Key Points Units 1 and 2 Psychiatric Nursing

Chapter 1 KEY POINTS TO REMEMBER

Mental health and mental illness are not either/or propositions, but end points on a continuum. Resilience is a personal characteristic that helps to promote adaptation to stressful circumstances. This is a trait that can be promoted and improved to strengthen responses to stress. Culture influences behavior, and symptoms may reflect a person's cultural patterns or beliefs. Symptoms must be understood in terms of a person's cultural background. The United States mental health care system has been influenced by scientific shifts in thinking, broad-reaching reports, and legislative initiatives. The consumer and recovery movement shifted the focus of mental health care from something done to patients to something consumers choose. The study of epidemiology can help identify high-risk groups and behaviors, which can lead to a better understanding of the causes of some disorders. Incidence provides us with the number of new cases in a given period of time. Prevalence rates help us to identify the proportion of a population experiencing a specific mental disorder at a given time. Comorbid conditions are those disorders that occur at the same time as another condition. For example, a person with schizophrenia may also have comorbid diabetes, depression, and hypertension. The five axes of the DSM-IV-TR make it possible for clinicians to make a more holistic and realistic assessment of their patients and thus allow for more comprehensive and appropriate interventions. Psychiatric mental health nurses work with a broad population of patients in diverse settings to promote optimal mental health. They may

be prepared as basic level nurse generalists, or they may gain additional training and function as advanced practice nurses. Due to social, cultural, scientific, and political factors, the future holds many challenges and possibilities for the psychiatric mental health nurse.

Chapter 2 KEY POINTS TO REMEMBER

Sigmund Freud advanced the first theory of personality development. Freud articulated levels of awareness (unconscious, preconscious, conscious) and demonstrated the influence of our unconscious behavior on everyday life, as evidenced by the use of defense mechanisms.

 Freud identified three psychological processes of personality (id, ego, superego) and described how they operate and develop. Freud articulated one of the first modern developmental theories of personality, based on five psychosexual stages. Various psychoanalytic therapies have been used over the years. Currently a short-term, time-limited version of psychotherapy is common. Erik Erikson expanded on Freud's developmental stages to include middle age through old age. Erikson called his stages psychosocial stages and emphasized the social aspect of personality development. Harry Stack Sullivan proposed the interpersonal theory of personality development, which focuses on interpersonal processes that can be observed in a social framework. Hildegard Peplau, a nursing theorist, developed an interpersonal theoretical framework that has become the foundation of psychiatric mental health nursing practice. Abraham Maslow, the founder of humanistic psychology, offered the theory of self-actualization and human motivation that is basic to all nursing education today. Cognitive-behavioral therapy is the most commonly used, accepted, and empirically validated psychotherapeutic approach. A biological model of mental illness and treatment dominates care for psychiatric disorders. Milieu therapy is a philosophy of care in which all parts of the environment are considered to be therapeutic opportunities for growth and healing. The milieu includes the people (patients and staff), setting, structure, and emotional climate.

Chapter 3 KEY POINTS TO REMEMBER

All actions of the brainsensory, motor, and intellectualare carried out physiologically through the interactions of nerve cells. These interactions involve impulse conduction, neurotransmitter release, and receptor response. Alterations in these basic processes can lead to mental disturbances and physical manifestations. In particular, it seems that excess activity of dopamine is involved in the thought disturbances of schizophrenia, and deficiencies of norepinephrine, serotonin, or both underlie depression and anxiety. Insufficient activity of GABA also plays a role in anxiety. Pharmacological treatment of mental disturbances is directed at the suspected neurotransmitter-receptor problem. Antipsychotic drugs decrease dopamine, antidepressant drugs increase synaptic levels of norepinephrine and/or serotonin, and antianxiety drugs increase the effectiveness of GABA or increase 5-HT and/or norepinephrine.

 Because the immediate target activity of a drug can result in many downstream alterations in neuronal activity, drugs with a variety of chemical actions may show efficacy in treating the same clinical condition. Thus newer drugs with novel mechanisms of action are being used in the treatment of schizophrenia, depression, and anxiety. Unfortunately, agents used to treat mental disease can cause various undesired effects. Prominent among these can be sedation or excitement, motor disturbances, muscarinic blockage, antagonism, sexual dysfunction, and weight gain. There is a continuing effort to develop new drugs that are effective, safe, and well tolerated.

Chapter 4 KEY POINTS TO REMEMBER

Inpatient care has increasingly become more acute and short-term. Private insurers and a variety of governmental sources fund inpatient psychiatric care. Inpatient psychiatric mental health nursing requires strong skills in management, communication, and collaboration. The nurse plays a leadership role and also functions as a member of the multidisciplinary treatment team. The nurse advocates for the patient and ensures that the patient's rights are protected. Monitoring the environment and providing for safety are important components of good inpatient care. Psychiatric mental health nurses are skilled in protecting patients from suicidal impulses and aggressive behavior. Basic level nursing interventions include admission, providing a safe environment, psychiatric and physical assessments, milieu management, documentation, medication administration, and preparation for discharge to the community. Documentation is an important form of communication to promote consistency in patient care and justify the patient's stay in the hospital. Discharge planning begins on the day of admission and requires input from the treatment team and the community mental health provider.

Chapter 5 KEY POINTS TO REMEMBER

Community psychiatric mental health nursing has historical roots dating to the 1800s and has been significantly influenced by public policies. Deinstitutionalization brought promise, as well as problems, for people with chronic, serious mental illness. The basic level community psychiatric mental health nurse practices in many traditional and nontraditional sites. In the multidisciplinary team, the community psychiatric mental health nurse functions as a biopsychosocial care manager. The continuum of psychiatric treatment includes numerous community treatment alternatives with varying degrees of intensity of care. The community psychiatric mental health nurse needs access to resources to address ethical dilemmas encountered in clinical situations. There are still barriers to mental health care that the community psychiatric mental health nurse may be able to diminish through daily practice.

Chapter 7 KEY POINTS TO REMEMBER

The states power to enact laws for public health and safety and for

the care of those unable to care for themselves often pits the rights of society against the rights of the individual. Psychiatric mental health nurses frequently encounter problems requiring ethical choices. The nurse's privilege to practice carries with it the responsibility to practice safely, competently, and in a manner consistent with state and federal laws. Knowledge of the law, the ANA's Code of Ethics for Nurses, and the Standards of Practice and Professional Performance from the Psychiatric-Mental Health Nursing: Scope and Standards of Practice are essential for providing safe, effective psychiatric mental health nursing care and will serve as a framework for decision making.

Chapter 8 KEY POINTS TO REMEMBER

The nursing process is a six-step problem-solving approach to patient care. The primary source of assessment is the patient. Secondary sources of information include family members, neighbors, friends, police, and other members of the health team.

 A professional translator often is needed to prevent serious misunderstandings during assessment, treatment, and evaluation with nonEnglish speaking patients. The assessment interview includes gathering objective data (mental or emotional status) and subjective data (psychosocial assessment). Medical examination, history, and systems review round out a complete assessment. Assessment tools and standardized rating scales may be used to evaluate and monitor a patient's progress. Determination of the nursing diagnosis (NANDA-I) defines the practice of nursing, improves communication between staff members, and assists in accountability of care. A nursing diagnosis consists of (1) an unmet need or problem, (2) an etiology or probable cause, and (3) supporting data. Outcomes are variable, measurable, and stated in terms that reflect a patient's actual state. NOC provides 385 standardized outcomes. Planning involves determining desired outcomes. Behavioral goals support outcomes. Goals are short, specific, and measurable; indicate the desired patient behavior(s); and include a set time for achievement. Planning nursing actions (using NIC or other sources) to achieve outcomes includes the use of specific principles. The plan should be (1) safe, (2) compatible with and appropriate for implementation with other therapies, (3) realistic and individualized, and (4) evidence based whenever possible. NIC provides nurses with 542 standardized nursing interventions applicable for use in all settings. Psychiatric mental health nursing practice includes four basic level interventions: coordination of care, health teaching and health promotion, milieu therapy, and pharmacological, biological, and integrative therapies. Advanced practice interventions are carried out by a nurse who is

educated at the master's level or higher. Nurses certified for advanced practice psychiatric mental health nursing can prescribe certain medications, practice psychotherapy, and perform consulting work. The evaluation of care is a continual process of determining to what extent the outcome criteria have been achieved. The plan of care may be revised based on the evaluation. Documentation of patient progress through evaluation of the outcome criteria is crucial. The medical record is a legal document and should accurately reflect the patient's condition, medications, treatment, tests, responses, and any untoward incidents.

Chapter 10 KEY POINTS TO REMEMBER

Knowledge of communication and interviewing techniques is the foundation for development of any nurse-patient relationship. Goaldirected professional communication is referred to as therapeutic communication. Communication is a complex process. Berlo's communication model has five parts: stimulus, sender, message, medium, and receiver. Feedback is a vital component of the communication process for validating the accuracy of the sender's message. A number of factors can minimize, enhance, or otherwise influence the communication process: culture, language, knowledge level, noise, lack of privacy, presence of others, and expectations. There are verbal and nonverbal elements in communication; the nonverbal elements often play the larger role in conveying a person's message. Verbal communication consists of all words a person speaks. Nonverbal communication consists of the behaviors displayed by an individual, in addition to the actual content of speech. Communication has two levels: the content level (verbal speech) and the process level (nonverbal behavior). When content is congruent with process, the communication is said to be healthy. When the verbal message is not reinforced by the communicator's actions, the message is

ambiguous; we call this a double (or mixed) message. Cultural background (as well as individual differences) has a great deal to do with what nonverbal behavior means to different individuals. The degree of eye contact and the use of touch are two nonverbal behaviors that can be misunderstood by individuals of different cultures. There are a number of therapeutic communication techniques nurses can use to enhance their nursing practices. There are also a number of nontherapeutic communication techniques that nurses can learn to avoid to enhance their effectiveness with people. Most nurses are most effective when they use nonthreatening and open-ended communication techniques. Effective communication is a skill that develops over time and is integral to the establishment and maintenance of a therapeutic relationship. The clinical interview is a key component of psychiatric mental health nursing, and the nurse must establish a safe setting and plan for appropriate seating, introductions, and initiation of the interview. Attending behaviors (e.g., eye contact, body language, vocal qualities, and verbal tracking) are key elements in effective communication. A meaningful therapeutic relationship is facilitated when values and cultural influences are considered. It is the nurse's responsibility to seek to understand the patient's perceptions.

Chapter 15 KEY POINTS TO REMEMBER

Schizophrenia is a biological disorder of the brain. It is not one disorder but a group of disorders with overlapping symptoms and

treatments. The primary differences among subtypes involve the spectrum of symptoms that dominate, their severity, the impairment in affect and cognition, and the impact on social and other areas of functioning. Psychotic symptoms are often more pronounced and obvious than are symptoms found in other disorders, making schizophrenia more likely to be apparent to others and increasing the risk of stigmatization. Neurochemical (catecholamines and serotonin), genetic, and neuroanatomical findings help explain the symptoms of schizophrenia. However, no one theory accounts fully for the complexities of schizophrenia. When the nurse works with patients with schizophrenia, four categories of symptoms may be evident. The positive and negative symptoms of schizophrenia are two of the major categories of symptoms. Symptoms vary considerably among patients and fluctuate over time. The positive symptoms of schizophrenia (e.g., hallucinations, delusions, associative looseness) are more pronounced and respond best to antipsychotic drug therapy. The negative symptoms of schizophrenia (e.g., social withdrawal and dysfunction, lack of motivation, reduced affect) respond less well to antipsychotic therapy and tend to be more debilitating. The degree of cognitive impairment warrants careful assessment and active intervention to increase the patient's ability to adapt, function, and maximize the ultimate quality of life. Comorbid depression must be identified and treated to reduce the potential for suicide, substance abuse, nonadherence, and relapse. Some applicable nursing diagnoses include Disturbed sensory perception, Disturbed thought processes, Impaired communication, Ineffective coping, Risk for self-directed or other-directed violence, and Impaired family coping.

 Outcomes are chosen based on the type and phase of schizophrenia and the patient's individual needs, strengths, and level of functioning. Short-term and intermediate indicators are also developed to better track the incremental progress typical of schizophrenia. Interventions for people with schizophrenia include trust-building, therapeutic communication techniques, support, assistance with selfcare, promotion of independence, stress management, promotion of socialization, psycho-education to promote understanding and adaptation, milieu management, cognitive-behavioral interventions, cognitive enhancement/remediation techniques, and medication administration. Because antipsychotic medications are essential in the care of patients with schizophrenia, the nurse must understand the properties, adverse and toxic effects, and dosages of conventional and atypical antipsychotics and other medications used to treat schizophrenia. The nurse helps the patient and family understand and appreciate the importance of medication to recovery. Schizophrenia can produce countertransference responses in staff; clinical supervision and self-assessment help the nurse remain objective and therapeutic.

Chapter 23 KEY POINTS TO REMEMBER

A crisis is not a pathological state but a struggle for emotional balance. Crises offer opportunities for emotional growth but can also lead to personality disorganization. There are three types of crisis: maturational, situational, and adventitious. Crises are usually resolved within 4 to 6 weeks. Crisis intervention therapy is short term, from 1 to 6 weeks, and focuses on the present problem only. Resolution of a crisis takes three forms: a patient emerges at a higher level, at the pre-crisis level, or at a lower level of functioning. Social support and intervention can promote successful resolution. Crisis therapists take an active and directive approach with the patient in crisis.

 The patient is an active participant in setting goals and planning possible solutions. Crisis intervention is usually aimed at the mentally healthy patient who generally is functioning well but is temporarily overwhelmed and unable to function. The crisis model can be adapted to meet the needs of patients in crisis who have long-term and persistent mental problems. The steps in crisis intervention are consistent with the steps of the nursing process. Specific qualities in the nurse that can facilitate effective intervention are a caring attitude, flexibility in planning care, an ability to listen, and an active approach. The basic goals of crisis intervention are to reduce the individual's anxiety level and to support the effort to return to the patient's pre-crisis level of functioning. Critical incident stress debriefing is a group approach that helps groups of people who have been exposed to a crisis situation.

Chapter 25 KEY POINTS TO REMEMBER

Angry emotions and aggressive and violent actions are difficult targets for nursing intervention. Nurses benefit from an understanding of how the angry, aggressive, or violent patient should be handled. Understanding patient cues to escalating aggression, appropriate goals for intervention for individuals in a variety of situations, and helpful nursing interventions is important for nurses in any setting. The expression of anger can lead to increased anger and to negative physiological changes. Psychosocial, cognitive, and biological theories provide explanations for anger and aggression. It is helpful for providers of care to know what cues should be looked for and what should be assessed when a patient's anger is escalating (verbal cues; nonverbal cues that include facial expression, breathing, body language, and posture). A patient's past aggressive behavior is the most important indicator of future aggressive episodes. Working with angry and aggressive patients is a challenge for all nurses, and a careful understanding and recognition of one's personal responses to angry or threatening patients can be crucial. Many approaches are effective in helping patients deescalate and maintain control.

 Different interventions are used, depending on the patient's coping abilities, cognitive status, and potential for violence. Specific medications such as antipsychotics, mood stabilizers, and antianxiety medications may be useful. Restraints may be necessary to ensure the safety of both the patient and other patients and the staff. Each unit has a clear protocol for the safe use of restraints and for the humane management of care during the time the patient is restrained, as well as clear guidelines for understanding and protecting the patient's legal rights.