nclex-rn preparation program mental health disorders module 6, part 1 of 3

NCLEX-RN PREPARATION PROGRAM

MENTAL HEALTH

DISORDERS

Module 6, Part 1 of 3

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Module Description

This module will prepare the graduate nurse to pass the NCLEX exam in the area of mental health. Included in this module is a review of the following areas: Therapeutic communication and milieu

therapy Nursing process Mental illnesses and disorders Psychopharmacology Life span development issues

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Introduction

The nurse must be aware of the therapeutic or nontherapeutic value of the communication techniques used with the client—they are the “tools” of psychosocial intervention.

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What is Communication? Interpersonal communication is a

transaction between the sender and the receiver. Both persons participate simultaneously.

In the transactional model, both participants perceive each other, listen to each other and simultaneously engage in the process of creating meaning in a relationship.

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Communication Includes: dominant language, dialects,

contextual use of language; Paralanguage variations such as voice volume,

tone, inflections and willingness to share thoughts and feelings;

Nonverbal communications such as eye contact, gesturing and facial expressions, use of touch, body language, spatial distancing practices and acceptable greetings;.

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Communication Communication is:

Temporary in terms of past, present and future orientation of worldview;

Clock versus social time, and the amount of formality in use of names

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Therapeutic communication techniques encourage the client or other individual with whom the nurse is communicating to express their thoughts and feelings.

Communication

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Technique Active Listening

Broad Openings

Description Carefully noting what the client is saying and observing the client’s nonverbal behavior

Encouraging the client to select topics for discussion

Communication

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Technique:Clarifying

Focusing

Description:Making the message clearer, to correct any misunderstanding, and to promote mutual understanding

Directing the conversation onto the topic being discussed

Communication

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Technique:Informing

Open-ended questions

Description:Giving information to the client

Encourage conversation because questions require more than just one-word answers

Communication

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Technique:Paraphrasing

Reflecting

Silence

Description:Restating in different words what the client said

Directing the client’s question or statement or feelings back to the client

Allowing time for formulating thoughts

Communication

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Approval/Disapproval Asking excessive

questions Changing the subject Close-ended questions

Giving advice False reassurance Value judgments Why questions Minimizing the client’s

feelings

Non-therapeutic Communication Techniques

Communication

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NCLEX Communication Question Guidelines

Look for the option that indicates the use of a therapeutic communication technique.

Eliminate non-therapeutic communication techniques.

Look for the option that focuses on feelings, concerns, anxieties or fears.

Consider cultural differences as you answer the questions.

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Impact of Preexisting Conditions

Both sender and receiver bring certain preexisting conditions to the exchange that influence both the intended message and the way in which it is interpreted.

Values, attitudes, and beliefs. Attitudes of prejudice are expressed through negative stereotyping.

Culture or religion. Cultural mores, norms, ideas and customs provide the basis for ways of thinking. How do these affect the relationship?

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Social status. High-status persons often convey their high-power position with gestures of hands on hips, power dressing, greater height, and more distance when communicating with individuals considered to be of lower social status.

Gender. Masculine and feminine

gestures influence messages conveyed in communication with others.

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Age or developmental level. The influence of developmental level on communication is especially evident during adolescence, with words such as “cool,” “awesome” and others.

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Impact of Preexisting ConditionsThe environment in which the transaction takes place. Territoriality, density, and distance are aspects of environment that communicate messages.

Territoriality – the innate tendency to own space Density – the number of people within a given environmental space Distance – the means by which various cultures use space to communicate

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With regard to communication, there are three cultural characteristics to consider:

Communication styleUse of eye contactThe meaning of touch

The goal is to promote cultural sensitivity and culturally competent care that respects each person’s right to be understood and treated as a unique individual.

CommunicationCultural Considerations

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Communication Style

African Americans• Personal questions asked on initial contact

may be viewed as intrusive

Communication Cultural Consideration

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Communication Style

Asian cultures Open expression of emotions not valued Silence is valued Criticism or disagreement not expressed Head nodding does not necessarily mean agreement May interpret the word “no” as disrespect for others Do not use hand gestures


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Communication Style

Americans of Northern European descent Silence can be used to show respect or

disrespect, depending on situation May show little facial emotion because they

value concept of self-control


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Communication Style

French and Italian Americans May use expressive hand gestures and

animated facial expressions


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Communication Style

Hispanic Americans May use dramatic body language such as

gestures or facial expressions to express emotion or pain

Confidentiality important Direct confrontation disrespectful, and

expression of negative feelings impolite


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Communication Style

Native Americans Silence indicates respect for the speaker Speak in a low tone of voice and expects

others to be attentive Body language is important Obtaining input from extended family

important


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Use Of Eye Contact

Asian Cultures Eye contact is limited and may be

considered inappropriate or disrespectful


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Use Of Eye Contact

European (White) Americans Eye contact viewed as indicating trustworthiness

Native Americans Eye contact may be viewed as a sign of disrespect Client may be attentive even when eye contact is

absent


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Use Of Eye Contact

Hispanic Americans Avoiding eye contact with a person in

authority indicates respect and attentiveness


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Meaning of Touch

African Americans• Comfortable with close personal space when

interacting with family and friends

European (White) Americans Tend to avoid close physical contact Respect personal space


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Meaning of TouchAsian Cultures Prefer formal personal space except with family & close friends Usually do not touch others during conversation Touching unacceptable with members of the opposite sex; if

possible, a female client prefers a female health care provider The head is considered to be sacred; touching someone on the

head may be considered disrespectful Avoid physical closeness and excessive touching and only touch

a client’s head when necessary, informing before doing so


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Meaning of Touch

Hispanic Americans Comfortable with close proximity with family,

friends and acquaintances Protect privacy Tactile and sensory are important - use

embraces and handshakes Ask if it would be all right to touch a child

before examining him or her


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While communicating with a client, a nurse decides to provide the client with feedback. The primary reason for this is that giving appropriate feedback makes it possible for the nurse to:

A. Present advice

B. Explore feelings

C. Provide information

D. Explain behavior

Practice Question - Communication

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Overview of Psychiatric Mental Health Nursing

Mental Health

The ability to see oneself as others do Fit into one’s culture and society Indicators of mental health

Positive attitudes toward self, growth, development, self actualization, integration, autonomy, reality perception and environmental mastery.

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Mental Illness

Inability to see as others do Not having the ability to conform to the norms

of the culture and society

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Medical Diagnosis of Mental Illness

Classified according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), of the American Psychiatric Association.

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The DSM-IV Classification system uses five axes for diagnostic purposes:

Axis I: Adult and child clinical disorders

Axis II: Personality disorders; mental retardation

Axis III: General medical conditions

Axis IV: Psychosocial and environmental problems

Axis V: Global assessment of functioning (0-100)

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Mental Health Nurses

Need both general and specific cultural knowledge

If above absent, nurses won’t know what questions to ask

Generalizations made are almost certain to be oversimplifications

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Mental Health Nurses Must first address their own personal and

professional knowledge, values, beliefs, ethics and life experiences in a manner that optimizes assessment of and interactions with culturally diverse clients

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Mental Health Nurses Self awareness includes a deliberate

process of getting to know oneself; one’s own personality, values, beliefs, professional knowledge, standards, ethics and the impact of the various roles one plays when interacting with individuals who are different from oneself.

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Overview of PMHN Duties/Responsibilities

Psychiatric Mental Health Nurses (PMHNs): Assess, formulate nursing interventions, and

implement individualized treatment plans with culturally competent interventions.

Document progress. Document changes. Attend interdisciplinary meetings to discuss

progress, issues and treatment updates. Complete assault prevention training and other

required trainings.

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Overview of PMHN Duties/Responsibilities

Uphold professional standards of behavior, appearance, language, dress and demeanor.

As a member of an integrated treatment team, assist families, agency representatives and other staff.

Understand the legal framework for the delivery of mental health services.

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Nursing Process

Assessment Nsg Dx Outcome ID Planning Implementation Evaluation

Gathering and organizing data Identify (ID) areas for

intervention Setting outcome criteria Planning action to meet the goals Carrying out actions Evaluating if goals (outcomes)

are met

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Mental Health Assessment

INTERVIEW

During the interview, the nurse uses verbal and nonverbal therapeutic communication techniques to collect subjective and objective data about the client.

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Purpose Establish rapport Determine reason client is seeking help Obtain an understanding of current illness (via

client, family, chart review and interdisciplinary team)

Understand how this illness has affected client’s life

Identify client’s recent life changes or stressors

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Gather current life style information Social patterns Interests and abilities Relationship issues Substance use and abuse


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Assess for risk factors Suicide or self-harm Assault or violence Physiological instability

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Appraisal of health and illness Info on previous psychiatric problems or

or disorders Current and past medications Physiological coping responses Psychological coping responses Resources

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Nursing Conditions During Assessment

Self-awareness Accurate observations Therapeutic communication Establish nursing contract Obtain information Organize data

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Analyze Data/Norms Formulate Nursing Diagnoses

Identify patterns in data Compare with norms Analyze and synthesize data Identify problems and strengths Validate problems with client Formulate nursing diagnoses Set priorities of problems

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Outcome Identification (Goals) Identify expected outcomes individualized to client Planning

Interventions to attain outcomes Nursing Conditions

Application of theory Nursing Behaviors

Prioritize goals Identify nursing activities Validate plan with client/family

Key Elements Individualized, collaborative, documented

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Implementation Implements interventions identified in the

plan of care Experience Evidence-based practice Nursing behaviors

Know available resources, implement, generate alternatives, coordinate with other team members

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Evaluation

Evaluation of progress in attaining expected outcomes

An ongoing process Client and family participation essential Goal achievement should be documented Revisions in the plan of care PRN

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Levels of Intervention Counseling Milieu therapy Self-care activities Psychobiological

interventions Health teaching Case management

Health maintenance and promotion

Based on Nurse Practice Act

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Nursing Interventions Form a trusting one-on-one relationship with the

client Mutual learning experience for both the nurse and

client Corrective emotional experience for the client

Explore stressors Give constructive feedback Promote development of insight and constructive

coping Overcome resistance behavior

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Nursing Interventions Behavioral change is the focus Emphasize positive results Provide an environment that is safe and private

with decreased stimuli as needed Ensure physical and psychosocial needs are met Encourage client participation in treatment

planning Administer medications as ordered and assess

results Educate client and family

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Specific Nursing Interventions

Active listening Anger control Assertiveness training Behavior management Body image enhancement Delusion management Eating disorders

management Grief work facilitation Hallucination management

Impulse control training Milieu therapy Mood management Role enhancement Sleep enhancement Spiritual support Substance abuse Tx Suicide prevention Teaching (meds…)

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Legal and Ethical Issues

Definitions

Voluntary admission:

Client consents to confinement in the hospital and signs a document indicating as much.

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Definitions

Mental Health 72-hour Hold (“5150”):May be implemented on the basis that client poses a danger to self or others or is gravely disabled due to mental illness. Some states also have the criterion of prevention of significant physical or mental deterioration for involuntary admission. Police, doctors, psychologists, county-approved mental health professionals, nurses may initiate.

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Criteria for Involuntary Confinement

DANGER TO SELF DANGER TO OTHERS GRAVELY DISABLED(Due to mental illness)

72-hour hold (5150) 72-hour hold 72-hour hold

14-day certification (5250)

14-day certification 14-day certification

Certification Review Certification Review Certification Review

Hearing Hearing Hearing

Writ of Habeas Corpus Writ of Habeas Corpus Writ of Habeas Corpus

14-day Extension 90-day Extension Temporary conservatorship (30-day-6 months)

1 year conservatorship

Rehearing

Reappointment

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Involuntary Confinement (continued)

DANGER TO SELF ASSESSMENT

DANGER TO OTHERS ASSESSMENT

GRAVELY DISABLED ASSESSMENT

Suicidal ideation Homicidal ideations Inability to provide food, clothing, shelter for self.

Delusions or hallucinations which increase potential of suicide.

Delusions or hallucinations which increase potential for harm to others.

Amount of income, how it is spent

Lethality Lethality Medical, psychological, educational, social and legal situation

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Definitions

Competency: A legal determination that a client can make reasonable judgments and decisions about treatment and other significant areas of personal life.

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Legal and Ethical IssuesInformed consent: Client’s right to be given enough info to:

Make a decision Understand the information Communicate his or her decision to others Receive explanation of client rights and unit policies Receive signed statement of understanding/refusal to receive Tx Receive explanation of insurance benefits or payment options/third-party reimbursement

In an emergency situation, where there is not time to obtain consent without endangering health or safety a client may be treated without legal liability.

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Client Rights/Nursing Responsibility Right to appropriate treatment Right to know qualifications of those involved in

treatment process Right to receive explanations of treatment Right to be involved in planning of own care Right to refuse to be a part of experimental treatment

methods Right to understand the effects of prescribed

medication Right to treatment in least restrictive environment Right to refuse treatment - decide which treatment

option is best for them

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Principle of Confidentiality

Federal laws regarding chemical dependence confidentiality; staff members are not allowed to disclose any admission or discharge information.

States have laws regarding when HIV test results or the diagnosis of acquired immunodeficiency syndrome (AIDS) may be disclosed.

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Legal and Ethical Issues Principles of Confidentiality Client’s right

Prevent written or verbal communications from being disclosed to outside parties without authorization

Required by Nurse Practice Act HIPAA (Health Insurance Portability and Accountability

Act of 1996 (2003) Ensures that security procedures protect the privacy and

confidentiality of information Client has right to know what information is disclosed, to

whom and for what purpose

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Required disclosure Intent to commit a crime Duty to warn endangered persons Evidence of child, elder, vulnerable adult

abuse Initiation of involuntary hospitalization

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An adult client says, “No, I don’t want that medicine. I won’t take it.” The nurse says, “Take it. It’s good medicine.” The nurse then places the cup in front of the client’s mouth and forcefully presses it against the client’s lips. In counseling this nurse, what important legal principle(s) can be applied to the nurse’s action? Select all that apply.

A. If a client does not object a second time, a nurse can administer the medication.

B. If treatment is given without consent, legal charges of battery can be filed.

C. Clients have the right to be treated in the least restrictive manner possible.

D. Clients, unless declared legally incompetent, have the right to refuse medication.

E. Clients who wish to do so may establish psychiatric advance directives.

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A client has purposefully attempted to embarrass a nurse by making a sexually explicit comment. The best response by the nurse is to:

A. Clarify the intention of the client.B. Leave the situation altogether.C. Refuse to talk with the client any further.D. Continue to interact as if the comments

did not cause embarrassment.

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Crisis

Definition of Crisis

Being confronted by a stress with which the individual is unable to cope/problem-solve

Threatens the individual’s equilibrium Generally time limited, lasting from 4 to 6 weeks Potential for increased psychological vulnerability

or personal growth

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Crisis

Interventions Establish a relationship Identify the problem Identify and reduce perceptual distortions Enhance self-esteem Alleviate anxiety Promote engagement of support systems Reinforce healthy coping Validate client’s ability to problem-solve. Keep safe if at risk for suicide

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A client seeks assistance at a crisis center. The client describes being intensely anxious and sleepless since assisting with cleanup activities at a school where a student fatally shot a classmate. To assist the client to cope more effectively, what should be the first intervention of the nurse?

A. Arrange for a member of the clergy to visit the client

B. Advise the client to avoid going near the school for at least 6 weeks

C. Send the client to the Emergency Department for further evaluation

D. Allow ventilation of feelings

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When the nurse is working with a client in crisis, which nursing action is most important?

A. Obtaining a complete assessment of the client’s past history

B. Remaining focused on the client’s immediate problem

C. Determining the relationship of early life experiences and the crisis state

D. Developing an action plan for the client

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Suicide Prevention

Assessment Determine suicidal ideation Evaluate how client sought help Suicide plan? Mental status Available support systems Lifestyle

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Suicide Prevention

Interventions

Inpatient interventions Providing a safe milieu in which the client’s

ability to act out on suicidal ideations is minimized

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Suicide Prevention

Safe Milieu (continued)

Depending on the degree of suicidal ideation and lethality assessed

Constant observation for 24 hours or until the degree of suicidal risk is lessened

15-minute checks thereafter Maintain awareness of the client’s

whereabouts constantly

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Suicide Prevention

Safe Milieu (continued)

Upon admission to the unit: Assess personal belongings and remove any

items that could be used to harm client (drugs, potentially sharp objects, cords and neck ties) and keep them in a safe place.

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Suicide Prevention

Safe Milieu (continued) Keep the unit free of materials that can be used

by clients to harm themselves. For example, metal or glass objects that may be altered

to create a sharp edge, light fixture or call bell cords Keep windows locked, count silverware, and

check the client’s belongings when returning from a pass.

Check gifts and other items brought in by visitors for safety before being given to the client.

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Suicide Prevention

Safe Milieu (continued) Develop a safety plan and assess frequently Oral check for hoarding medications for a later overdose Assign a roommate to reduce the opportunity for solitude Work with the client to identify an aftercare plan that includes:

A commitment to attend aftercare appointments An agreement to maintain contact with social support systems Identification of a safety plan with emergency contact

numbers An action plan should suicidal ideations return

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Psychopharmacology Prevent SuicidePharmacologic interventions Pharmacologic interventions aimed at treating:

Underlying mood disorder Other psychiatric disorders Co-existing psychiatric disorders

Depressive disorders treated with antidepressants SSRIs relatively low risk of lethal overdose Tricyclic antidepressants can be highly lethal in

overdose Quantity of prescribed/dispensed kept at a minimum and

may need to be managed by a family member

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For the third time within a month, a client with borderline personality disorder took a handful of pills, called 911, and was admitted to the Emergency Department. The nurse overhears an unlicensed staff member say, “Here she comes again. If she was serious about committing suicide, she’d have done it by now.” The nurse determines there is a need to teach the staff member which of the following?

A. Clients with personality disorders rarely kill themselves.

B. Each suicide attempt should be taken seriously.

C. Exploration of suicidal ideas and intent should be avoided.

D. The nurse should prepare the client for direct inpatient admission.

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A client has been treated in the surgical intensive care unit after sustaining a self-inflicted gunshot wound. The client is now admitted to a psychiatric unit. The nurse schedules time to meet with the client on a one-to-one basis with the goals that the client will: (Select all that apply.)

A. Explore current life events that led to the suicide attempt.

B. Initiate contact with the nurse spontaneously.

C. Discuss past suicidal ideations and behavior.

D. Enter into a contract for safety with the nurse.

E. Identify post-discharge living arrangements.

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Mental Health Therapies

Inpatient Hospitalization

Conditions for hospitalization: Dangerous to oneself or others Incapable of providing for one’s basic physical

needs; gravely disabled In need of care or treatment in the hospital

(voluntary)

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Milieu Therapy An environment designed to promote healing

experiences and to provide a corrective setting for the enhancement of the client’s coping abilities. Includes: Correcting perceptions of stressors Changing coping mechanisms from maladaptive to

adaptive Improving interpersonal relationship skills Learning effective stress management strategies

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Critical Issues

Boundaries define functions in the therapeutic relationship and imply responsibility.

The nurse must clarify/maintain boundaries to make the client more at ease in the new relationship and environment.

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What Is Child Abuse?

Definition Child abuse: Any act of omission or commission

that endangers or impairs child’s physical or emotional health and development.

Sexual Abuse: Victimizer uses victim for sexual gratification & victim incapable of consenting to this sexual activity or of resisting when it occurs.

Physical Abuse: Deliberate violent actions that inflict pain and/or non-accidental injury.

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What Is Child Abuse?

Child Abuse

Physical neglect - Deprivation or non-provision of necessary & socially-available resources

Psychological abuse - Deliberate destruction of a person’s sense of competence

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Elder AbuseElder abuse Mistreatment or neglect of an elderly person Most victims are women 75 years of age or older Victims usually physically, emotionally or

financially dependent on their abusers Types:

Psychological abuse Physical abuse Neglect (intentional or unintentional) Financial or material abuse

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Mandated Reporters: Abuse

Mandated Reporters Nurses who suspect abuse of children,

dependent adults or elders must report it. You must immediately call and report the

suspected abuse. A follow-up written report is required within two

working days. Failure to report abuse is a misdemeanor.

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A 5-year-old girl is brought to the clinic for symptoms of a urinary tract infection (UTI). The nurse’s assessment reveals bruises in the child’s genital and rectal areas. The mother reports that she left the little girl with her boyfriend the night before. The nurse’s first priority with this client is to take what action?

A. Obtain a urine sample to confirm a UTI.

B. Teach the mother about symptoms of UTI.

C. Report suspected sexual abuse to protective services.

D. Assess the child for other health problems.

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An 85-year-old client is brought into the Emergency Department after a fall at home. The client appears confused and malnourished and is severely dehydrated. The client can speak but appears reluctant to explain how the fall happened. The client’s 62-year-old daughter frequently interrupts the client and does not allow the client to answer questions. Which of the following nursing interventions is a priority?

A. Take the history from the daughter because the client is confused.

B. Provide the daughter with nutritional teaching.

C. Request a psychiatric evaluation for the client.

D. Interview the client alone first and assess for abuse.

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Protection in the Mental Health Setting - Restraints

Restraints

Seclusion – placement of client in controlled environment to treat a clinical emergency

Physical restraint – use of mechanical devices to provide limited movement by client

Chemical restraint – use of medication to calm client and prevent need for physical restraint

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Protection in the Mental Health Setting- Restraints

Restraints

Physical restraint appropriate after all other types of interventions are used to assist the client to control his/her behavior and remain safe

Documentation of all interventions and results are critical

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Protection in the Mental Health Setting- Restraints

Restraints

Legal Implications Physician’s order is a necessity Facility rules and state laws Liability for false imprisonment Liability for assault and battery KNOW LIMITATIONS OF THE LAW!

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Documentation should include: Description of a clear process from less restrictive

interventions Criteria for a removal of restraints Care and observation during the use of restraints Regular assessment of the client and potential

complications of restraints Reasons for removal of restraints Follow-up interventions, including processing with client,

event leading to restraint.

Protection in the Mental Health Setting - Restraints

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Photo Acknowledgement:All unmarked photos and clip art

contained in this module were obtained from the

2003 Microsoft Office Clip Art Gallery.

nclex-rn preparation program mental health disorders module 6, part 1 of 3

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