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Termination- relationship ends. Termination actually begins during the orientation phase, when the nurse first
sets meeting times (lets p/t know that it will eventually end). Summarize & don't initiate new topics unless
p/t shows signs that treatment is still needed.
offering advice
belittling
disagreeing
probing
challenging
minimizing the problem- that's nothing compared to other p/ts problems
judging
Effective responses include:
Silence-gives p/ts time to feel comfortable & respond when they are ready
Active listening- paraphrasing the p/ts thoughts & feelings, asking Qs
support & reassurance
providing information
open-ended statements
transference- unconscious association of person w/ another person in their life
displacement- transfers feelings & attitudes about another person to the nurse.
Nursing response- listen & then use TC to clarify, reflect & problem solve
Counter transference- nurses unconscious emotional response to the p/t that is irrational, highly emotionally
charged & does not match the situation or interactions
use self-appraisal to identify source of CT. seek outside help if necessary
gain a better understanding of the p/t's background & refocus on the p/t
be aware of your + & - response to the p/t
don't let CT get in the way
1.6 Relate Orem's Self-Care Deficit Theory to the care of the mental health p/t
The primary focus of the PMH nurse is to assist the p/t to cope w/ or overcome self-care deficits that are
emotionally r/t.
Wholly compensatory- a p/t's self-care agency is so limited that he/she depends on others well-being.
Partially compensatory- a p/t can meet some self-care requisites but needs nurse to help meet others.
Supportive/educative- a p/t can meet self-care requisites but needs help in decision making, behavior control,
or knowledge acquisition.
1.7 Identify the components of a psychosocial assessment & the mental status examination .
Mental status examination
Mental health originates in a person's biology, then is demonstrated in various perceptions, thoughts,
emotions, & behaviors. Determined through evaluation of a person's emotional, perceptual, cognitive &
behavioral status.
Appearance-dress/grooming
behavior/activity- hypo/hyperactivity, relaxed/restlessness/gait
attitude- cooperative, resistive, hostile
speech- quality, quantity, rate
mood- sad, angry , depressed
affect- apathetic, flat, euphoric, bizarre
perceptions- hallucinations, distortions
thoughts- logical vs illogical, obsessions, delusions, abstract vs concrete
sensory & cognition- orientation to person, place, time and situation. Attention span, memory, intelligence
judgment-assess & evaluate situations, make rational decisions
insight- ability to perceive & understand the cause in nature of own & others situations
reliability- interviews impressions whether reported info is accurate & complete.
Psychosocial Assessment
1.8 Identify nursing diagnosis used in the care of p/ts in the psychiatric setting.
Ineffective coping (use cautiously)
disturbed thought process
risk for suicide
dysfunctional grieving
hopelessness
chronic low self-esteem
focus on the disturbed thoughts & sensory perceptions that result from delusions & hallucinations rather than
attempting to treat the disorder.
Voluntary Commitment: P/ts enter voluntarily by consenting to be admitted & treated. If they seek a
discharge from the hospital but are in immediate danger to themselves or others they may be placed on an
emergency commitment status pending further evaluation & treatment.
Emergency Commitment: When the effects of the p/ts mental illness result in an immediate risk for self-harm
or harm of others. In some states, if the effect of the mental illness is such that the p/t is unable to provide
food, clothing or shelter for himself/herself.
-Short period/ restrictive criteria for admission.
-Physician, psychologist, social worker or advance practice nurse must see the individuals
-After the individual is brought to the inpatient unit, a second mental health professional, usually a
psychiatrist, has to make an examination.
-within 5 days or less, a probable cause hearing has to take place to continue the person's hospitalization.
Civil or Judicial Commitment: longer amount of time than an emergency commitment. Lies in the states
power to protect & care for individuals w/ disabilities & the police power to protect the community.
Individual has the right to attorney & trial by jury. Utilized to mandate inpatient or outpatient treatment.
P/t who are ruled competent & who are voluntarily or involuntarily committed have the right to refuse
treatment & medication. During emergency situations if there is potential danger, p/ts can be forcibly
medicated.
Patient must sign a Written Intent To Terminate Treatment if they want to leave the hospital AMA. The
hospital must discharge within 3 days unless the hospital determines the patient may be a risk to self or other
and has petitioned the court for an involuntary commitment.
1.3 Describe the legal & ethical considerations in maintaining p/t confidentiality
HIPAA Law:
Guarantees the security & privacy of p/t health information; outlines standards of performance; &
consequences of violation of act.
Covers verbal, written & electronic information
protected informationAny individually identifiable health information that an organization keeps, files,
uses of shares
P/t treated for mental health & substance use disorders have more restrictions in act
release of information signed by p/t is required to share information
the confidentiality of the p/t's information & the necessity of having a signed release from the p/t before
releasing informationeven when family members who are closely involved w/ the p/t's daily carepresent
challenges for the nurse.
1.4- 1.43 Describe common liability issues applicable to the psychiatric-mental health setting
Duty to warn/duty to protect (tarasoff)- protective privilege ends where the public peril begins established
the responsibility of a treating mental health professional to notify an intended and identifiable victim.
Seclusion & restraints- only used when less restrictive alternatives to ensure p/t safety had failed, such as
talking to the p/t. Coercion, discipline, punishment, and staff convenience are never acceptable reasons for
placing a person in S/R. Within 1 hr a face to face assessment is required even if the p/t has been released
from restraints before the arrival of the LIP. P/t's family and legal representatives are to be notified when
restraints are used. Continuous in-person observation (15-min checks) of any p/t restraints for the duration for
the restraint procedure.
Mal-practice/Negligence- A health professional omits or commits an act that a reasonable prudent
professional would not do.
Non-intentional-negligence (primary basis for most mal-practice lawsuits in the USA)
Lawsuits must establish that the nurse had a legal duty or relationship to provide a certain standard of
care to a client. Did the nurse cause this to occur?
Protect yourself by documenting & keeping detailed records
1.5-1.55 Describe the client's rights in the psychiatric mental health setting.
Right to treatment-cannot keep in a psychiatric hospital if not providing treatment.
Right to refuse treatment- in MI an involuntary committed p/t cannot refuse medication or treatment, but
he/she can question treatment & participate in his/her treatment planning process.
ECT- remains controversial, an effective therapy for resistant & life threatening depression, requires informed
consent, requires 2 psychiatric evaluations (MI), issues pertaining to informed consent, potential side effect is
memory loss that is usually temporary but is sometimes irreversible.
Research- client must be thoroughly informed about the purpose, risks, benefits, alternatives, etc before
agreeing to be in research or trial treatments/projects. Requires informed consent.
Psychiatric advanced directives- a legal document is created when the person is able to make decisions, and
that is utilized only when the p/t is unable to participate in their own decision making. Surrogate decision
maker is a p/t advocate who carries out the p/ts wishes or makes decisions about his/her care, but only when
the p/t is so ill or injured that he/she cannot make his/her own treatment decisions.
1.6-1.64 Describe aspects of documentation of care
purpose of medical records- records are an excellent source of communicating w/ other mental health
professionals as well as other agencies. Used to validate reimbursement for care.
Facility use of medical records- track p/t's progress. Important for legal issues such as confidentiality &
privacy acts, accreditation, quality assurance, case management, utilization review, peer review, and research.
Medical record as evidence- legal document that is valuable in any litigation that takes place. Adequate &
legal documentation is the best means of defense against a lawsuit & the best way to validate that the nurse
adhered to their scope of practice & safe standard care.
Nursing guidelines for charting- Be specific and document symptoms by writing in quotes what the p/t
expresses to you. Chart in a timely & legible manner. Avoid late entries if not label & initial them. Document
when the person has achieved the goals outlined in the treatment plan. Informed consents.
1.7 discuss the ethical principles of autonomy, beneficence & distributive justice in relationship to ethical & legal
issues.
Autonomy- having respect for an individual's decisions or self-determination regarding health issues.
Important w/ problems such as the right to die &, in mental health, treatment w/ the use of the least restrictive
alternative. When involuntary commitment is necessary, it is difficult for mental health providers to have to
follow the law rather than to do what the p/t currently desires.
neurotransmitters bind at receptor sites. Axons and dendrites do not actually touch, but come very close. The
small gap between them is called a synapse. Neurotransmitters are released by axons into the fluid of the
synapse. Some of these chemicals bind to receptor sites on the corresponding dendrite, some of them return to
the axon, and some of them are broken down, or metabolized.
Steps
crosses synapse or gap b/t cells
attaches to receptor site
excites or inhibits cell to influence other neurons
after attaching to receptor sites that transmitter is :
deactivated by enzymes on the site or in the gap
taken back into the cell that released it and reused
deactivated by an enzyme in the cell
Identify the relationship of neurotransmitters in schizophrenia, mood disorders, Alzheimer disease, and
anxiety and describe the action of the major categories of drugs to treat these disorders:
A problem in impulse conduction
transmitter release
receptor response
Psychotropic drugs target these areas.
Categories of neurotransmitters:
Monoamides:
dopamine (malfunction in p/ts w/ schizophrenia & depression)
Norepinephrine (deficiencies in mood disorders I.e major depression. Foods high in tyrosine &
tyramine are avoided by p/ts who are taking certain psychotropic medications)
Serotonin (decreased in depression)
Histamine
Amino Acids
GABA (chemically derived from glutamate, inhibitory neurotransmitter)
Glutamine (excitatory neurotransmitter)
both are the subject of extensive research in disorders such as Alzheimer's disease & schizophrenia
Cholinergics
Acetycholine (Ach)
primarily involved in Alzheimer's disease
Neuropeptides
Substance P
Somatostatin
Neurotensin
CRH
Endorphin
Depression- serotonin, dopamine & norepinephrine. Major classes of antidepressantstricyclic
antidepressants & selective serotonin levels.
Anxiety- Panic disorders & extreme phobiasoverproduction of some excitatory neurotransmittersGABA
inhibitor
Neurotransmitter
Dysfunction
Mental disorder
Dopamine
Increase
Schizophrenia
Serotonin
Decrease
Depression
Norepinephrine
Decrease
Depression
GABA
Decrease
Anxiety disorders
Acetylcholine
Decrease
Alzheimer's disease
1.3 describe how mental disorders & psychotropic drugs alter the structure & function of the brain
Antipsychotic medication (typical & atypical)
Typical control psychotic symptoms such as delusions, hallucinations, and thought disorders (positive
symptoms)
first generation antipsychotic drugs
Phenothiazine & Non-Phenothiazine's act by blocking Dopamine, Acetylcholine, & epinephrine
Also block Norepinephrine & Histamine
side effects- extra pyramidal symptoms, dry mouth, orthostatic hypertension.
Haldol, Thorazine, Stelazine
Atypical Antipsychotics or 2nd generation:
Block dopamine (in a different way), block serotonin
Less side effects, few or no extra pyramidal symptoms
work on negative (decreased motivation, poor self-care, blunted effect) as well as positive symptoms of
schizophrenia
Clozaril, Zyprexa, Risperdal
Antidepressants (SSRI's, tricyclic's MAIO's)
treat depression & some anxiety disorders
Tricyclic antidepressants:
Elavil, Tofranil
block reuptake of norepinephrine, histamine, & serotonin
side effects- orthostatic hypotension, sedation.
Selective serotonin reuptake inhibitors (SSRI):
Prozac, Zoloft, Paxil
block reuptake of serotonin
may be used to reat OCS's & social phobias
Do not have the anticholinergic & sedating effect of TCA's.
1.4 Describe noninvasive structural & functional brain imaging techniques used to visualize the brain
Structural imaging shows gross anatomical details of brain structure
Computed Tomography (CT) detects:
lesions, infarct, aneurysms
schizophrenia: cortical atrophy, 3rd ventricle enlargement, cognitive disorders
contradictions- individuals w/ pacemakers; individuals w/ metallic objects such as screws, prostheses, &
orthopedic devices; p/ts on life-support systems
Magnetic Resonance Imaging (MRI) detects:
Brain edema, ischemia, infection, neoplasm & trauma
Schizophrenia: enlarged ventricles, reduction in temporal & frontal lobes
Functional imaging shows activity of the brain
Positron-emission tomography (PET) detects:
oxygen use, glucose metabolism, blood flow, some neurotransmitter interactions
schizophrenia- increased dopamine receptors, abnormalities in limbic system
mood disorder- abnormalities in temporal lobe
adult ADHD- decreased utilization of glucose
Single photon emission computed tomography (SPECT) detects:
similar to PET also measures brain function & provides images of multiple layers of the CNS
Replace the negative self-talk with positive self-talk that reflects control & strength. I want I Can I will
1.2 practice relaxation techniques to promote a positive mental attitude & reduce anxiety
Breathing
muscle relaxation
imagery
exercise
desensitize fear response
a routine
set goals for studying
find a suitable environment
control distracting in studying environment
prepare for class ahead of time
make sure to take notes
1.3 Manage daily routines & study habits before test day
decide what is needed & unneeded in a normal studying habit
set a normal routines
1.4 + 1.5 self-explanatory