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What is mental health?
- Reaction = stimulus or situation
- Rational decisions
- Coping skills--> situation and age dependent
- Within the norm
- Range of emotions --> joy
- Reality testing
- self destructive
- Self responsible
- Relationship with people
- Connection to something that is bigger than yourself --> spiritual
What are the 7 signs of mental health?
- 1. Happiness
- 2. Control over behavior
- 3. Appraisal of reality
- 4. Effectiveness in work
- 5. Healthy self-concept
- 6. Satisfying relationships
- 7. Effective coping strategies
Why do we study the distribution of mental disorders?
- Identify high-risk groups
- Identify high-risk factors
When we study mental disorders, what do we use the information for?
- Improve clinical practice
- Plan public health policies
What is used to diagnose a psychiatric disorder?
In the DSM-IV-TR:
Mental disorders are considered what?
a dysfunction of the individual
The DSM-IV-TR Multiaxial System
- Axis I: Mental disorder that is the focus of treatment
- Axis II: Personality disorders and mental retardation
- Axis III: General medical disorder relevant to the mental disorder in Axis I
- Axis IV: Psychosocial and environmental problems
- Axis V: Global Assessment of Functioning (GAF) --> we no longer use Axis 5
What are the factors effecting mental health?
- Support Systems
- Family influences
- Developmental events
- Cultural beliefs and values
- Health practices
- Negative influences
When you are demonstrating caring, who/what do we have to care about?
- About what you do
What are the reasons for psychiatric hospitalizations?
- Danger to self or others
- De-compensation under long term tx
- Failure of outpatient tx, need for intensive structured treatment
- Medical need associated with psychiatric tx
What are the goals for psychiatric inpatient treatment
- Prevent harm to self or others
- Stabilize crisis
- Initiation or modification of RX
- Brief specification problem solving
- Rapid establishment of outpatient tx
What is due process in civil commitment?
- Writ of habeas corpus means "free the person". This is the procedure to challenge unlawful detention by the government
- Least restrictive alternative doctrine
What are the different admission types into a psychiatric facility?
- Involuntary (commitment)
What are the nature and purpose of involuntary admission?
- Observational or temporary
- Long-term or formal
What are client's rights under the law in a psychiatric facility?
- Right to treatment
- Right to refuse treatment (unless involuntary)
- Right to informed consent
- Rights surrounding involuntary commitment
- Psychiatric advanced directives
- Rights regarding seclusion and restraint
What are the exceptions to client confidentiality?
- Duty to warn and protect third parties
- Child and elder abuse reporting statues
What is a tort?
A civil wrong for which monetary damages may be collected by the injured party (plaintiff) from the wrongdoer (the defendant)
A voluntary act performed with the intent to bring about the physical consequence
What are examples of intentional tort?
- False Imprisionment
- Punitive damages
What are examples of unintentional tort?
What are some guidelines for avoiding liability?
- Always put the client's rights and welfare first
- Comply with the rules and regulations in the hospital's or agency's policy manual
- Practice within the scope of the state's nurse practice act
- Maintain current understanding and knowledge of established practice standards
- Keep accurate, concise, and timely nursing records
What is important to remember about violence and the nursing field?
- Nurses must protect themselves in institutional or community settings
- Employers are not typically held responsible for employee injuries caused by violent client behavior
- Nurses have placed themselves knowingly in the range of danger by agreeing to care for unpredictable clients
- Good judgement means --> not placing oneself in a potentially violent situation
What is Negligence?
An act or an omission to act that reaches the duty of due care and results in or is responsible or a person's injuries
What are the 5 elements required to prove negligence?
- 1. Duty
- 2. Breach of Duty
- 3. Cause of Fact
- 4. Proximate cause
- 5. Damages
What are the guidelines for nurses who suspect negligence?
Duty to intervene --> psych nurse has duty to intervene when safety or well-being of client or another person is obviously at risk
Duty to report
Unethical or illegal practices
What is important to remember about documenting care and a records usefulness?
The usefulness is determined by evaluating the record is read later, how accurately and completely it portrays the client's behavioral status at the time it was written
What is Milieu therapy?
(physical and social environment)
In Milieu therapy, what is the nurse responsible for on the management of a unit?
- communication open and constructive
- patient involve in some decisions and explain others
- real life learning and problem solving
In milieu therapy, what are examples of group activities that can be used?
- Community meetings
- Special groups --> goal setting
- Family groups + educational groups
In milieu therapy, what are part of the safety aspect?
- track patients that are off the unit
- flow of visitors
- control of sharp objects + ETOH & drugs
- sexual activity prevented
- minimize violence and disruption
- minimize elopement w/o making atmosphere one of imprisionment
In milieu therapy, what is part of the medication administration?
- safe administration
- monitor reactions
- "med nurse" or "primary nurse"
- central location & patient responsible
- patient request of RX
In milieu therapy, what is involved in crisis management?
- Medical crisis
- Behavioral crisis --> violence
In milieu therapy, what is involved in documentation?
- Whole team is responsible
- Nurse coordinates: 24 hour responsibility
- (and how its run)
What is the protocol of group therapy?
- Clear, concise objections
- Methods to evaluate success of group
What is the role of a nurse in group therapy?
In group therapy, what are some therapist techniques?
In group therapy, what are the different types of groups?
- Time limited
- Therapeutic milieu
- Story telling
In group therapy, what is involved in establishing a group?
General guidelines + Inpatient + Outpatient group
In group therapy, what are the phases of group development?
- Forming --> role, expectations
- Storming --> resistant to task & group influence (conflict)
- Norming --> intimate personal feelings + cohesiveness
- Performing --> problem solving & work
In group therapy, what are some behaviors that might be a problem?
- Person who monopolizes a group
- Person who complains but continues to reject help
- Person who avoids personal issues by helping others
- Disliked person
In group therapy, what diagnostic categories may not be suitable?
- Antisocial PD
- Paranoid behaviors
- Borderline PD
- Special populations
- Serious and persistently mentally ill
- Dual DX
- Eating disorders
What is anger?
A normal human emotional response to the perception of frustration of desires, threat to one's needs (emotional or physical), and challenge
What is aggression?
Harsh physical or verbal action that reflects rage, hostility, and potential for physical or verbal destructiveness
What are the stages of anger and aggression?
Where are the areas of the hospital that may be more prone to anger and aggression?
- Psychiatric units
- Emergency departments
- Waiting rooms
- Geriatric units
What are some co-morbidities that anger occurs with?
- Oppositional defiant disorder
- Impulsivity in children
- Psychotic disorders with paranoid delusions
- Alzheimer's disease
- Personality disorders
- Tourette's syndrome
What is important to remember about the expression of anger?
- Not always beneficial to client
- Can lead to escalation of anger
- Association with negative physiological change (i.e. cardiac reactivity)
- Venting of anger in close relationship blocs development of healthy interaction
What is part of the behavioral theory of anger and aggression?
- Children learn aggression by imitating others
- People repeat behavior that is rewarded
What is part the cognitive theory of anger and aggression?
Perceived assault on areas of personal domain, values, moral codes, and protective rules can lead to anger
What are the areas of the brain that are involved with aggressiveness?
- Limbic system
- Temporal lobe
In anger and aggression, what are low levels of serotonin consistent with?
What genetic and environmental factors are important in anger and aggression?
Family dynamics affect dispositions of infants
Self-assessment of a nurse
What part of personal responses are important?
- Choice of words
- Tone of voice
- Nonverbal communication
- Personal triggers
- Personal sense of competence
Self-assessment of a nurse
Without self-knowledge nurse are likely to make...?
- Impulsive interventions
- Emotion-based repsonses
What are some techniques for the nurse to be able to respond calmly to anger and aggression?
- Deep breathing
- Relaxation of muscles not in use
- Empathetic interventions
What is the single best predictor of future violence?
History of violence
What are some demographic risk factors for anger and aggression?
- Aged 14-24 years
- Low socioeconomic status
- Low support system
What are some milieu characteristics conductive to violence?
- Staff inexperience
- Provoking or controlling behaviors by staff
- Lack of limit setting
- Random taking away of privileges
What should be involved in the pre-assaultive stage?
- analyze client and situation
- use verbal techniques of de-escalation
- show respect for clients of personal space
- quiet environment, visible to staff
- Ensure safety
What are some de-escalation techniques?
- Respond as early as possible
- Remain honest
- Be goal oriented
- Give several options
What is seclusion?
Involved confinement alone in a room that the client is prevented from leaving
What are restraints?
Restriction of movement of client's body by manual or mechanical method
During an assaultive stage, what is important to remember about seclusion and restraint?
- Can only be used if client is a danger to self or others
- Can only be used when less-restrictive methods have been tried failed
- Require a physician's order and assessment
- Order includes reason client has been condined, how he or she should be confined, maximum time of confinement, and criteria for release
- Client must be directly observed by a staff member for safety during the entire confinement
- Licensing and accreditation agencies guide the times for assessment, hydration, toileting needs, nutrition, comfort, and documentation
What medications are typically used during the assaultive phase of anger and aggression?
- Major tranquilizers (antipsychotic)