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NSG211 Test #1 - TEST 1 NOTES
Health Care Concepts II (NSG 211)
Germanna Community College
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Test 1: Halter/Varcarolis, Chapters: 1, 9, 15, 16, read key points (end of chapter) for 2-8, 13, 14, 15 read key points (end of chapter) for 17 Lilley, Chapters: 16
Week 1:
Watch Mental Health Concepts Content Video Links (1-2) Watch Generalized Anxiety Disorder Content Video Links (1-7) Watch Personality Disorder Content Video Links (1-6) Watch Somatic and Dissociative Disorders Content Video Links (1-11) Exemplars: Generalized Anxiety Disorder Phobias Obsessive Compulsive Disorder (OCD) Panic Disorders Posttraumatic Stress Disorder (PTSD) Pharmacology: Benzodiazepines Anxiolytics (Buspirone, Hydroxyzine)
Concept 1:
Powerpoint: Introduction to Mental Health Concepts Part 1 Introduction ● Individuals experience both physical and psychological responses to stress ● Mental health ○ State of well-being in which individuals reach their own potential, cope with the normal stresses of life, work productively, and contribute to the community ● Capacity for ○ Rational thinking ○ Communication skills ○ Learning ○ Emotional growth ○ Resilience ○ Self-esteem Basic Concepts related to Mental Health
❖ Mental Health Continuum ➢ On the illness end, the person is rarely in touch with reality, but on the healthy side, the person demonstrates a high level of wellness ➢ The point at which a person is deemed to be mentally ill is determined by the behavior exhibited as well as the context in which the behavior is observed ➢ Mental illness results from an inability to cope with an overwhelming situation Mental Illness ➢ Psychiatric disorders with definable diagnoses ➢ Significant dysfunction in mental functioning related to ○ Developmental ○ Biological ○ Physiological disturbances ➢ Culturally defined ➢ Considered clinically significant when marked by ○ Unable to fulfill roles Cultural Concepts ➔ Nurses must understand cultural concepts because cultural influences affect human behavior, the interpretation of human behavior, and the response to human behavior ➔ Caution must be taken not to assume that all individuals who share a culture or ethnic group are the same. This constitutes stereotyping and must be avoided. All individuals must be appreciated for their uniqueness ➔ Culture-Bound Syndromes ◆ Symptoms associated with specific cultures that may be expressed differently from the American culture Background ★ 1860s: Asylums have roots in Civil War era ★ 1950s: First antipsychotic medication ★ 1960s: Medicare and Medicaid with no funding for psychiatric care ★ 1999: Olmstead Decision: Deinstitutionalization
Diathesis- Stress Model ➢ Diathesis- biological predisposition ➢ Stress- environmental stress or trauma ➢ Most accepted explanation for mental illness ➢ Combination of genetic vulnerability and negative environmental stressors ➢ Assertion: Most psychiatric disorders result from a combination of genetic vulnerability and negative environmental stressors Basic Concepts ➔ Anxiety ◆ Vague feeling of apprehension that results from a perceived threat to self ◆ Major component of all mental health disturbances ● Mild forms ready the body to meet stressful demands ○ Problem solving and constructive action ● Severe forms interfere with daily activities ○ Immobilized coping skills and result of emotional chaos ◆ Degree of anxiety influenced by ● How the person views the stressor ● The number of stressors being handled at one time ● Previous experience with similar situations ● Magnitude of change the even represents for the individual Diagnoses ★ DSM (Diagnostic and Statistical Manual) ○ Focuses on research and clinical observation when constructing diagnostic categories of a mental disorder ★ DSM is considered the “bible” for mental health workers (e., psychiatrists, psychiatric nurses, psychologists) ★ North American Nursing Diagnoses Association (NANDA) ○ International describes a nursing diagnosis as a clinical judgment about responses to health problems ○ Psychiatric- mental health nursing includes that diagnoses and treatment responses to mental health problems Biological Aspects ● In recent years, a greater emphasis has been placed on the study of the organic basis for psychiatric illness ● A number of mental illnesses are now being considered as physical disorders that are the result of malfunctions or malformations of the brain
● The study of the biological foundations of cognitive, emotional, and behavioral processes is called psychobiology Function of Brainstem and Hypothalamus ❖ Core- regulates internal organs and vital functions ❖ Hypothalamus- basic drives and link between thought and emotion and function of internal organs ❖ Brainstem- processing center for sensory information Functions of the Cerebellum and Cerebrum ➢ Cerebellum ○ Regulates skeletal muscle ○ Maintains equilibrium ➢ Cerebrum ○ Mental activities ○ Conscious sense of being ○ Emotional status ○ Memory ○ Control of skeletal muscles- movement ○ Language and communication Activities of Neurons ➔ Once an electrical impulse reaches the end of a neuron, a neurotransmitter (neuro messenger) is released Destruction of Neurotransmitters ★ First way: immediate inactivation of the neurotransmitter at the postsynaptic membrane
Neurotransmitters ❖ Monoamines ➢ Dopamine ■ Decrease: Parkinson disease, depression ■ Increase: Schizophrenia, mania ➢ Norepinephrine ■ Decrease: Depression ■ Increase: Anxiety states ➢ Serotonin ■ Decrease: Depression ■ Increase: Anxiety states ➢ Histamine ■ High levels associated with anxiety and depression ❖ Amino Acids ➢ Gamma-amino butyric acid (GABA) ■ Decrease: anxiety disorders, schizophrenia, mania, Hunting chorea ■ Increase: reduction of anxiety, schizophrenia, mania ➢ Glutamate ■ Is the major mediator of excitatory signals in the central nervous system ■ Is involved in most aspects of normal brain function including cognition, memory, and learning ❖ Cholinergics
➢ Acetylcholine ■ Decrease: Alzheimer disease, Huntington chorea, Parkinson disease ■ Increase: Depression Implications for Psychiatric Illness ➢ Schizophrenia ○ Anomalies of the brain include: ■ Enlarged ventricular size, decreased temporal lobe ■ Dilation of cortical sulci and fissures ■ Functional asymmetry related to language comprehension and speech production ■ Histological changes in limbic system, thalamus, basal ganglia, hippocampus, and frontal cortex ○ Neurotransmitter hypothesis: various biochemicals implicated ■ An excess of dopamine ■ Abnormalities in norepinephrine, serotonin, acetylcholine, GABA, prostaglandins, and endorphins may contribute ○ Possible endocrine correlation ■ Possible correlation with decreased levels of the hormone prolactin ➢ Mood Disorders ○ Neuroanatomical considerations- possible pathology of the limbic system, the basal ganglia, and the hypothalamus (HPA axis) ○ Neurotransmitters hypothesis ■ Depression- deficiency of serotonin, norepinephrine and dopamine ■ Mania- excess of norepinephrine and dopamine ■ Serotonin appears to remain low in both states ○ Possible endocrine correlation: Hormonal anomalies include: ■ Depression- failure of normal hormonal inhibition results in a hypersecretion of cortisol ■ Hypothyroidism has been associated with symptoms of depression and hyperthyroidism with acute mania ■ Increased secretion of melatonin- seasonal mood issues ➢ Anxiety Disorders ○ Neuroanatomical considerations- pathology in areas includes ■ Stimulation of the limbic system produces anxiety and fear responses ■ The cingulate gyrus of the limbic system implicated in OCD ■ The locus coeruleus has been implicated, particularly panic disorder ○ Neurotransmitters hypothesis
★ Patient-centered medical homes (PCMHs) ★ Community mental health centers ★ Psychiatric home care ★ Assertive community treatment (ACT) ★ Intensive outpatient programs and partial hospitalization ★ Other outpatient venues for psychiatric care ○ Telepsychiatry ○ Mobile mental health units Levels of Care ● Inpatient psychiatric facilities ○ Voluntary vs involuntary (TDO) ○ Criteria for admission ■ Danger to Self/Others ■ Unable to protect self from harm ○ Partial hospitalization ○ Day programs/clubhouse model ○ Intensive outpatient programs ○ Outpatient therapy Inpatient Care Settings ❖ Crisis Stabilization/ Observational Units ❖ General Hospitals and Private Hospitals ❖ State Psychiatric Hospitals Treatment Modalities ➢ Biological ○ Medications ○ ECT ➢ Psychosocial ○ Psychoanalytical ○ Milieu ■ A scientific structuring of the environment to effect behavioral changes and to improve the psychological health and functioning of the individual (think of this as “everything”) ■ Within the therapeutic community setting, the client is expected to learn adaptive coping and interaction and relationship skills that can be generalized to other aspects of his or her life ■ Surroundings and physical environment ● Managing behavioral crisis ● Safety
● Unit design ■ Goals of unit design ● Promote an environment of safety and empower patients to partner with clinical staff and take ownership of their own health and safety ■ Basic assumptions of milieu therapy ● The health in each individual is to be realized and encouraged to grow ● Every interaction is an opportunity for therapeutic intervention ● The client owns his or her own environment and behavior ● Peer pressure is a useful and powerful tool ● Inappropriate behaviors are dealt with as they occur ● Restrictions and punishments are to be avoided ○ Group ○ Family ○ Activity ○ Play ○ Behavioral ➢ Other ○ Music ○ Art ○ Recreation The Program of Therapeutic Community ➔ Care is directed by an interdisciplinary team ➔ A comprehensive treatment plan is formulated by the team ➔ Team members of all disciplines sign the plan and meet regularly to update the plan as needed ➔ Disciplines may include psychiatry, psychology, nursing, social work, occupational therapy, recreational therapy, art therapy, music therapy, dietetics, and chaplain’s service Conditions that Promote a Therapeutic Community ★ Basic physiological needs are fulfilled ★ The physical facilities are conducive to achievement of the goals of therapy ★ A democratic form of self-government exists ★ Responsibilities are assigned according to client capabilities ★ A structured program of social and work-related activities is scheduled as part of the treatment program
➢ Personality has 3 parts: ■ Id- unconscious, immediate, pleasure principle, avoiding pain ■ Ego, conscious, based in reality, controls problem-solving and rational thinking, serves a balance between self and environment ■ Superego- both unconscious and conscious, uncompromising, basis of shame and guilt, morals ➢ Importance of early life trauma in later mental disorders ➢ Focuses on 3 layers of mental activity: ■ Conscious ■ Unconscious ■ Preconscious ➢ Concepts important ■ Transference ■ Countertransference ➢ Defense mechanisms and anxiety ■ Operate on unconscious level ■ Deny, falsify, or distort reality to make it less threatening ● Compensation: Overachievement in one area to offset deficiencies (real or imagined), frustration, or failures in another area. Making up for a deficit by excelling in another area (i., poor student becomes super jock) ● Conversion: Anxiety converted into a physical symptoms that is motor or sensory in nature (i., hysterical paralysis, hysterical blindness) ● Denial: Refusal to acknowledge a fact of reality. Disavowing thoughts, feelings, wishes, needs or other reality factors ● Displacement: Directing feelings about one object/person toward a less threatening object or person ● Dissociation: Separation or splitting off of one aspect of mental process from conscious awareness ● Identification: a person regards as his own traits, accomplishments, and/or feelings of another. Unconscious modeling of another person ● Isolation/ Intellectualization: Actual facts of a situation are allowed to remain conscious, but the link between these facts and the related emotions or impulses is broken. Person can actually explain the situation without showing emotion. In intellectualization the focus is on details rather than feelings, the feelings are repressed ● Projection: Placing own undesirable trait onto another; blaming others for own difficulty
● Rationalization: Developing an acceptable, justifiable (to self) reason for behavior. Justification of behavior or offering a socially acceptable, intellectual and apparently logical explanation for an act or decision caused by unconscious impulses ● Regression: Behavior that reflects an earlier level of development ● Repression: Unable to have conscious awareness of conflicts that are sources of anxiety. Thoughts or emotions are thrust out of consciousness ● Reaction/formation: Engaging in behavior that is opposite of true desire. Unaccepted impulses are repressed, denied and reacted to by opposite overt behavior ● Sublimation: Anxiety channeled into socially dependable behaviors. Substituting unacceptable sexual or aggressive drives or impulses with socially acceptable behavior ● Symbolization: Representing an idea or object by a substitute object or idea which comes to stand for another through some quality they have in common ● Undoing: behaviors that are opposite of earlier unacceptable behavior or thought. A specific action is taken which neutralizes a previous unacceptable action ● Suppression: Consciously putting a threatening/unwanted thought out of one’s awareness. Choosing not to think about something ❖ Interpersonal Theory ➢ Purpose of all behavior is to get needs met through interpersonal interactions and to reduce or avoid anxiety ➢ Sullivan- impact of social environment or interpersonal relationships ➢ Interpersonal therapy is most effective in treating: ■ Grief and loss ■ Interpersonal disputes ■ Role transition ➢ Implications of interpersonal theory to Nursing ■ Foundations: Hildegard Peplau ● Seen as founder of mental health nursing as a science ● Nurse as both participant and observer ◆ Self-awareness helps keep focus on patient ● Application of sullivan’s theory of anxiety to nursing practice ● Lowering patients’ anxiety improves ability to think and function
● Mindfulness ● Distress tolerance ● Interpersonal effectiveness ● Emotional regulation ❖ Maslow’s Hierarchy of Needs ➢ Maslow identified: ■ A “hierarchy of needs” ■ Self-actualization as fulfillment of one’s highest potential ➢ Implications for Nursing ■ Emphasis on human potential and the patient’s strengths ■ Prioritizing: establishes what is most important in the sequencing of nursing actions ❖ More Biological Therapies ➢ Pharmacotherapy ■ Use of medication to treat psychiatric illness
➢ Brain stimulation therapies ■ Electroconvulsive therapy (ECT) ■ Transcranial magnetic stimulation- repetitive (rTMS) ■ Vagus nerve stimulation (VNS) ■ Deep brain stimulation (DBS) ❖ Developmental Theories ➢ Theory of Psychosocial Development (Erikson’s) ■ Eight stages of development ● Personality continues to develop through old age ■ Psychodynamic Therapy ➢ Focuses more on here and now ➢ Uses many tools of psychoanalysis ➢ Best candidates are the “worried well” ○ Have a clear area of difficulty ○ Are intelligent and well motivated for change ➢ Increased back and forth between therapist and patient Theory of Human Motivation ➔ Asserts that psychology must go beyond experiences of hate, pain, misery, guilt, and conflict to include love, compassion, happiness, exhilaration, and well-being ➔ Human beings are active participants in life, striving for self-actualization ➔ When lower needs are met, higher needs are able to emerge Basic Concepts Related to Mental Health ★ Adaptation and Coping ○ Adaptation ■ An individual’s ability to adjust to changing life situations using various strategies ○ Coping Responses ■ Used to reduce anxiety brought on by stress ■ Examples: overeating, drinking, smoking, withdrawal, seeking someone to talk to, yelling, exercising, fighting, pacing, or listening to music ○ May be used consciously or unconsciously
intervenes by stating, “You may approach the nurse’s station only once an hour.” Which nursing intervention has been employed? ● A. Providing reality orientation ● B. Ensuring physical need fulfillment ● C. Setting limits on behavior ● D. Providing client education ● Rationale: in this situation the nurse is responsible for setting limits on unacceptable behavior in the therapeutic milieu. Consistency in carrying out the consequences of violation of the established limits is essential if learning is to be reinforced Hospital Admission Procedures ★ Voluntary admission (sought by patient or guardian) ★ Involuntary admission (without patient’s consent) ○ Danger to self or others ○ Gravely disabled (unable to protect self from harm) ○ In need of treatment and illness prevents voluntary help seeking ★ Emergency commitment (temporary admission) ○ Used for observation, diagnosis and treatment VA Involuntary Commitment Laws ● ECO petition initiated through civil court ● Law enforcement executes ● Patient transported to safe evaluation site ● CSB evaluator has 8 hours to complete evaluation and confirm need for TDO and find bed placement ● Patient hospitalized- hearing within 72 hours Question Which individual may need involuntary hospitalization? A. A person with alcoholism who has been sober for 6 months but begins drinking again B. An individual with schizophrenia who stops taking prescribed antipsychotic drugs C. An individual with bipolar disorder, manic phase, who has not eaten in 4 days D. Someone who repeatedly phones a national TV broadcasting service with news tips Patient’s Rights Under the Law ➢ Right to treatment ➢ Right to refuse treatment
➢ Right to informed consent ○ Patient is informed of risks, benefits, and alternatives ○ Person must voluntarily accept treatment ○ Implied consent ○ Capacity and competency ➢ Rights regarding psychiatric advance directives ➢ Rights regarding restraint and seclusion ○ Orders and documentation ○ In an emergency, a nurse may place a patient in seclusion or restraint but obtains a written or verbal order as soon as possible thereafter ○ Orders for restraint or seclusion are never written as an as needed or standing order Use of Restraint/Seclusion ➔ Only as a last resort- Danger to self/others ➔ Requires doctor’s order. RN can initiate but must immediately contact physician for order ➔ Order is time-limited based on age: ◆ Adult- 4 hours ◆ Adolescent- 2 hours ◆ Child 9 and under- 1 hour ➔ Someone remains with patient at all times ➔ Documentation is key- every 15 minutes typically ➔ Every 2 hours- document fluids, food, toileting, range of motion ➔ Continue to document patient’s behavior justifying continued restraints Legal Issues in Psychiatric/ Mental Health Nursing ★ Confidentiality and Right to Privacy ○ HIPPA ○ Doctrine of privileged communication ○ Exception: a duty to warn ★ Informed consent ★ Restraints and seclusion ○ False imprisonment ★ Commitment issues ○ Voluntary admissions ○ Involuntary commitments ■ Emergency commitments ■ The mentally ill person in need of treatment ■ Involuntary outpatient commitment ■ The gravely disabled client
NSG211 Test #1 - TEST 1 NOTES
Course: Health Care Concepts II (NSG 211)
University: Germanna Community College
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