review 2 final sp2011 pdf

7/30/2019 Review 2 Final Sp2011 PDF

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The Birth of Community Mental Health(contd)

Community Mental Health Centers Actpassed by Congress in 1963

Expanded community care for theprevention of serious mental illness with

early intervention and outpatient therapy Provided for reimbursement of mental health

services through Medicare and Medicaid

Resulted in the deinstitutionalization of the

mentally ill State mental hospitals were closed

Individuals diagnosed with a mental illness weredischarged to the community for ongoing care


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Cause of Revolving Door in Mental

Health

Cost of care for hospitalized psychiatric

clients continue to rise.

Individuals with severe mental illness had

no place to go when their symptoms

became worst except back to the hospital.

Lack of funding for adequate

community services


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Primary Prevention

Primary prevention aims to prevent the

disease from occurring. So primary

prevention reduces both the incidence and

prevalence of a disease.

Encouraging people to protect themselves

from the sun's ultraviolet rays is an

example of primary prevention of skincancer.


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Secondary Prevention

Secondary prevention is usedafter the

disease has occurred, butbefore the

person notices that anything is wrong.

A doctor checking for suspicious skin

growths is an example of secondary

prevention of skin cancer. The goal of

secondary prevention is to find and treatdisease early. In many cases, the disease

can be cured.


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Tertiary Prevention

Tertiary prevention targets the person who

already has symptoms of the disease

The goals of tertiary prevention are: prevent damage and pain from the disease

slow down the disease

prevent the disease from causing otherproblems (These are called

"complications.")


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Tertiary Prevention (Contd)

give better care to people with the disease

make people with the disease healthy again

and able to do what they used to do

Developing better treatments for melanoma is

an example of tertiary prevention.

Other examples include better surgeries, newmedicines, rehabilitation etc.


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Characteristics Mental Health

Reality orientation: one characteristic of

mental health is that a person is able to

distinguish facts from fantasy, real world

from a dream world. Must have ability to

perceive reality without distortions, have a

good sense of consequences of your actions.


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Selfawareness/Introspection

Introspection is to look inward in an effort toward self

understanding.

Recognize own feelings, possible prejudices

Two of Socrates most well-known quotes are "knowthyself" and "the unexamined life is not worth living."

Introspection

helps the nurse identify thoughts and feelings

helps the nurse learn about his/her behavior prevent barrier to communication and

understanding of patients behavior


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What is Introspection?

Defined as: the observation or examination ofone's own mental and emotional state, mentalprocesses, etc.; the act of looking within oneself.

This implies that through introspection webecome self-aware.

The nurse needs to be aware of, understand,and consider his/her own feelings/behavior in

order to remain objective and to promotetherapeutic relationship.


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What defines a social

relationship?

A social relationship is reciprocal, that is bothpeople expect to get their needs met.

Have something in common

It involves friendship, companionship. Boundaries are not as defined

There are not necessarily goals to be met

We may give advice, have small talk


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Therapeutic Relationship

(Contd)

Therapeutic Relationship Goal specific

Client centered

Responsibility and reliability of nurse

Professional boundaries

Clients gain only

Clients needs are foremost

Open to supervision.


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Introspection (Contd)

Assists the nurse in identifying herthoughts and feelings and to learn abouthis/her behavior.

It promotes understanding of clientsbehavior by preventing barriers to

interpretation.


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Establishing Therapeutic

Relationship


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Establishing a Therapeutic

Relationship: Orientation Phase

Meeting nurse, client

Establishment of roles

Discussion of purposes, parameters of future

meetings

Clarification of expectations

Identification of clients problems

Nurse-client contracts/confidentiality, duty towarn/self-disclosure


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Behavior of Client During

Orientation Phase

Client May

Be distrustful, superficial, quiet, avoiddiscussion of issues

Resistance

Exaggerate problems

Have rambling speech/anxiety Act out


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Establishing the Therapeutic

Relationship: Working Phase

Problem identification: issues or concernsidentified by client; examination of clientsfeelings and responses.

During this phase trust begins to develop

and the patient begins to respondselectively to person who seem to offerhelp.

The patient begin to identify with the nurse

and identify problems, which can beworked on


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Therapeutic Roles of the

Nurse in a Relationship

Teacher identifying needs of pt.(coping, problemsolving, medication regimen, communityresources)


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Definition of a Scientific Theory

A theory comprises of a collection of

concepts used to explain observations


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Harry Stack Sullivan, a psychiatrist

He thought that inadequate or non-satisfying relationshipproduce anxiety and is the basis for all emotionalproblems

Sullivan thought that human nature must be understoodfrom the vantage point of interpersonal relations.

He believed that the development of self concept isinfluence by reflected appraisal.

The term reflected appraisal refers to a processwhere we imagine how other people see us. The waywe believe others perceive us is the way we perceiveourselves.

The self is the sum of reflected appraisals of others.

Interpersonal/Social Psychology

Theories


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Erik Erikson

The new Ego.

Erikson believed that the Ego Freud described was far

more than just a mediator between the superego and the

id.

Erikson saw the Egos main job was to establish and

maintain a sense of identity. (a sense of belonging).

Erikson developed stages of psychosocial development.

The inability to complete the first stage of Trust Vs.Mistrust may result in anxiety, heightened

insecurities, and an over feeling of mistrust in the

world around him/her.


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Eriksons Theory

Autonomy vs. Shame & Doubt

This is the stage of I am what I can do. The child egoskills continue to develop along with his/herwill

powerand self control. If a person develops a low self-esteem accompanied

by secretiveness. This person has not completed theautonomy vs. shame & doubt stage and needs tocomplete this stage before moving on to the other

stage of development. Initiative vs. Guilt (preschool) development of

conscience learning to manage conflict and anxiety.Continuation of autonomy.


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Eriksons Theory

Industry versus inferiority

Taking pleasures in his/her competence. Developing

confidence in his/her abilities. Failure to complete this

stage the child becomes a conformist and thoughtlessperson who others exploit . The person develops an

inferiority complex.

Identify vs. role confusion (adolescence)

Prior to this stage, development depends onwhat is done to the person.


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Defense Mechanism

An ego defense mechanism becomes

pathological only when its persistent use

leads to maladaptive behavior such that the

physical and/or mental health of theindividual is adversely affected.

The purpose of the ego defense mechanisms

is to protect the mind/self/ego from anxiety.


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Levels of Anxiety

Definition of Anxiety: is a state of dread,unpleasant feeling which leads to increased

helpless feeling. There are four levels of anxiety

Mild, Moderate, Severe,Panic

The nurse intervention must include:

Reducing the anxiety to a lower level

Observing the anxiety and identify the level

Inform the patient what is being done.


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Levels of Anxiety

MENTAL HEALTH NURSING:

Psychiatric Disorders

Mild

Associated with the tension of everyday life

The individual is alert The perceptual field is increased

Ability to learn is increased

Effective problem solving

S & S: Restlessness, fidgeting, buttterflies, sleep

disturbance, hypersensitive to noise.


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Anxiety Levels

Mild (Contd) Intervention: generally requires no direct intervention.

keep the clients anxiety level from escalating.

Assist the client to identify the event or situation that

preceded the symptoms of anxiety. Help the client to problem solve.

Assist the client to slow breathing rate and depth.

On Long term basis assist client to problem solve todecrease stress and anxiety

Assess the thoughts and feelings prior to the anxiety(i.e., what cause the anxiety).

Note anxiety is very contagious

Teaching can be very effective when there is mildanxiety.


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Obsessive-Compulsive Disorder

Obsessions((the thinking aspect) are recurrent,persistent, intrusive, and unwanted thoughts,images,or impulses that cause marked anxietyand interfere with interpersonal, social, or

occupational functioning.e.g. obsessed with contamination

Compuls ions(the acting aspect) are ritualistic orrepetitive behaviors or mental acts that a person

carries out continuously in an attempt to neutralizeanxiety.e.g. compulsion - repetitive hand washing


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Nursing Process for OCD

Intervention (Contd)

Assist client to identify events that increase

their rituals.

Plan schedule around clients rituals

Allow the client to perform the rituals but setlimits.

Be supportive to the client but limit the

behavior Protect client from harmful rituals e.g., give

gloves if the ritual is washing hands 90

times/day.


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OCD (Contd)

Important Nursing Implication: The

nurse must understand that the client

recognize that his/her symptoms are

unacceptable or foolish


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SOMATOFORM DISORDERS

Is a mental disorder characterized by physical

symptoms that suggest a medical condition.

Upon physical examination, the findings are

negative. Usually occurs before age 30. Client will talk

about multiple vague physical complaints

involving various parts of the body or various

body systems.

It is a chronic disorder


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SOMATOFORM DISORDERS

Onset and Clinical Course:

Symptoms usually onset in adolescence or early

adulthood

All the somatoform disorders are either chronicor recurrent

Clients will go from one physician or clinic to

another, or they may see multiple providers atonce in an effort to obtain relief of symptoms


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Somatoform Disorder

Intervention

Providing health teaching about the

manifestation of the disorder

Establishing a firm therapeutic alliance,( that

is, a therapeutic relationship between the

nurse/therapist and the client)

Providing consistent reassurance to client Evaluate any new complaints


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Conversion Disorder

Conversion disorder: unexplained deficits in sensoryor motor function associated with psychologicalfactors;

The client display a lack of concern towards the

physical symptoms. This is called la belleindif ference. It is believed the physicalsymptoms may relieve anxiety and result insecondary gains in the form of sympathy and

attention given by others.Primary gain is the relief of the emotional

conflict/anxiety.

Secondary gain is attention getting from others.


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Somatoform Disorders -Nursing

Conversion - Intervention

Meet the dependency needs that is, take care

of client physical needs, eg. paralysis,

perform ROM exercises of the limb.

Never imply the symptoms are not real Dont react to the client indifference (la Belle

Indifference)

Teach stress reduction and assertiveness

Be positive,make sure the client has a positive

feelings and has positive outcomes.


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SYMPTOMS OF SCHIZOPHRENIA

Types of symptoms

Negative symptoms

Positive symptoms


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SCHIZOPHRENIA NEGATIVE

SYMPTOMS

Soft or negative symptoms include:

Affect is an outward manifestation of feelings or

emotions.

Affect may be flat, blunt, labile inappropriate

Flat Affect Absence of any facial expression

that would indicate emotions or mood.

Blunted Affect showing little or slow to respond

with facial expression or no facial expression, voice

monotone and no eye contact.


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SCHIZOPHRENIA NEGATIVE

SYMPTOMS (Contd)

Labile Affect rapidly changing, unstable

and fluctuating emotions. May not fit

the situation with content and speech Apathy (lack of emotional involvement) -

the patient has build a wall of indifference

around himself.

Inappropriate incongruency between the content ofthe speech and the expressed emotion.


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SCHIZOPHRENIA POSITIVE

SYMPTOMS - Defense Mechanism -

Projection

Hallucinations are distortions orexaggerations of perception in any of the

senses that do not exist in realtiy. E.g.

auditory hallucinations (hearing voices) -

visual hallucinations.


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Hallucination and Defense

Mechanism

Hallucination and defense mechanismprojection:

Auditory hallucination means when there is

no one talking to the patient, the patientperceives that some one else is talking tohim. This is projection.

The patient is projecting unacceptable

feelings onto some one else. Forexample,The voice told me to kill the nonbelievers..



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SYMPTOMS (Contd)

Delusions - fixed false beliefs that have no basis in

reality.

Delusions defend against feelings, impulses or ideas

that cause client anxiety. Delusions of being followed or watched are common,

as are beliefs that comments, radio or TV programs,

etc., are directing special messages directly to

him/her. Eg. FBI

Short term goal for delusional client: That the

patient will report decreased frequency of

delusional thoughts.


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DELUSIONAL DISORDERS

Grandiose: People are convinced that

they have some great talent or have made

some important discovery. The grandiosity

is a symptom of low self esteem.

Nursing Outcome: Patient self-esteem

will increase


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Antipsychotic Side Effects mostly of

conventional antipsychotics drugs

Tardive dyskinesia (TDs) are involuntary

movements of the tongue lips, (sucking,

chewing and pursing movements of the

tongue and mouth) face, trunk and extremitiesthat occurs in patient treated with long term

dopaminergic antagonist medications.

Is common in patients with schizophrenia,

schizoaffective d/o and bipolar disorder.Treatment: cogentin, haldol, benadryl

S


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Schizophrenia Maintenance

Therapy

Three antipsychotics meds are available in depot

injection forms for maintenance therapy:

Fluphenazine (Prolixin) in decanoate and

enanthate preparationsHaloperidol (Haldol) in decanoate

RISPERDAL CONSTA

The effects of the medications last from 2 to 4 weeks,

eliminating the need for daily oral antipsychoticmedication

The medication improve patient compliancewith treatment.


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Antisocial Personality Disorder -

Characteristics

Very charming, cunning, superficial and veryaggressive in meeting their needs.

Adept at getting his way at the expense ofothers

Feelings of boredom which leads to impulsivityand irresponsibility

No blame or guilt acceptance

Lack definite goals. Lots of restlessness Impaired ability to sustain long lasting close,

warm responsible relationship.

A ti S i l P lit D/O


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Anti Social Personality D/O

Intervention

Provide structure and limit setting

Point out the unacceptable behavior.

Be direct and consistent about the

statement of the behavior.

Point out the consequences of the

unacceptable behavior and follow

through consistently.


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Characteristics Of Client With

Personality Disorder

Personality Disorder is characterized by

inflexible behavior pattern that causes

problem in functioning and relationship.

It is a maladaptation to interpersonal

interaction and social environment or

context (i.e. how the client viewed things,

objects, situations)


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Personality Disorders

Borderline Personality Disorder

Assessment:

Patients often has dysphoric mood( feeling of

unhappiness, emotional lability)

Dependency

Display impulsive behavior

Splitting, Over- idealization and devaluing

Experience suicidal feelings

Complains of feeling of emptiness,

suspiciousness and loneliness


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Borderline Personality Disorder

(Contd)

Intervention

Monitor for suicidal gestures because client

generally feel abandon and suicidality is a great

risk factor


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Individual Psychotherapy

Modifies a persons feelings, attitudes,and behavior

Involves one-on-one work between patient

and therapist. Allows the patient to have the full attention

of the therapist

Is limited - it does not allow the therapistan opportunity to observe the patientwithin social or family relationships.


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ETOH Withdrawal

Usually begins 4-12 hours after cessation or

marked reduction of ETOH.

Symptoms: coarse hand tremors, sweating,

elevated pulse and BP, insomnia, anxiety, N&V May progress to hallucination, seizures,

illusion, gross tremors and delirium tremens

(DTs)

Treatment: benzodiazepines to prevent

seizures


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Major Depression Disorder

Involves 2 or more weeks of sad mood, lack ofinterest in life activities (anhedonia), and at leastfour (4) other symptoms:

Changes in appetite or weight, sleep, or psychomotor

activity Decreased energy (persistent fatigue)

Feelings of worthlessness, hopelessness

helplessness

Persistent feeling of guilt or self-criticism Persistent sadness


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Major Depressive Disorder

Intervention

Provide for the clients safety and the safety ofothers

Promote a therapeutic relationship bymaintaining planned contact with patient.

Establish daily schedule of activities

Structure activities to facilitate completion of one

specific task. Sit silently with patient when patient is not too

communicative

Promote activities of daily living and physical care


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Treatment (Contd)

TCAs: amitriptyline (elavil), imipramine (tofranil),moderate and severe depression. Their onset of actionis 1-4 weeks. i.e., they take 1-4 weeks before the clientsymptoms begin to decrease.

Have anticholinergic side effects: blurred vision,dry mouth, constipation).

MAOIs (marplan, parnate, nardil) used infrequentlybecause interaction with tyramine causes hypertensivecrisis.

TCAs and MAOIs cannot be given concurrently The primary side effect is hypertensive crisis if the

drug is taken with food containing tyramine


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Bipolar Disorder

Assessment

Some people with mania exhibit psychoses e.g

delusions (unshakable beliefs in something untrue)

and/or hallucinations.

Some get hostile and aggressive if they needs are not

met.

Hyperactive, disorganized and has an elevated mood.

Easily stimulated by what is going on around him/her.

For how much the client is eating and sleeping


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Bipolar Disorder (Contd)

Assessment

Major symptoms of mania include:

Inflated self-esteem or grandiosity

Decreased need for sleep Psychomotor agitation

Pressured speech

Flight of ideas

Distractibility

Euphoria, labile mood


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Bipolar - Treatment

LITHIUM CARBONATE

Treatment and Prognosis - Medication

Treatment involves a lifetime regimen of

medications Lithium; regular monitoring of serum lithium levels is

needed.

Lithium not only competes for salt receptor sites butalso affects calcium, potassium and magnesium ionas well as glucose metabolism.

Therapeutic level 0.5-1.5 mEq/L


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Bipolar Treatment (Contd)

Lithium (Contd) Nursing Implication: Teach patient to maintain

adequate salt in the diet.

If patient is toxic, hold medication and report to MD

Anticonvulsant drugs are used for their mood-stabilizingeffects:

Depakote therapeutic level 50-100 mcg/ml.

Side effect: Weight gain, agranulocytosis

Tegretol therapeutic level 6-12 mcg/ml

Side effects:agranulocytosis, thrombocytopenia,aplastic anemia


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Bipolar Disorder

Intervention

Providing for safety of client and others

Meeting physiologic needs

Providing therapeutic communication Promoting appropriate behaviors

Managing medications

Providing client and family teaching

Set limits on intrusive or interruptive behaviors.

review 2 final sp2011 pdf

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