional o Professional boundaries: limit and outline expectations for appropriate professional relationships with pts  Separate therapeutic behavior from any other behavior that could lessen the benefit of care to pts  Concerns are commonly r/t these issues:  Self-disclosure  Gift-giving  Touch  Friendship or Romantic Association o Boundary crossings can threaten the integrity of the nurse-patient relationship • Components of Therapeutic Relationships o Consistency o Pacing o Listening o Constant self-assessments o Positive initial impression o Promoting pt comfort Chapter 8: Communication Skills • The Communication Process: an interactive process of transmitting information between two or more entities • Interpersonal Communication: a transaction between the sender and the receiver o In all interpersonal transactions, both the sender and the receiver bring certain preexisting conditions to the exchange that influences both the intended message and the way in which it is interpreted o Examples of preexisting conditions:  One’s own value system  Internalized attitudes and beliefs  Cultures or religion  Social status  Gender  Background knowledge and experience  Age or developmental level  Type of environment that communication takes place • Nonverbal Communication: primary communication system in which meaning is assigned to various gestures and patterns of behavior o Meaning of the nonverbal components of communication is culturally determined o Components of Nonverbal Communication:  Physical appearance and dress  Body movement and posture  Touch  Facial expressions  Eye behavior  Vocal cues or Paralanguage  Paralanguage: the gestural component of the spoken word, it consists of pitch, tone and loudness of spoken messages, the rate of speaking, expressively placed pauses, and emphasis assigned to certain words • Therapeutic Communication: Caregiver verbal and nonverbal techniques that focus on the care receiver’s needs and advance the promotion of healing and change (PG 153-155) o Therapeutic communication encourages exploration of feelings and fosters understanding of behavioral motivation o It is nonjudgmental, discourages defensiveness and promotes trust o Examples of Therapeutic Communication:  Using silence  Active listening  Accepting  Giving recognition  Offering self  Making observations  Restating  Focusing  Presenting reality  Voicing doubt  Formulating a plan of action • Nontherapeutic Communication: RNs must also be aware of and avoid techniques that are considered to be barriers to effective communication (PG 156-158) o Examples of Nontherapeutic Communication:  Giving reassurance  Approving/disapproving  Giving advice  Probing  Defending  Introducing an unrelated topic (changing the subject) • Active Listening: being attentive to what the pt is saying, through both verbal and nonverbal cues o Skills associated with active listening include:  Sitting squarely facing the pt  Observing an open posture  Leaning forward toward the pt  Establishing eye contact  Relax: communicate a sense of being relaxed & comfortable with pt • Process Recordings: written reports of verbal interactions with pts used as a learning tool for professional development (PG 159-160) • Feedback: a method of communication for helping the pt consider a modification of behavior o Descriptive rather than evaluative – focuses on behavior rather than on pt o Specific, not general o Directed toward behavior that pt can modify o Impart information rather than offer advice (which fosters dependence) o Well-timed Chapter 9: Nursing Process • Nursing Process in Mental Health: provides a methodology that helps RNs deliver care using a systematic, scientific approach (PG 165) o The psychiatric nurse uses the nursing process to assist clients to adapt successfully to stressors within the environment o The focus of the nursing process is goal directed and based on a decision-making or problem-solving model, consisting of six steps: Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, and Evaluation • Assessment: a systematic collection of comprehensive health data that is pertinent to the pts health or situation • Diagnosis: analysis of assessment data to determine diagnoses or problems, including level of risk o Provides the basis for selection of nursing interventions to achieve outcomes for which the RN is accountable o Conforms to NANDA diagnoses • Outcomes Identification: end results that are measureable, desirable & observable and translate into observable behaviors o Outcomes are attainable, measureable, expected, patient-focused goals o Identifies expected outcomes for a plan individualized to the pt or situation • Planning: a plan that prescribes strategies and alternatives to attain expected outcomes • Implementation: implements the identified plan o Specific interventions include:  Coordination of care  Health teaching and health promotion  Milieu therapy  Pharmacological, biological, and integrative therapies  Prescriptive authority and treatment  Psychotherapy  Consultation • Evaluation: processof determining both the pts progress toward the attainment of expected outcomes and the effectiveness of nursing care • Types of Documentation o Examples of documentation methods:  Problem-Oriented Recording (POR)  Corresponds to the steps in the nursing process  SOAPIE: Subjective, Objective, Assessment, Plan, Implementation & Evaluation (PG 181)  Subjective: info gathered from pt, family or other sources  Objective: info gathered by direct observation by person performing the assessment  Assessment: RNs interpretation of subjective & objective data  Plan: actions or treatments to be carried out  Interventions: nursing actions that were actually carried out  Evaluation: evaluations of problem following nursing interventions  Focus Charting  Also uses the nursing process  Differs from POR b/c main perspective is “focus” - not problem  DAR: Data, Action, Response (PG 182)  Data: info that supports the stated focus or describes pertinent observations about pt  Action: nursing actions that address the focus, evaluation of present care plan and changes needed  Response: description of pts responses to medical or nursing care  Problem, Intervention, Evaluation (PIE) system  Problem-oriented system: documenting to nursing process & nursing Dx  The PIE method or APIE: Assessment, Problem, Intervention & Evaluation (PG 183)  Assessment: assessment completed each shift  Problem: problem list or list of Nursing Dx  Intervention: nursing actions performed, directed at resolution of the problem  Evaluation: outcomes of implemented interventions are documented • Book Resources PG 166-171: Nursing History & Assessment Tool PG 172: Brief Mental Status Evaluation PG 175: Standards of Psychiatric Nursing Practice PG 962-966: Mental Status Assessment PG 974-977: NANDAs PG 978-979: Client Behaviors/Nursing Dx PG 982-1000: Sample Client Teaching Guides Chapter 2: Mental Health/Historical and Theoretical Concepts • Practicing the Art & Science of Psychiatric Nursing o The focus is the Tx of human responses to mental health problems and psych disorders o It employs a purposeful use of self as its art and nursing psych neurobiology • Models of Treatment o Evidence Based Practice (EBP)  Practice which is scientifically grounded by which the best available research evidence clinical expertise and ptpreferences are used for making clinical decisions  Examples of Previous EBP procedures: Insulin Shock Therapy, Ice Therapy, Lobotomy o Recovery Therapy  Empowering those with mental illness to find meaning and satisfaction, realize potential and function at maximum level of independence • The Art of Nursing o Nurses use intuition, interpersonal skills, and therapeutic use of self to interact with pts for preventative care or in crisis o Caring  Empathic understanding, actions and patience on another’s behalf  Use of actions and words and being there for pts  Giving of self while preserving self (pay attention to your own mental self)  Nurse must be competent and capable of comforting  Nurse must be capable of nurturing o Attending  Intensity of presence or being there  In tune with the patient  Ability to make a human connection  Touching  Giving attentive physical care  Active listening  Using effective communication skills  These behaviors are learned and inherent in a true therapeutic relationship o Advocacy  Taking action regarding instances of incompetence, unethical, illegal or impaired practice by any member of the health team  Committing to pts health well-being and safety  Advising pts of their rights  Provides accurate and current information  Helps improve and expand mental health care for everyone • Concepts of Mental Health and Mental Illness o Change over time o Reflect change in:  Cultural norms  Society’s expectations and values  Professional biases  Political climate (funding) • Definitions Mental Illness:Maladaptive responses to stressors from the internal or external environment evidenced by thoughts feelings and behaviors that are incongruent with the local cultural norms and interfere with the individuals social occupational and or physical fx Mental Health:Successful performance of mental fx resulting in the ability to engage in productive activities enjoy fulfilling relationships and change or cope with adversity • 6 Indicators of Mental Health o (1) Positive attitude toward self o (2) Growth development and ability to achieve self-actualization o (3) Maintaining equilibrium o (4) Autonomy o (5) Accurate reality perception o (6) Achieved satisfactory role within environment • Factors Affecting Severity of Mental Illness o Support systems o Family influence o Cultural beliefs and values o Negative influences (bad neighborhood) o Environmental perceptions of mental illness o Labeling of people which encourages stigma (negative label) • DSM-IV-TR o Standard resource of mental illnesses published by the APA o A manual that presents guidelines and diagnostic criteria for various mental disorders o Evaluates individuals from numerous cultural/ethnic groups o Uses multiaxial system for Dx • Multiaxial Diagnostic System(PG 26) o A system that evaluates more than one presenting problem in order to define a comprehensive Dx which should guarantee an accurate Tx plan o Axis I: Mental Disorder  Focus of Tx – clinical dx o Axis II: Personality Disorders and Mental Retardation  It is possible to be dx with Axis I and Axis II at the same time, but often Axis II is referred to as deferred o Axis III: General Medical Conditions  Relevant to axis I and may be cause of abnormal behavior  Diabetes, HTN, GERD o Axis IV: Psychosocial and environmental problems  Legal, school, living arrangements, occupation, finances, marital status/family  Stressors in the environment (religion) o Axis V: Global Assessment of Functioning (GAF)  A single measure of the psychological, social and occupational functioning  Uses a scale of 0-100 • Book Resources PG 26-27 Box 2-2 for GAF Scale PG 967-973 Appendix C for Axis I and Axis II Dx Chapter 3: Theories • Theoretical Models o Nurses must have a basic knowledge of human personality development to understand maladaptive behavioral responses commonly seen in psych • PsychoAnalytic Theory (Freud) o Determined importance of early life development b/c it builds an individual’s basic character o He also pioneered psychotherapy – talk therapy that focuses on the complexity and inner workings of the mind and emphasizes environmental influences on its development and its stability o Organized the Structure of the Personality into the 3 Major Components:  ID: primitive, pleasure principle – impulsive and may be irrational  EGO: reality principle – rational self, experiences reality of the external world. Primary fx of the EGO is mediator to the maintain harmony between the id and the superego  SUPEREGO: perfection principle – conscious influenced by morals and ethics o Focuses on the 3 Layers of Mental Activity (conscious functioning)  Conscious: current awareness – thoughts, beliefs and feelings. Ability to recall a phone number  Pre-conscious: whatlies immediately below the surface, not currently the subject of our attention but easily accessible – bringing up a memory from long ago  Unconscious: primitive feelings, drives, memories and dreams • Psychosocial Development (Erikson)(PG 39 ) o 8 Stages from infancy to older adulthood describing influence of social processes on the development of the personality o Each stage consist of central age-appropriate tasks o Resolution of each stage can be positive or negative o Application to nursing: tailor care to pts developmental level • Humanistic Theory (Maslow)(PG 15) o Emphasized an individual’s motivation in the continuous quest for self-actualization o Uses a hierarchy of needs approach o Basic needs must be met before progressing to higher needs Chapter 12: Milieu Therapy (Environment) • Definitions Milieu: for psychiatric purposes means environment Milieu Therapy: structuring of the environmentin order to bring about behavioral changes and to improve psychological health and functioning • Basic Assumptions o Each individual’s health is to be realized and encouraged to grow o Every interaction is an opportunity for therapeutic interventions o The client owns his own environment o Each client owns his behavior o Peer pressure is a useful and powerful tool o Inappropriate behaviors are dealt with as they occur o Restrictions and punishment are to be avoided • Community Setting o The setting for psychiatric care is considered to be the foundation of the program o The reasons are:  Basic physiological needs are met  Physical facilities are conducive for meeting goals of therapy  A democratic form of self-government exists • Interdisciplinary Team o Care of the client is directed by a team to ensure appropriate assessments interventions and evaluations o May include:  Psychiatrist  Psychologist  Nurse  Metal health technician  Social worker  Activity therapist  School liaison  Spiritual advisor Chapter 19: Behavior Therapy • Definitions Behavior: the manner in which one acts the actions or reactions of individuals under specific circumstances A behavior is maladaptive when it is age inappropriate when it interferes with adaptive fx or when others misunderstand… • Classical Conditioning: Pavlov o Pavlov did experimental work with conditioning in order to manipulate behaviors o He introduced the concepts of:  Unconditioned responses  salivating when eating food and  Conditioned responses salivating when the bell rung • Operant Conditioning: Skinner o Skinner believed that the connection between a stimulus and a response is strengthened or weakened by the consequences of the response o It is usually utilized in the psychiatric setting as a reward system with rewards for positive behavior and consequences for negative behavior  Token system for positive behavior  Behavioral methods (time out) for negative behavior Chapter 20: Cognitive Therapy • Cognitive Therapy: A type of psychotherapy based on identifying negative thinking and emotions and restructuring them into positive thinking o Therapy is based on an individual’s cognition (awareness, perception, judgment and memory) and the appraisal of an event and the resulting emotions and behaviors o Usually a time limited therapy because if there are no positive results after a period of time then the pt should be reassessed for a new diagnosis • Cognitive Behavioral Therapy (CBT)(PG 333: Goals of Cognitive Therapy) o Aaron Beck Why do we do this?  The individual identifies thought distortions  Examines evidence for those thought distortions  Reformats negative thinking and replaces with more realistic thoughts  Learn to use healthy coping mechanisms in order to not return to thought distortions • Automatic Thoughts(PG 335: Examples of Automatic Thoughts) o Thoughts that occur rapidly in response to a situation and without rational analysis o They are often negative and based on erroneous logic o Schemas: (PG 336: Examples of Schemas)  Concepts that contain the individual’s fundamental beliefs and assumptions  Develop early in life from personal experience and can be reinforced throughout life  EX) One man acts out now… “All men are the same!” Chapter 4: Psychobiology & Psychopharmacology • Structure of the Brain (PG 53-54) o Alteration in cerebral functioning accounts for disturbances in behavior and mental experience o Mental disorders usually are based biologically and can be treated by psychopharmacology • Description of the Four Lobes o Frontal Lobe: Controls thought processes, executive functioning, mental activity, consciousness, perception of external world, emotional status, memory, voluntary motor activity, language and communication o Parietal Lobe: Controls sensory and motor functions such as touch, taste, pain perception, pressure, temperature, and language interpretation o Occipital Lobe: Controls visual fx, visual reception and interpretation ability to judge spatial relationships such as distance  Has own memory fx o Temporal Lobe: Controls auditory fx, sensory experience, memory, learning processing of fear and anxiety  The limbic system (emotional brain) is housed here • Limbic System (emotional brain) o Located in temporal lobe o The part of the brain that is associated with feelings of fear anxiety aggression love sexuality joy o Regulates social behaviors o Activity slowed by anti-anxiety drugs • Neurotransmitters (NTs) o Neurotransmitters are chemicals that convey information across synaptic gaps by:  Pre-synaptic neuron releases the neurotransmitter  Neurotransmitter diffused across synapse and locks into receptor site  After influencing the target receptor the neurotransmitter is either destroyed (dissolved by enzymes) or recycled to be used again (reuptake) • Role of NTs in Psychopharmacology(PG 62-63) o Most psychotropic drugs affect NTs in one of two ways:  Block NTs from entering receptor site on postsynaptic neuron  Prevent destruction of NTs at synapse by interfering with enzymes at the synapse and allow them to be used again o PG 73: Biological Implication of Psychiatric Disorders o PG 74: Diagnostic Procedures Used to Detect Altered Brain Functioning • Dopamine(mood & psychosis) o Dopamine fx includes regulation of movements and coordination, emotions and voluntary decision making ability o Also has a role in the pleasure center, such as sexuality or substance abuse o Dopamine Hypothesis:  Excessive levels are r/t psychotic symptoms of schizophrenia (excess) and mania (deficieny) • Norepinephrine(mood) o Neurotransmitter that produces activity resulting in the fight or flight response o It regulates mood, cognition, perception, locomotion, sleep and arousal o It is implicated in certain mood disorders such as mania, depression and in schizophrenia o Norepinephrine imbalance results:  Excess = mania  Deficiency = depression • Acetylcholine o Functions include sleep, arousal, pain, perception, coordination of movement and memory o Alterations in the neurotransmitter have been found in pts with Parkinson’s, Huntington’s and Alzheimer’s disease • Serotonin(mood) o Plays a role in sleep and arousal, libido, appetite, mood, pain, perception and aggression o Serotonin imbalance results:  Excess = mania  Deficiency = depression • GABA and Anxiety Disorders o GABA regulates anxiety o When GABA is not working correctly it will not regulate anxiety which allows it to increase o Antianxiety Medications:  Enhance GABA activity to decrease anxiety  Can cause excessive drowsiness  Tolerance and w/d associated with these drugs • Psychopharmacology o Psychotropic Medications (PG 79-80)  Most psychotropic medications have their effects at the synapse, producing changes in the neurotransmitter release and the receptors they bind to  Each category of medications antipsychotics, antidepressants have varying effects on the neurons and receptors therefore the therapeutic effects are experienced differently • Standard (Typical) Antipsychotics(neuroleptics) o These are the first generation older drugs and very effective for symptom reduction o There are many dangerous side effects especially EPS (extrapyramidal symptom) and tardive dyskinesia  Tardive dyskinesia can become irreversible (when the bigger side effects are showing) o Work on neurotransmitters to decrease positive symptoms of schizophrenia o Inhibits dopamine activity o Need to monitor for neuroleptic malignant syndrome, tardive dyskinesia o Examples: Thorazine, Haldol, Prolixin, Mellaril o Antidote to Haldol: Cogentin (used for EPS) • Atypical Antipsychotics o Very effective second generation drugs but very expensive o Target both dopamine and serotonin o There are fewer side effects o Affect both negative and positive symptoms of schizophrenia o Examples: Zyprexa, Resperal, Clozaril, Seroquel, Geodon, Abilify  Clozaril: used as a last resort due to the dangerous side effects of agranulocytosis (WBCs) PG 539-548 Psychotic Disorder Psychopharmacology PG 541 Antipsychotic • Mood Stabilizers o Believed that there are many neurotransmitter fx that are altered with mood stabilizers o Lithium  Acts intracellularly to stabilize electrical activity and decrease mania  Side Effects: fluid imbalance, cardiac and kidney disorders, seizures  Must monitor blood levels due to the narrow therapeutic index between high therapeutic level and toxicity  If unmonitored toxicity can be fatalTherapeutic Levels: .5 to 1.6  Patients NEED to drink 8 glasses of water a day o When apt cannot use Lithium then use anticonvulsants which enhance GABA and decrease mania  Examples: Depakote, Tegretol, Trileptal, Neurontin, Topamax  Lamictal: should be watched for a fatal autoimmune response manifested through a skin rash PG 613-625 Mood Disorders Psychopharmacology-Bipolar PG 614-617 Mood Stabilizing Agents PG 681-621 Interactions of Mood Stabilizing Agents PG 622-623 Side Effects of Mood Stabilizing Agents • Antidepressants o Selective Serotonin Reuptake Inhibitors (SSRIs)  Block the reuptake of serotonin which increases available serotonin in the synapses  Monitor for suicidal impulses, sexual dysfunction (noncompliance issues with men)  Slow tapering to avoid withdrawal • Tricyclic Antidepressants o Block reuptake of serotonin and norepinephrine and block both receptors allowing for more to be available o Monitor for dangerous cardiac side effects, weight gain o Problems with noncompliance more with women (r/t to weight gain) • Monoamine Oxidase Inhibitors (MAOIs) o Inhibit both types of enzymes (MOA A and MAO B) that metabolizes serotonin and norepinephrine o Whatever norepinephrine is left over can cause a dangerous elevation in BP o Must be on a low tyramine (enzyme) diet so as not to potentiate HTN leading to stroke  Tyramine: aged cheeses, red wines, raisins, yogurt, sour cream o Cannot mix SSRIs and MAOIs together or the effect will be fatal  Need to wait 2 weeks to clear out of system before starting new med PG 582-589 Mood Disorders – Depression PG 583-584 Medications Used in Tx of Depression PG 585-586 Diet and Drug Restrictions for MAOI Therapy • Antianxiety Medications o Also known as anxiolytics or tranquilizers o Used in treatment of anxiety disorders/symptoms, ETOH w/d and convulsive disorders o They potentiate the effects of GABA thereby producing a calming effect o Examples: Valium, Librium, Xanax PG 633-634: Anxiolytic Medications PG 660-663: Antianxiety Agents • Resources Medication therapy for other disorders can be found on: PG 385: Autistic Disorders PG 394-397: ADHD PG 410: Tourett’s Disorder PG 444-448: Medical Treatments PG 445-446: Medications Used in the Treatment of Clients with Dementia PG 501-505: Pharmacotherapy Chapter 13: Crisis and Disaster • Concept of Crisis o Crises are acute time limited occurrences experienced as overwhelming emotional reactions o The individual’s usual coping mechanisms become ineffective in dealing with the threat o Crisis represents struggle for equilibrium  Presents both danger to personality, organization, as well as opportunity for personal growth • Phases of Crisis o Phase 1: person is confronted by conflict or problem that threatens self and causes anxiety. Problem solving techniques are employed o Phase 2: If usual defensive response fails and threat persists, anxiety continues to rise and person feels helpless o Phase 3: Trial and error attempts are made to cope. May be successful but if not anxiety can rise to panic levels o Phase 4: if problem is not solved and new coping skills are ineffective, anxiety can overwhelm person. Emotions are labile and psychotic thinking may be present • Assessment Guidelines o Patient’s perception of precipitating event o Assess patient’s situational supports o Assess patient’s personal coping skills • Types of Crises o Dispositional/Situational: occur when a life event upsets an individual’s equilibrium  Arises from external rather than internal source: usually unanticipated  Usually involves a loss or change that threatens a person’s self-concept and self-esteem  Examples: loss of job, death of loved one, change in financial status, divorce  A support system will help determine the severity of the crisis response o Maturational/Life Transitional: developmental events requiring role changes  Related to identified developmental stages occurring throughout life: marriage, baby, aging, retirement  Each new stage requires new coping mechanisms  Former coping skills will not work with the new crises so for a time the person will be without effective defenses o Adventitious/Traumatic Stress  Crisis or disaster not part of everyday life and should not happen  Usually a large scale response which can leave responders overwhelmed and exhausted  Arise from  Natural disaster (tornado, floods)  National disaster (bombings, terrorism)  Crime of violence (rape, assault, murder, abuse) o Developmental: occurs in response to unresolved issues in life  Example: An pt dealing with every day pressures aggressively because he/she was raised by an abusive parent o Emotional/Psychiatric  A change in routine or a stressful event that triggers disequilibrium for someone with an existing altered mental status  Focus becomes potential hospitalization and safety precautions • Goals of Crisis Intervention o Goals of Crisis Intervention:  Resolution of immediate crisis  Return individual to pre-crisis level of functioning with new ways of problem solving  May require inpatient hospitalizations depending on the ineffective coping mechanisms • Role of the Nurse o Assessment: gathering and analyzing information o Diagnose: the problem o Planning: selecting care appropriate nursing actions o Intervention: implementing actions o Evaluation: assessing outcomes • Levels of Nursing Care for Crisis Intervention o Primary: Promote mental health and decrease incidence of crisis, avoidance of hospitalization o Secondary: Interventions to prevent prolonged anxiety and personality disorganization, occurs during hospitalization o Tertiary: Support for those who have experienced severe crisis and are now recovering o Goal: facilitate optimal level of functioning, occurs after hospitalization Chapter 17: Anger and Aggression • Anger and Aggression o It is critical for a psychiatric RN to know the difference between anger and aggression in order to be able to anticipate needs o Anger is not a primary emotion but a necessary one for survival o Depending on how a person uses anger will determine their level of preparedness to deal with stressors • Anger o Normal healthy emotion that serves as a warning signal and alerts us to a potential threat or trauma o Can range from mild irritation to white hot energy o The expression of anger islearned - the emotion is not PG 296: The Functions of Anger • Aggression o Means: “to assault or attack” o Aggression is one way to express anger and is a response aimed at inflicting pain or injury o It is a destructive use of anger • Theories Related to Anger and Aggression o Neurobiological: brain differences in a person with anger issues o Genetics: anger issues may run in families o Psychological: inappropriate coping mechanisms and inability to recognize triggers • Nursing Assessment o The single best predictor of violence is a history of violence o Identify factors for violent outcomes:  Angry, irritable affect, hyperactivity, increasing anxiety, verbal abuse, loud voice  History of recent acts of violence  Suspiciousness or paranoid thinking  Substance abuse  Possession of a weapon  Affect is how you exhibit emotion • Stages of the Violent Cycle o Violence occurs in a set if stages that a trained professional should be able to recognize and attempt to de-escalate  Pre-assaultive Stage  Assaultive Stage  Post-assaultive Stage • Pre-assaultive Stage (de-escalation stage) o Patient becomes agitated o Staff should be able to recognize anxiety and intervene with distraction or 1:1 interaction o If anxiety continues to escalate staff uses verbal and physical techniques for de-escalation • Assaultive Stage: o Patient has become physically aggressive toward target. May include punching, slapping, kicking, spitting o Staff may have to use seclusion, restraint, and/or medication as means to contain situation to avoid further injury • Post-Assaultive Stage: after crisis o Critical incident debriefing: staff reviews incident with patient as well as among themselves • Role of the Psychiatric Nurse o Nurse uses techniques to decrease anxiety:  Distraction  Patient education regarding coping mechanisms  Meeting needs before patient can react  Counseling in 1:1 sessions to allow patient to vent feelings appropriately • Treatment for Anger/Aggression o Psychotherapy: cognitive-behavioral approaches to teach anger management skills o Behavioral Interventions based on social learning theory (use of token economy) o Group therapy o Psychopharmacology