Chapter One

Chapter One

Foundations of Psychiatric Mental Health Nursing

Mental Health

The WHO defines health as a state of complete physical, mental, and social wellness, not merely the absence of disease or infirmity.

Mental health is influenced by individual factors, including biologic makeup, autonomy, and independence, self-esteem, capacity for growth, vitality, ability to find meaning in life, resilience or hardiness, sense of belonging, reality orientation, and coping or stress management abilities; by interpersonal factors, including effective communication, helping others, intimacy, and maintaining a balance of separateness and connectedness; and by social/cultural factors, including sense of community, access to resources, intolerance of violence, support of diversity among people, mastery of the environment, and a positive yet realistic view of the world (damn, that was a mouthful!). Mental Illness

The APA (2000) defines a mental disorder as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. Deviant behavior does not necessarily indicate a mental disorder.

Diagnostic and statistical manual of mental disorders

The DSM-IV-TR is a taxonomy published by the APA. The DSM-IV-TR describes all mental disorders, outlining specific criteria for each based on clinical experience and research. The DSM-IV-TR has 3 purposes:

To provide standardized nomenclature and language for all mental health professionals.

To present defining characteristics or symptoms that differentiates specific diagnoses.

To assist in identifying the underlying causes of disorders. A multiaxial classification system that involves assessment on several axes, or domains of information, allows the practitioner to identify all the factors that relate to a persons condition.

Axis I is for identifying all major psychiatric disorders except MR and personality disorders. Examples include depression and schizophrenia.

Axis II is for reporting mental retardation and personality disorders as well as prominent maladaptive personality features and defense mechanisms.

Axis III is for reporting current medical conditions that are potentially relevant to understanding or maintaining the persons mental disorder as well as medical conditions that might contribute to understanding the person.

Axis IV is for reporting psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of mental disorders. Included are problems with the primary support group, the social environment, education, occupation, housing, economics, access to health care, and the legal system.

Axis V presents a Global Assessment of Functioning which rates the persons overall psychological functioning on a scale of 0 to 100. This represents the clinicians assessment of the persons current level of functioning. All clients admitted to a hospital or psychiatric treatment will have a multiaxis diagnosis from the DSM-IV-TR. Period of Enlightenment and Creation of Mental Institutions

In the 1790s Phillippe Pinel in France and Willian Tukes of England formulated the concept of asylum as a safe refugee or haven offering protection at institutions where people had been beaten, whipped, and starved for their mental illness.

In the US, Dorothea Dix (1802-1887) began a crusade to reform the treatment of mental illness after a visit to the Tukes institution in England. She was instrumental in opening 32 state hospitals that offered asylum to the suffering. 100 years after establishment of the first asylum, state hospitals were in trouble. Attendants were accused of abusing the residents, the rural locations of the hospitals were viewed as isolating patients from their families and homes, and the phrase insane asylum took on a negative connotation.

Development of Psychopharmacology

In the 1950s the development of psychotropic drugs were used to treat mental illness. Chlorpromazine (Thorzine), an antipsychotic drug, and lithium, an anti-manic agent, were the first drugs to be developed. 10 years later, monoamine oxidase inhibitors, haloperidol (Haldol), an antipsychotic; tricyclic antidepressants; and antianxiety agents (benzodiazepines), were introduced.

Because of these new drugs, hospital stays were shortened, and many people were well enough to go home. Move toward Community Mental Health

The enactment of the Community Mental Health Centers Act came about in 1963. Deinstitutionalization, a deliberate shift from institutional care in state hospitals to community facilities, began. In addition to deinstitutionalization, federal legislation was passed to provide an income for disabled persons: SSI and SSDI. This allowed people with mental illnesses to be more independent financially and not to rely on family for money. Mental Illness in the 21st Century

The Department of Health and Human Services (DHHS) estimates that 56 million Americans have a diagnosable mental illness. The term Revolving door effect is used to explain how people with severe and persistent mental illness have shorter hospital stays, but they are admitted more frequently. People with severe and persistent mental illness may show signs of improvement in a few days but are not stabilized. Thus, they are discharged into the community without being able to cope with community living. Substance abuse issues cannot be dealt with in the 3-5 days typical for admissions in the current managed care environment. Many providers believe todays clients are to be more aggressive than those in the past. Between 4% and 8% in clients seem in Psychiatric ERs are armed. People not receiving adequate mental health care commit about 1,000 homicides each year. In state prisons, 1 in 10 prisoners take psychotropic medications and 1 in 8 receives counseling or therapy for mental health issues. 85% of the homeless population has a psychiatric illness and/or a substance abuse problem. The United States has the largest percentage of mentally ill citizens (29.1%) and provided care for only 1 in 3 people who needed it (Bijl et al., 2003). Persons with minor or mild cases are most likely to receive treatment while those with severe and persistent mental illness were least likely to be treated. Cost containment and managed care

Managed Care is a concept designed to purposely control the balance between the quality of care provided and the cost of that care. In a managed care system, people receive care based on need rather than request. Case management or management of care on a case-by-case basis represented an effort to provide necessary services while containing costs. The client is assigned a case manager, a person who coordinates all types of care needed by the client. In 1996, Congress passed the Mental Health Parity Act, which eliminated annual and lifetime dollar amounts for mental health care for companies with more than 50 employees. However, substance abuse was not covered by this law, and companies could limit the number of days in the hospital or the number of clinic visits per year. Thus, parity did not really exist. Psychiatric Nursing Practice

In 1873, Linda Richards improved nursing care in psychiatric hospitals and organized educational programs in state mental hospitals in Illinois. Richards is called the first American psychiatric nurse.

The first training of nurses to work with persons with mental illness was in 1882. The care focused on nutrition, hygiene and activity. Nurses adapted medical-surgical principles to the care of clients with psychiatric disorders and treated them with tolerance and kindness. Treatments such as insulin shock therapy (1935), psychotherapy (1936), and electroconvulsive therapy (1937) required nurses to use their medical skills more extensively. John Hopkins was the first school of nursing to include a course on psychiatric nursing in its curriculum. In 1950, the National League for Nursing (which accredits nursing programs) required schools to include an experience in psychiatric nursing. In 1973, the ANA developed Standards of care, which states the responsibilities for which nurses are accountable. Psychiatric nursing practice has been profoundly influenced by Hildegard Peplau and June Mellow, who wrote about the nurse-client relationship, anxiety, nurse therapy, and interpersonal nursing therapy. Psychiatric Mental Health Nursing Phenomena of Concern

The maintenance of optimal health and well-being and the prevention of psychobiologic illness.

Self-care limitations or impaired functioning related to mental and emotional distress.

Deficits in the functioning of significant biologic, emotional, and cognitive symptoms. Emotional stress or crisis components if illness, pain, and disability.

Self-concept changes, developmental issues, and life process changes.

Problems related to emotions such as anxiety, anger, sadness, loneliness, and grief. Physical symptoms that occur along with altered psychological functioning.

Alterations in thinking, perceiving, symbolizing, communicating, and decision making.

Difficulties relating to others

Behaviors and mental states that indicate the client is a danger to self or others or has a significant disability.

Interpersonal, systemic, sociocultural, spiritual, or environmental circumstances or events that affect the mental or emotional well-being of the individual, family, or community.

Symptom management, side effects/toxicities associated with psychopharmacologic intervention, and other aspects of the treatment regimen. Standards of Psychiatric mental health clinical nursing practice.

Standard I. Assessment

The psychiatric-mental health nurse collects health data

Standard II. Diagnosis

The psychiatric-mental health nurse analyzes the data in determining diagnoses.

Standard III. Outcome identification.

The psychiatric-mental health nurse identifies expected outcomes individualized to the client.

Standard IV. Planning.

The psychiatric-mental health nurse develops a plan of care that prescribes interventions to attain expected outcomes.

Standard V. Implementation The psychiatric-mental health nurse implements the interventions identified in the plan of care. Standard Va. Counseling

The psychiatric-mental health nurse uses counseling interventions to assist clients in improving or regaining their previous coping abilities, fostering mental health, and preventing mental illness and disability.

Standard Vb. Milieu Therapy

The psychiatric-mental health nurse provides structures, and maintains a therapeutic environment in collaboration with the client and other health care practitioners. Standard Vc. Self-care activities.

The psychiatric-mental health nurse structures interventions around the clients activities of daily living to foster self-care and mental and physical well-being.

Standard Vd. Psychobiologic Interventions.

The psychiatric-mental health nurse uses knowledge of psychobiologic interventions and applies clinical skills to restore the clients health and prevent further disability.

Standard Ve. Health teaching.

The psychiatric-mental health nurse, through health teaching, assists clients in achieving, satisfying, productive, and healthy patterns of living.

Standard Vf. Case Management.

The psychiatric-mental health nurse provides case management to coordinate comprehensive health services and ensure continuity of care.

Standard Vg. Health promotion and maintenance. The psychiatric-mental health nurse employs strategies and interventions to promote and maintain mental health and prevent illness.

Areas of practice

Counseling

Interventions and communication techniques

Problem solving

Crisis intervention

Stress management

Behavior modification

Milieu therapy

Maintain therapeutic environment

Teach skills

Encourage communication between clients and others

Promote growth through role modeling

Self-care activities

Encourage independence

Increase self-esteem

Improve function and health

Psychobiologic interventions

Administer medications

Teaching Observations

Health teaching

Case management

Health promotion and maintenance

Advanced level functions

Psychotherapy

Prescriptive authority for drugs (in many states)

Consultation

Evaluation

Self-awareness issues

Self-awareness is the process by which the nurse gains recognition of his or her own feelings, beliefs, and attitudes. Chapter Two

Neurobiologic Theories and Psychopharmacology

The Nervous system and how it works

The cerebrum is the center for coordination and integration of all information needed to interpret and respond to the environment.

The cerebellum is the center for coordination of movements and postural adjustments.

The brain stem contains centers that control cardiovascular and respiratory functions, sleep, consciousness, and impulses. The limbic system regulates body temperature, appetite, sensations, memory, and emotional arousal.

Neurotransmitters

Neurotransmitters are the chemical substances manufactured in the neuron that aid in the transmission of information throughout the body. They either excite or stimulate an action in the cells (excitatory) or inhibit or stop an action (inhibitatory). After neurotransmitters are released into the synapse (point of contact between the dendrites and the next neuron) and relay the message to the receptor cells, they are either transported back from the synapse to the axon to be stored for later use (reuptake) or are metabolized and inactivated by enzymes, primarily monoamine oxidase (MAO). Dopamine, a neurotransmitter located primarily in the brain stem. Dopamine is generally excitatory and is synthesized from tyrosine, a dietary amino acid. Antipsychotic medications work by blocking dopamine receptors and reducing dopamine activity.

Norepinephrine and Epinephrine

Norepinephrine, the most prevalent neurotransmitter, is located primarily in the brain stem. It plays a role in mood regulation.

Epinephrine is also known as noradrenaline and adrenaline. Epinephrine has limited distribution in the brain but controls the fight-or-flight response in the peripheral nervous system. Serotonin

A neurotransmitter found only in the brain, is derived from tryptophan, a dietary amino acid. The function of serotonin is mostly inhibitory, involved in the control of food intake, sleep and wakefulness, temperature regulation, pain control, sexual behavior, and regulation of emotions. Some antidepressants block serotonin reuptake, thus leaving it available longer in the synapse, which results in improved mood.

Histamine

The role of histamine in mental illness is under investigation. Acetylcholine

Acetylcholine is a neurotransmitter found in the brain, spinal cord, and peripheral nervous system. It can be excitatory or inhibitory. It is synthesized from dietary choline found in red meat and vegetables and has been found to affect the sleep-wake cycle and to signal muscles to become active. Studies have shown that people with Alzheimers disease have decreased acetylcholine secreting neurons.

Glutamate

Glutamate is an excitatory amino acid that at high levels can have major neurotoxic effects. Gamma-Aminobutyric Acid (GABA)

GABA is a major inhibitory neurotransmitter in the brain and has been found to modulate other neurotransmitter systems rather than to provide a direct stimulus. Drugs that increase GABA function such as benzodiazepines are used to treat anxiety and to induce sleep.

Neurobiologic causes of mental illness

Current theories and studies indicate that several mental disorders may be linked to a specific gene or combination of genes but that the source is not solely genetic; nongenetic factors also play important roles. Two genetic links to Alzheimers disease are chromosomes 14 and 21. The Human Genome Project, funded by NIH and the US Department of Energy, is the largest of its kind. It has identified all human DNA. In addition, the project also addresses the ethical, legal, and social implications of human genetics research. Stress and the Immune system (Psychoimmunology)

This is a relatively new field of study, which examines the effect of psychological stressors on the bodys immune system. Infection as a possible cause

Some researchers are focusing on infection as a cause of mental illness. Studies such as this are promising in discovering a link between infection and mental illness. The Nurses role in research and education

The nurse must ensure that clients and families are well informed about progess in these areas and must also help them to distinguish between facts and hypotheses. The nurse can explain if or how new research may affect a clients treatment or prognosis. The nurse is a good resource for providing information and answering questions.

Psychopharmacology

Efficacy refers to the maximal therapeutic effect that a drug can achieve.

Potency describes the amount of the drug needed to achieve that maximum effect; low-potency drugs require higher doses to achieve efficacy, whereas high-potency drugs achieve efficacy at lower doses.

Half Life is the time it takes for half of the drug to be removed from the bloodstream. Drugs with shorter half-life may need to be given three or four times a day, but drugs with a longer half-life may be given once a day.

The FDA may issue a black-box warning when a drug is found to have serious or life-threatening side effects. This means that package inserts must have a highlighted box, separate from the text, which contains a warning about the serious side-effects. Antipsychotic drugs

Also known as neuroleptics, are used to treat the symptoms of psychosis, such as the delusions and the hallucinations seen in schizophrenia, schizoaffective disorder, and the manic phase of bipolar disorder.

Antipsychotics work by blocking receptors of the neurotransmitter, dopamine. Dopamine receptors are classified into subcategories (D1, D2, D3, D4, and D5) and D2, D3, and D4 have been associated with mental illness. The typical antipsychotic drugs are potent antagonists (blockers) of D2, D3, and D4. This makes them effective in treating target symptoms but also produces many extrapyramidal side effects because of the blocking of the D2 receptors. Newer, atypical antipsychotic drugs such as clozapine (Clozaril) are relatively weak blockers of D2, which may account for the lower incidence of extrapyramidal side effects. The newer antipsychotics also inhibit the reuptake of serotonin, increasing their effectiveness in treating the depressive aspects of schizophrenia. Extrapyramidal Side Effects (EPS) are the major side effects of antipsychotic drugs. They include acute dystonia (prolonged involuntary muscular contractions that may cause twisting of the body parts, repetitive movements, and increased muscular tone), pseudoparkinsonism, and akathisia (intense need to move about). Blockage of the D2 receptors in the midbrain region of the brain stem is responsible for the development of EPS. Included in the EPS are:

Torticollis: twisted head and neck

Opisthotonus: tightness of the entire body with head back and an arched neck. Oculogyric crisis: eyes rolled back in a locked position. Immediate treatment with anticholinergic drugs usually brings rapid relief.

Pseudoparkinsonism, or drug-induced Parkinsonism if often referred to by the generic label of EPS. Symptoms include a stiff, stooped posture; mask-like facies; decreased arm swing; a shuffling. festinating gait; drooling; tremor; bradycardia; and coarse pill rolling movements of the thumb and fingers while at rest. Treatment of these symptoms can include adding an anticholinergic agent or amantadine, which is a dopamine agonist that increases transmission of dopamine blocked by the antipsychotic drug.

Neuroleptic Malignant syndrome

(NMS) is a potentially fatal idiosyncratic reaction to an antipsychotic. Death rates have been reported at 10% to 20%. Symptoms include rigidity, high fever; autonomic instability such as unstable blood pressure, diaphoresis, and pallor; delirium; and elevated levels of enzymes, particularly creatine and phosphokinase. Clients with NMS are confused and often mute; they may fluctuate from agitation to stupor. Dehydration, poor nutrition, and concurrent medical illness all increase the risk of NMS. Treatment includes immediate discontinuation of the antipsychotic and the institution of supportive medical care to treat dehydration and hyperthermia. Tardive Dyskinesia

(TD) is a syndrome of permanent involuntary movements. This is most commonly caused by the long-term use of antipsychotic drugs. There is no treatment available. The symptoms of TD include involuntary movements of the tongue, facial, and neck muscles, upper and lower extremities, and truncal musculature. Tongue thrusting and protruding, lip smacking, blinking, grimacing, and other excessive unnecessary facial movements are characteristic. One TD has developed, it is irreversible. Agranulocytosis

Some antipsychotics produces agranulocytosis. This develops suddenly and is characterized by:

Fever

Malaise

Ulcerative sore throat

Leucopenia

The drug must be discontinued immediately if the WBC drops by 50% or to less that 3,000. Antidepressant drugs

Although the mechanism of action is not completely understood, antidepressants somehow interact with the two neurotransmitters, norepinephrine and serotonin. Antidepressants are divided into four groups:

Tricyclic and the related cyclic antidepressants

Selective serotonin reuptake inhibitors (SSRIs)

MAO inhibitors (MAOIs)

Other antidepressants such as venlafaxine (Effexor), bupropion (Wellbutrin), duloxetine (Cymbalta), trazodone (Desyrel), and nefazodone (Serzone). MAOIs have a low incidence of sedation and anticholinergic effects, they must be used with extreme caution for several reasons:

A life-threatening side effect, hypertensive crisis, may occur if the client ingests food containing tyramine (an amino acid) while taking MAOIs. Mature or aged cheeses

Aged meats (sausage, pepperoni)

Tofu

ALL tap beers and microbrewery beer. Sauerkraut, soy sauce, or soybean condiments

Yogurt, sour cream, peanuts, MSG

MAOIs cannot be given in combination with other MAOIs, tricyclic antidepressants, Demerol, CNS depressants, and hypertensives, or general anesthetics. MAOIs are potentially lethal in overdose and pose a potential risk for clients with depression who may be considering suicide. SSRIs, venlafaxine, nefazodone, and bupropion are often better choices for those who are potentially suicidal or highly impulsive because they carry no risk of lethal overdose in contrast to the cyclic compounds and the MAOIs. However, SSRIs are only effective for mild to moderate depression. The major actions of antidepressants are with the monoamine neurotransmitter systems in the brain, particularly norepinephrine and serotonin. Norepinephrine, serotonin, and dopamine are removed from the synapses after release by reuptake into presynaptic neurons. After reuptake, these three neurotransmitters are reloaded for subsequent release or metabolized by the enzyme MAO. The SSRIs block the reuptake of serotonin; the cyclic antidepressants and venlafaxine block the reuptake of norepinephrine primarily and block serotonin to some degree; and the MAOIs interfere with enzyme metabolism. Mood stabilizing drugs

Mood stabilizing drugs are used to treat bipolar disorder by stabilizing the clients mood, preventing or minimizing the highs and lows that characterize bipolar illness, and treating acute episodes of mania. Lithium is considered the first-line agent in the treatment of bipolar disorder. Lithium normalizes the reuptake of certain neurotransmitters such as serotonin, norepinephrine, acetylcholine, and dopamine. It also reduces the release of norepinephrine through competition with calcium. Lithium produces its effects intracellularly rather than within neuronal synapses. Lithium serum levels should be about 1.0 mEq/L. Levels less than 0.5 mEq/L are rarely therapeutic, and levels of more than 1.5 mEq/L are usually considered toxic. If Lithium levels exceed 3.0 mEq/L, dialysis may be indicated. The mechanism of action for anticonvulsants is not clear as it relates to their off-label use as mood stabilizers. Valporic acid and topiramate are known to increase the levels on the inhibitatory neurotransmitter, GABA. Both are thought to stabilize mood by inhibiting the kindling process. The kindling process can be described as the snowball-like effect seen when minor seizure activity seems to build up into more frequent and severe seizures. In seizure management, anticonvulsants raise the level of the threshold to prevent these minor seizures. It is suspected that this same kindling process may occur in the development of full-blown mania with stimulation by more frequent, minor episodes. Antianxiety drugs (Anxiolytics)

Benzodiazepines mediate the actions of the amino acid GABA, the major inhibitory neurotransmitter in the brain. Because GABA receptor channels selectively admit the anion chloride into neurons, activation of GABA receptors hyperpolarizes neurons and thus is inhibitory. Benzodiazepines produce their effects by binding to a specific site on the GABA receptor.

Stimulants

Today, the primary use of stimulants is for ADHD in children and adolescents, residual attention deficit disorder in adults, and narcolepsy. Stimulants are often termed indirectly acting amines because they act by causing release of the neurotransmitters (norepinephrine, dopamine, and serotonin) from presynaptic nerve terminals as opposed to having direct agonist effects on the postsynaptic receptors. They also block the reuptake of these neurotransmitters. By blocking the reuptake of these neurotransmitters into neurons, they leave more of the neurotransmitter in the synapse to help convey electrical impulses in the brain. Cultural considerations

Im not going to go much into this. Just know that clients from various cultures may metabolize medication at different rates and therefore require alterations in standard dosages. Psychosocial Theories and Therapy

Sigmund Freud, the Father of Psychoanalysis

Founded the personality components; Id, Ego, and Superego

Id: The part of ones nature that reflects basic or innate desires such a pleasure seeking behavior, aggression, and sexual impulses. The id seeks instant gratification, causes impulsive thinking behavior, and has no rules or regard for social convection.

Superego: The part of ones nature that reflects moral and ethical concepts, values, parental and social expectations; therefore, it is the directional opposite to the id.

Ego: The balancing or mediating force between the id and the superego. The ego represents mature and adaptive behavior that allows a person to function successfully.

Psychosexual development

Oral (birth to 18 months)

Anal (18 to 36 months)

Phallic/Oedipal (3 to 5 years)

Latency (5 to 11 or 13 years)

Genital (11 or 13 years)

Transference and Countertranference

Transference occurs when the client onto the therapist/nurse attitudes and feelings that the client previously felt in other relationships.

Countertranference occurs when the therapist/nurse displaces onto the client attitudes or feelings from his or her past.

Developmental Theorists; Erikson and Piaget

Erikson focused on personality development across the life span while focusing on social and psychological development in life stages.

Trust vs. Mistrust (infant)

Autonomy vs. Shame and Doubt (toddler)

Initiative vs. guilt (preschool)

Industry vs. Inferiority (school age)

Identity vs. Role confusion (adolescence)

Intimacy vs. isolation (young adult)

Generativity vs. stagnation (middle adult)

Ego integrity vs. despair (maturity)

Erikson believed that psychosocial growth occurs in sequential stages, and each stage is dependent on the completion of the previous stage/life task.

Piaget explored how intelligence and cognitive functioning develop in children.

Sensorimotor (birth to 2 years): The child develops a sense of self as separate from the environment and the concept of object permanence. Begins to form mental images.

Preoperational (2-6 years): Child begins to express himself with language, understands the meaning of symbolic gestures, and begins to classify objects.

Concrete operations (6-12 years): Child begins to apply logical thinking, understands reversibility, is increasingly social and able to apply rules; however, thinking is still concrete.

Formal operations (12 to 15 years and beyond): Child learns to think and reason in abstract terms, further develops logical thinking and reasoning, and achieves cognitive maturity.

Harry Stacks Sullivan: Interpersonal Relationships and Milieu therapy

The importance and significance of interpersonal relationships in ones life was Sullivans greatest contribution to the field of mental health.

Sullivan developed the first therapeutic community or milieu with young men with schizophrenia in 1929. He found that within the milieu, the interactions among clients were beneficial, and then the treatment should emphasize on the roles of the client-client interaction.

Milieu therapy is used in the acute care setting; one of the nurses primary roles is to provide safety and protection while promoting social interaction.

Hildegard Peplau: Therapeutic nurse-patient relationship (The bomb-diggity of nursing)

Developed the concept of the therapeutic nurse-patient relationship, which includes 4 phases: orientation, identification, exploitation, and resolution.

The orientation phase is directed by the nurse and involves engaging the client in treatment, providing explanations and information, and answering questions. During this time the nurse would orient the patient to the rules and expectations (if in an acute setting).

The identification phase begins when the client works interdependently with the nurse, expresses feelings, and begins to feel stronger. This phase can begin either within a few hours to a few days; the patient can identify the nurse and environment on his own. They come together. Kinky.

In the exploitation phase, the client makes full use of the services offered. He moves toward independence.

In the resolution phase, the client no longer needs professional services and gives up dependent behavior.

Keep in mind that after the resolution phase, the client can regress and move back into the above mentioned phases.

Paplau defined anxiety as the initial response to a psychic threat, describing 4 levels of anxiety: acute, moderate, severe, and panic.

Acute anxiety is a positive state of heightened awareness and sharpened senses, allowing the person to learn new behaviors and solve problems. The person can take in all available stimuli (perceptual field).

Moderate anxiety involved a decreased perceptual field (focus on immediate task only); the person can learn new behavior or solve problems only with assistance. Another person can redirect the person to the task. Remember, this is the ideal anxiety state for teaching a client regarding health concerns such as diabetes, as Cathy says so. (

Severe anxiety involves feelings of dread or terror. The person CANNOT be redirected to a task; he focuses only on scattered details and has physiologic symptoms such as tachycardia, diaphoresis, and chest pain. The client may go to the ER thinking he is having a heart attack. In lecture, Cathy stated that this person can still be talked down. The first priority is to move the person away from all stimuli, and then attempt to talk with them to calm down.

Panic anxiety can involve loss of rational thought, delusions, hallucinations, and complete physical immobility and muteness. The person my bolt and run aimlessly, often exposing himself and others to injury.

Humanistic Theories; Maslows Hierarchy of needs. Everyone should know this one. It is outlined on page 56 in your book.

He used a pyramid to arrange and illustrate the basic drives or needs to motivate people.

The most basic needs, physiologic needs, need to be met first. This includes food, water, shelter, sleep, sexual expression, and freedom of pain. These MUST be met first.

The second level involves safety and security needs, which involve protection, security, freedom from harm or threatened deprivation.

The third level is love and belonging needs, which include enduring intimacy, friendship, and acceptance.

The fourth level involves esteem needs, which includes the need for self-respect and esteem from others.

The highest level is self-actualization, the need for beauty, truth, and justice. Few people actually become self-actualized.

Remember, traumatic life experiences or compromised health can cause a person to regress to a lower level of motivation.

Pavlov: Classic conditioning (Behavior theory)

Pavlov believed that behavior can be changed through conditioning with external or environmental conditions or stimuli.

Crisis Intervention

Maturational crises, sometimes called developmental crises, are predictable events in the normal course of a life, such as leaving home for the first time, getting married, having children, etc.

Situational crises are unanticipated or sudden events that threaten an individuals integrity; such as a death of a loved one and loss of a job.

Adventitious crises, sometimes called social crises, include natural disasters like floods, earthquakes, or hurricanes; war, terrorist attacks; riots; and violent crimes such as rape or murder.

Non-violent crisis interventionThe heart of crisis intervention is: Care Welfare Safety (#1!) SecurityPeople in crisis need care and welfare.Staff responses should be safety and security.Anxiety: Increase or change in behavior. Can be anything different from usual behavior (excitement, pacing). Nursing interventions: Ask Whats going on? Give supportive care and let the patient know that youre there.Defensive: Loss of rationality. Nursing interventions: Direct approach to setting limits. Take away privileges. Give the patient some control and choices.Acting out person: Loss of rational control. Nursing interventions: Everything Cathy showed us on non-violent physical crisis interventionTension-Reduction: Subsiding of energy. Nursing interventions: Establish therapeutic rapport Prime time to talk and teach about preventions of behavior.What if the patient simply refuses? Set limits! Make the limits reasonable and enforceable. Releasing Venting Mad as heck! Allow the patient to do this! Just stay calm as a nurse While theyre venting, theyre also releasing. This is a good thing.Intimidation: This is NOT A GOOD THING. What if the patient tells you? I know what car you drive. I know your last name. I know you have 2 dogs and Im going to kill them. Nursing interventions: Get a witness! Do not be by yourself with this patient!Non-verbal behavior that affect proxemics Factors that affect: Size, gender, disability, environment, agitation, history, and speed. 18-36 is personal space (usually how wide ones arm length is). Always be the closest to the door. Kinesics (Body language) Facial expressions, stance, posture, breathing, hand gestures When approaching a client, stand at 45 degree angle Stand with hands to side (especially when with a paranoid client) Move when the patient moves. Be as calm as possible.Paraverbal communication 55% nonverbal 7% verbal 38% paraverbal( its not what you say; its how you say it! TVC (total voice control) Tone Volume CadenceAlways remember not to lose eye contact.If youre being grabbed Gain physiologic advantage Know where the weak point of grab is Leverage- use what you have! Momentumit comes in handy ( Gain psychological advantage Stay calm Have a plan Dont forget the element of surpriseNon-Violent physical control and restraint should be used as a LAST RESORT.

Mood disorders

Categories of Mood disorders

Unipolar

Major depression

Bipolar

Mania

Depression

Period of normalcy

Unipolar: Major depression

Sad mood or lack of interest in life for 2 or more weeks

Another 4 symptoms must also be present

Change in appetite (increase or decrease)

Change in sleep patterns (too much or too little)

Unable to concentrate and make decisions

Loss of self-esteem (guilt- how you were raised; how worthy a person perceives themselves). Those at risk:

PMS/PMDD

Suffering from anxiety and irritability

PP depression

Chronic illness (dialysis)

PTSD

Grief and loss

Can be observed by others, or the depression is just in ones head

Incidence

Major depression occurs at least twice as often in women

Single and divorced people have the highest rates of depression

Treatments

Psychotherapy (groups, counselor)

Psychopharmacology (Meds)

ECT

Electroconvulsive therapy

The biggest concern is memory loss. Patient is pre-medicated, much like a pre-op patient

Elders are treated for depression with ECT more frequently than younger persons.

Elder persons have increased intolerance of side effects of antidepressants ECT produces a more rapid response

Suicidal Ideation

Safety is primary concern

Watch for overt cues of suicide (Obvious) ( active

Covert cues are more subtlepassive People who suddenly are happier are of great concern; may have made the suicidal plan are content with their decision.

People whose meds are finally workinghave enough energy to carry out the act

Clients Affect

Compare verbal with non-verbal behaviorsdo they match up?

Asocial: Withdrawal from family and friends

Anhedonic: Lose sense of pleasure

When confronting these clients about their behavior, use I statements

I really wish youd join the group

Judgment

Feel overwhelmed with normal activities

Difficulty with task completion

Always exhausted

Self Concept

Ruminate: Worry to excess. Lack energy for normal activities (always tired)

Interventions

Assess safety for client (PRIORITY!)

Perform suicide lethality assessment

Orient client to new surroundings (they need structure)

Offer explanations of unit routine (again, need structure)

Start to promote a therapeutic relationship; schedule short interaction times.

Patient and Family teaching

Stress importance of follow-up carekeep it structured; make appointment for them.

Stress importance of continuing medications; assess if they can afford them

Make phone number lists of how to get help if they need it.

Bipolar disorder

Condition with cyclic mood changes

Person has manic episodes, periods of profound depression, and times of normal behavior in-between

Occurs equally in men and women; often seen in highly educated people.

Clinical course of mania

Episode of unusual, grandiose, or agitated mood lasting at least one week with three or more of the following symptoms:

Exaggerated self-esteem

Sleeplessness

Pressured speech

Flight of ideas

Reduced ability to filter out stimuli

Distractibility

More activities with increased energy

Drug treatment

Lithium

Lithium is not metabolized; rather, it is reabsorbed by the proximal tubule and excreted in the urine.

Thought to work in the synapse to increase destruction of dopamine and norepinephrine; decreases sensitivity to postsynaptic receptors (Basically- when a person is in a manic phase, they are synapsing super fast. Lithium helps slow this synapsing down).

Onset of action is 5-14 days; other drugs must be used during the acute phases to reduce symptoms of mania or depression.

Maintenance lithium level is 0.5-1.0 mEq/L. 3 is toxic! Duh. Lithium is a salt contained in the human body. It not only competes for salt receptor sites but also affects calcium, potassium, and magnesium ions as well as glucose metabolism.

MUST complete an electrolyte blood panel (focus on Chloride).

Having too much salt in the diet can cause the lithium level to be too low.

Not having enough dietary salt can cause the lithium levels to be too high.

Persistent thirst and diluted urine can indicate the need to call the MD; lithium dosage may need to be reduced. Anticonvulsant drugs: mechanism is unclear, but they raise the brains threshold for dealing with stimulation; this prevents the person from being bombarded with external and internal stimuli. Tegretol

Huge concern about agranulocytosis (a decrease in WBC).

Need serum levels monitored 12 hours after last dose.

Depakote

Need to monitor serum level, CBC with platelets, liver function including ammonia level (ammonia is a by-product of liver metabolism)

Klonopin

Anticonvulsant and benzodiazepine

Drug dependence can occur

Monitor CBC, liver function

Withdrawal drug slowly to prevent GI issues

Cannot be used alone to manage bipolar; must be used in conjunction with lithium or another mood stabilizer.

Helpful hints to care for bipolar clients

You cant teach a manic client

Safety is a huge issue because their judgment is poor.

Only spend short periods of time with patient

Must be flexible in taking intake assessment; may need to obtain data in several short sessions as well as talking to family members. Ask the client to explain any coded speech

Assist the client to meet socially accepting behaviors. Kathy, you are too close to my face. Please stand back two feet.

Feed them finger foods high in calories while in a manic phase; provide nutritional support!

Use simple sentences when communicating. It is also helpful to ask client to repeat brief messages to ensure they have heard and incorporated them. Please speak more slowly. Im having trouble following you.

Avoid becoming involved in power struggles over who will dominate the conversation. Suicide

4 out of 5 who actually commit suicide have made at least one prior attempt

In a majority of cases, there are clear indicators hat the person was very troubled.

Few than 15% of suicide victims leave suicide notes

The suicide risk is greatest in the 90 days following a major depressive episode. survivor guilt happens when 1 or more family members feel guilty that they are still living

Separation anxiety may cause they surviving to join the beloved deceased

Make the patient sign a contract for life

Crisis interventionmay need 1:1 care. The client is no more than 2-3 feet away from a staff member at any time, including going to the bathroom. Anxiety disorders & Substance abuse

Incidence

Most common emotional disorder in the U.S.

Prevalent in women; age