Mental Health #1

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Mental health is defined as

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successful performance of mental health functions, resulting in the ability to engage in productive activities, enjoy fulfilling relationships and change or cope with adversity.

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Mental health provides people with the

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capacity for rational thinking, communication skills, learning, emotional growth, resilience, and self-esteem

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Mental illness is considered a clinically significant….

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a clinically significant behavioral or psychological syndrome experienced by a person and marked by distress, disability, or the risk of suffering disability or loss of freedom

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Axis I refers to

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axis that is the collection of signs and symptoms that together constitute a particular disorder, for example, schizophrenia.

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Axis II refers to

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axis that is of personality disorders and mental retardation. For example a heroin addict would be diagnosed on ____ as having a substance-related disorder, this client might have a long-standing antisocial personality disorder, which would be noted on ______.

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Axis III

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axis that the physician indicates any general medical conditions believed to be relevant to the mental disorder in question.

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Axis IV

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axis that is for reporting psychosocial problems that may affect the diagnosis, treatment, and prognosis of a mental disorder (occupational problems, interpersonal difficulties, etc.).

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Axis V

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axis also called Global Assessment functioning (GAF), gives an indication of the person’s best level of psychological, social, and occupational functioning during the preceding year, rated on a scale of 1-100(where 1 indicates persistent danger of severely hurting oneself or others, and 100 indicates superior functioning in a variety of activities at the time of the evaluation, as well as the highest level of functioning for at least a few months during the past year).

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GAF

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Global Assessment functioning

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Psychiatric mental health nursing includes the diagnosis and treatment of human responses to actual or potential mental health problems. The North American Diagnosis Association (NANDA) describes…

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a nursing diagnosis as a clinical judgment about individual, family, or community responses to actual or potential health problems and life processes.

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DSM-IV-TR is used to

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diagnose a psychiatric disorder, whereas a well-defined nursing diagnosis provides the framework for identifying appropriate nursing interventions for dealing with the phenomena a client with a mental health disorder is experiencing, for example, hallucinations, low self-esteem issues, impaired ability to function (in a job and family), and so on.

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In determining the mental health or mental illness of the individual, we must consider

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"The norms and the influences of culture. Cultures differ not only in their views regarding mental illness but also in the types of behavior categorized as mental illness. For example dx. of anorexia.

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Sigmund Freud

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Theorist that revolutionized thinking about mental health disorders with his groundbreaking theory of personality structure, levels of awareness, anxiety, the role of defense mechanisms, and the stages of psychosexual development, as well as his insistence on psychological treatment of behavioral symptoms.

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Levels of awareness: Conscious

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part of the mind as the tip of the iceberg. It contains all of the material that the person is aware of at any one time.

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Preconscious

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Just below the surface of the awareness is the preconscious, which contains material that can be retrieved rather easily thru conscious effort.

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Unconscious

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Includes all the repressed memories, passions, unacceptable urges lying deep below the surface.

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Personality structure:Id

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"At birth we are all this. Is the source of all drives, instincts, reflexes, needs, genetic inheritance, and capacity to respond, as well as all the wishes that motivate us. Can not tolerate frustration and seeks to discharge tension and return to a more comfortable level of energy. Lacks the ability to problem solve, it is not logical and operates according to the pleasure principal.

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The ego

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Develops because the needs, wishes and demands of the id can not be satisfactorily met thru primary processes and reflex action. Emerges sometime in the 4th or 5th month of life, is the problem solver and reality tester. Uses secondary processes to negotiate a solution with the outside world. E.g. a hungry man feels hunger. The ____ plans where and what to eat.

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The process of ego is called what?

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The process is called reality testing because the individual is factoring in reality to implement a plan to decrease tension. It is the ___ that coordinates the expression of self and is the mediator of various demands from the id, superego, and reality.

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The superego

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The last portion of personality to develop. Represents the moral component of personality. It is internalized from parents. Represents the ideal rather than the real. It seeks perfection as oppose to pleasure or engaging reason. In a mature, well-adjusted person all 3 work together as a team under the leadership of the ego.

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Sullivan’s Interpersonal Theory

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the purpose of all behavior is to get needs met thru interpersonal interactions and decrease and avoid anxiety. He viewed anxiety as a key concept and defined it as any painful feeling or emotion arising from social insecurity or blocks to getting biological needs satisfied.

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Sullivan

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believed that therapy should educate patients and assist them in gaining personal insight. Would insist that the nurse interact with the pt. as an authentic human being. Mutual respect, empathy, unconditional acceptance of the pt. are the essential ingredients of the therapeutic relationship.

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Sullivan

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first used the term participant observer, which indicates that professional helpers cannot isolate from the therapeutic situation if they are to be effective.

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participant observer

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indicates that professional helpers cannot isolate from the therapeutic situation if they are to be effective.

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Mutual respect, empathy, unconditional acceptance of the pt

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Are the essential ingredients of the therapeutic relationship.

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Erickson’s Ego Theory

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Placed great emphasis on the role of the ego. He also stressed that the individual’s development is influenced by more than the limited mother-child-father relationship but also by society.

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Erickson

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He created a developmental model that spans the full life cycle. Nurses use this model to identify what types of developmental arrests the individual went thru to apply appropriate interventions.

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Reinforcer

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refers to the consequence of behavior and refers to anything that increases the behavior.

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Positive reinforcer

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Increases positive behavior and negative reinforces the negative behavior. Behavior modification programs based on this theory have been successful in altering targeted behavior.

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"

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reinforcers: positive

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Biological Theories

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Focuses on the neurological, chemical, biological, and genetic issues and seeks to understand how the body and brain interact to create emotions, memories, and perceptual experiences.

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A biological perspective

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Views abnormal behavior as part of the disease process or a defect and seeks to stop or alter that disease process or defect; It locates the disease in the body-usually in the limbic system of the brain and the synapse receptor sites of the central nervous system and uses drugs, diet, or surgery to alter the behavior.

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Peplau

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Was the first nurse that used interpersonal approach to nurse client relationship. She shifted the focus from what nurses do to patients to what nurses do with patients.

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Peplau

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Believed that is what essential for nurses is to observe not just the client’s behavior but also their own. S/he constantly reminds nurses to look beyond the illness and to “care for the person as well as the illness” and to “think exclusively of pts. as persons.”

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Positive Transference

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is developed when the client experiences feelings toward the nurse or therapist that were originally held toward significant others.

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Negative transference

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may also occur depending on the persons past experiences.

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Countertransference

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Is a health care worker’s unconscious and personal response to the client. E.g. the client reminds you of someone you don’t like and you react to the client “as if” the client is that individual.

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Cognitive Therapy: Aaron Beck

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This is based on the underlying theoretical principal that how people think and behave is largely determined by the way in which they think about the world and their place in the world. Clients are taught to challenge their negative thoughts and to replace them with positive thoughts. Homework assignments play an important role in this therapy.

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Milieu Therapy

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It is an all inclusive term that recognizes the people, setting, structure, and emotional climate as all important to healing. Takes naturally occurring events in the environment and uses them as rich learning opportunities for clients. Nurses constantly should assess this and provide a safe environment for the client(e.g. suicidal client).

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Examples of structured learning

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Community meetings, group activites and individual therapy sessions, recreational activities, psychoeducational classessuch as learning about medication side effects.

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What do psych. Nurses do?

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The main focus is to promote and maintain optimal mental functioning, prevent mental illness (or further dysfunction), and to help clients regain or improve their coping abilities.

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Psych nursing interventions

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Counseling, milieu therapy, promotion of self-care activites, psychobiological interventions, health teaching, case management, health promotion and health maintenance.

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Rights of hospitalized clients:

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The psychiatric team has an obligation to balance the client’s needs for safety with his/her rights as a citizen. All mental health facilities provide a written statement of these rights, often with copies of applicable state laws attached. Each student should be familiar with the unit’s procedures for 1. Suicide precautions, 2. Seclusion and restraints, 3. Client elopement.

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Nursing on the In-patient unit

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Nurses assume the bulk of the management of the daily functioning of the inpatient mental health unit. Nurses are responsible for the maintenance of the therapeutic milieu. Specific tasks, such as community meetings, special group activities, goal setting meetings are conducted by the nurses.

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Preparation for Discharge:

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Careful assessment and interventions should be done to prepare clients for discharge to prevent hospitalizations. These include teaching the clients better coping skills, medication management, psychoeducational groups.

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writ of habeas corpus

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to “free the person” is the procedural mechanism used to challenge unlawful detention by the government. A client can institute a court proceeding to seek a judicial discharge

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Voluntary admission

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is sought by the client or the client’s guardian thru a written application to the facility. These clients have the right to demand and obtain a release.

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Involuntary admission (commitment):

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is made without the client’s consent. Generally, it is necessary when a person is in need of psychiatric tx., presents a danger to self or others, or is unable to meet his/her own basic needs.

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Emergency involuntary hospitalization

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Most states provide for emergency involuntary hospitalization or civil commitment for a specific period (1-10 days on average) to prevent dangerous behavior that is likely to cause harm to self or others. Police officers, physicians, and mental health professionals may be designated by statute to authorize the detention of mentally ill person who are a danger to themselves or others.

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Release from the hospital depends on?

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the client’s admission status. Clients who sought informal or voluntary admission, as previously discussed, have the right to request and receive release.

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Tx. must meet the following criteria:

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"The environment must be humane, Staff must be qualified and sufficient to provide adequate tx., The plan of care must be individualized.

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Right to refuse tx.

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A client may also withdraw consent at any time. Retraction of consent previously given must be honored, whether it is a verbal or written retraction. However, the mentally ill client’s right to refuse tx. with psychotropic drugs has been debated in the courts based partly on the issue of client’s competency to give or withhold consent to tx. and their status under the civil commitment statutes.

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The Tarasoff:

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The Psychiatric clinician has a duty to worn the client’s potential victim of potential harm.

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Violence:

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Violent behavior is not acceptable in our society. Nurses must protect themselves in both institutional and community settings. Good judgment means not placing oneself in a potentially violent situation. Nurses as citizens have the same rights as clients not to be threatened or harmed.

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Assessment contains:

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"Mental status exam (MSE), Psychsocial, Physical, History, Interviews

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Psychiatric nursing assessment: the purpose is to:

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1. Establish report 2. Obtain understanding of the current problem. Assess for risk factors affecting the safety of the client or others (e.g. suicide, self-harm, assault or violence, substance use withdrawal, allergies). 3. Assess current level of psychsocial functioning and status. 4. Perform MSE 5. Identify what the client and family hope to gain from tx. 6. Identify what behaviors, beliefs, or other areas of client life need to be modified or effect positive change. 7. Formulate a plan of care.

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Therapeutic nurse-client relationship is

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is the basis, the very core, of all psychiatric nursing tx. approaches regardless of the specific aim. The relationship is consistently focused on the client’s problem and needs.

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Nurses must get their needs met

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outside of this relationship. When the nurse “wants the client to like them, do as they suggest, be nice to them,” the needs of the client can not be adequately met and the interaction could be detrimental (non-therapeutic) to the client.

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The key ingredient in building trust

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Genuineness or self-awareness of one’s feelings as they arise within the relationship and the ability to communicate them when appropriate. It is conveyed by actions such as holding behind the role of a nurse, listening to and communicating with others without distorting messages, and being clear and concrete in communications with others.

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Empathy

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means that one understands the ideas expressed, as well, as the feelings that are present in the other person. It includes: accurately perceiving the client’s situation, perspective and feelings. Communicating one’s understanding to the client and checking with the client for accuracy. Acting on this understanding in a helpful (therapeutic) way towards the client.

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Attending

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refers to an intensity of presence of being with the client. Body posture, eye contact, body lanuage (the degree of relaxation) are all part of the attending behavior.

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Helping the clients build recourses:

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The nurse becomes aware of the client’s strengths and encourages the client to work at his/her optimal functioning. The nurse does not act for client unless absolutely necessary.

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Peplau (1952, 1999) described the nurse-client relationship as

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"evolving thru interlocking, overlapping phases. The following distinctive phases of the nurse-client relationship are generally recognized: 1. Orientation 2. Working 3. Termination

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The content and direction of the interview are decided by who?

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the client. The client leads. Safe and secure environment for the nurse and the client is a must. Seating should be that the conversation can take place in a normal tone of voice. Eye contact is important.

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How to start the interview:

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After introductions the nurse turns the conversation over to the client, e.g. “tell me the reason that you are in the hospital.”

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Communication can be

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verbal and non-verbal. When we speak we communicate our beliefs and values. Communicate perceptions and meaning. Convey interest and understanding or insult and judgment. Convey messages clearly or convey conflicting or implied messages. Convey clear, honest feelings or disguised, distorted feelings. Even if the nurse and the client have the same cultural background the meaning of the word may not be exactly the same.

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Touch.

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The therapeutic use of touch is a basic aspect of the nurse-client relationship. Touch is normally perceived as a gesture of warmth and caring, and friendship. However, we need to be very careful in a psychiatric setting of the use of touch. In this setting it can mean invitation to intimacy for some clients or invasion of privacy.

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Use of silence

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Silence can feel uncomfortable and frighten the client and the nurse. Silence is not the absence of communication. It can have many significant meanings for the client. The client may need space to formulate his/her thoughts. It can mean resistance especially in the orientation phase. Remember that is is serving some kind of a function.

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Active listening includes the following:

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 Observing the client’s non-verbal behavior. Listening to and understanding the verbal messages. Listening for “false notes” inconsistencies and clarifying. Providing the client feedback about him/herself and reframing. You are tracking and present with the client.

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Degree of openness:

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remember no self-disclosure. Do not give them your phone number, address, do not talk about yourself. It is all about the client. Ask open ended questions to have them elaborate about what they are talking about. E.g. tell me-----

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Closed ended:

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Is your mother alive. Yes or a no question. Closed ended questions will obstruct the communication process.

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Obstructive techniques:

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1. Excessive questioning will overwhelm the client. Also it conveys lack of respect. Do not probe. Let the client tell you what they are comfortable about telling you. You need to ask more questions if the client e.g is suicidal to keep them safe.

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Obstructive techniques:

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Giving approval and disapproval. E.g. “you look great in that dress.” They may see this as a way of pleasing the nurse. Disapproval implies judgment. Observation should be made instead. E.g. “Give me two examples how cheating can affect your goal of graduating.”

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Obstructive techniques:

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Why questions imply criticism and judgment. E.g. why are you late? It is much more useful to ask what is happening rather than why it is happening. E.g. “I wonder what happened that you are late?”