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Assessment in Mental Health Nursing

• Utilizes observation, interviews, physical exams, and collaboration.
• Includes respecting client personal space and therapeutic communication.
• Requires obtaining detailed medical and psychosocial history.
• Involves continuous ongoing assessment with each client encounter.

Psychosocial History

• Includes assessing perception of health and illness.
• Considers activity level and leisure activities
• Explores substance use history
• Evaluates coping abilities and support systems.

Mental Status Examination (MSE)

Level of Consciousness

• Alert: Client who responds normally.
• Lethargic: Client is drowsy and falls asleep easily.
• Stuporous: Client who needs vigorous stimuli to respond.
• Comatose: Client is unconscious and does not respond to pain.
• Decorticate rigidity: Client with flexed arms and legs.
• Decerebrate rigidity: Client with extended arms and legs.

Physical Appearance

• Includes hygiene, grooming, and nutritional status.
• Also includes behavior, mood (subjective feeling), and affect (objective expression).

Cognitive & Intellectual Abilities

• Takes into account orientation (person, place, time)
• Includes memory, abstract thinking (problem-solving)
• Encompasses judgement (decision-making ability)

Cultural & Spiritual Considerations

• Involves assessing cultural beliefs, practices, and dietary restrictions.
• Spirituality involves internal values and purpose.
• Religion involves structured beliefs and rituals.

Standardized Screening Tools

• Includes Adverse Childhood Experiences Questionnaire.
• Includes Brief Patient Health Questionnaire (Brief PHQ).
• Includes Mini-Mental State Examination (MMSE).
• Involves assessing orientation, memory, attention, and language.

Considerations Across the Lifespan

Children & Adolescents

• Considers family dynamics, culture, and development.
• Use HEADSS tool (Home, Education, Activities, Drugs, Sexuality, Suicide risk, Safety).

Older Adults

• Includes considering functional ability, social support, and safety risks.

Trauma-Informed Care

• Requires recognizing signs of trauma and triggers.
• Requires to avoid re-traumatization.

Mental Health Diagnoses

• Use DSM-5-TR (2022) to diagnosing disorders.
• Serious mental illness (SMI) involves persistent disorders affecting someone's daily life.

Role & Life Changes

• Includes major transitions like loss of employment, divorce, or retirement which can impact mental health.
• Involves assessing coping strategies, support systems, and functional ability.

Therapeutic Strategies

• Includes counseling (therapeutic communication).
• Considers Milieu Therapy (structured, supportive environment).
• Screening assesses trauma history and coping skills.
• Employs Self-Care Promotion (independent care skills).
• Involves Psychobiological Interventions (medication management).
• Utilizes Cognitive-Behavioral Therapy (CBT techniques).
• Works with Health Promotion (smoking cessation, lifestyle changes).
• Includes Case Management (holistic care planning).

Legal and Ethical Issues in Mental Health Nursing

Legal Rights of Clients in Mental Health Settings

• Clients with mental health disorders have the same legal rights as any other citizen.
• Right to humane treatment & care (medical, dental, and psychiatric care).
• Right to vote & to obtain, forfeit, or deny a driver's license.
• Right to press charges against another person.
• Include informed consent & right to refuse treatment and confidentiality (HIPAA).
• Provide freedom from physical or chemical restraint, abuse, or neglect
• Right to a psychiatric advance directive
• Offer provision of care in the least restrictive environment (avoiding unnecessary seclusion or restraints)

Ethical Principles in Mental Health Nursing

• Beneficence is acting in the client's best interest
• Autonomy is client's right to make their own decisions
• Justice involves fair treatment for all.
• Fidelity involves keeping commitments and being loyal.
• Veracity is being truthful.

Types of Admission to a Mental Health Facility

• Informal Admission involves least restrictive, client can leave anytime.
• Voluntary Admission involves client choice of admission and the ability to refuse medication/treatment.
• Temporary Emergency Admission occurs for emergency mental health care, usually limited to ≤15 days.
• Involuntary Admission happens against the will, for dangerous, or disabled clients.

Client Rights Regarding Seclusion & Restraint

• Use a restraint only if less restrictive interventions fail.
• Restraint Time Limits; ≥18 years old: 4 hours, 9-17 years old: 2 hours, ≤8 years old: 1 hour
• Frequent monitoring & documentation is required (every 15-30 mins).
• Discontinue seclusion or restraints as soon as the client is safe.
• PRN (as-needed) prescriptions for restraints are NOT allowed.

Confidentiality & HIPAA

• Do NOT discuss client info publicly (e.g., social media, public places).
• Only share info with team members involved in treatment.
• Exceptions to confidentiality include, Duty to warn potential victims of harm (Tarasoff Law), Reporting abuse (child or vulnerable adult)

Legal & Ethical Client Issues

• Torts are civil wrongs that cause harm
• Intentional Torts include False imprisonment – Unjustly confining a client, Assault - Verbal threats, Battery - Physical harm (e.g., forcing medication)
• Unintentional Torts can be Negligence - Failure to meet the expected standard of care, Malpractice – Professional negligence leading to harm.

Documentation Guidelines

• Be clear, factual, and objective.
• Include client behavior (e.g., “Client ran down the hall screaming").
• Include staff response (e.g., "Nurse calmly redirected the client and ensured safety").
• Include when the provider was notified.

CHAPTER 3, Effective Communication

Basic Levels of Communication

• Intrapersonal Communication is self-talk or internal voice
• Interpersonal Communication is one-on-one communication.
• Small-group Communication is dialogue between multiple people
• Public Communication is with large groups.

Verbal Communication

• Vocabulary needs to avoid medical jargon; ensure clarity.
• Be aware that words can have different Denotative vs. Connotative Meaning.
• Clarity/Brevity allows best simple, clear communication
• Timing/Relevance for well timed communication
• Pacing needs to avoid speaking too fast which can increase anxiety.
• Intonation is the Tone of voice conveys emotions.

Nonverbal Communication

• Can be more impactful than verbal communication.
• Pay attention to: Appearance (grooming, hygiene), Posture & Gait, Facial Expressions & Eye Contact
• Also be aware of Gestures & Sounds, Territoriality & Personal Space & Silence (allows time for reflection)

Therapeutic Communication

• Purposeful communication builds a trusting relationship.
• Gathers information, provide support, and help clients express their feelings

Characteristics of Therapeutic Communication

• Client-centered (focuses on the client, not the nurse).
• Purposeful, planned, and goal-directed.

Essential Components

• Allow adequate Time, especially for clients with mental disorders (e.g., depression, schizophrenia).
• Active Listening allows to Hear, observe, and understand the client's communication.
• Caring Attitude needs to Show concern and emotional connection.
• Honesty, Trust, Empathy and Nonjudgmental Attitude are all key

Effective Communication Skills & Techniques

• Practicing Silence allows reflection.
• Active Listening lets you Engage with the client's message.

Questioning Techniques

• Open-ended questions get deeper responses
• Close-ended questions give specific information
• Projective questions uses “What if” to explore thoughts
• Presupposition questions creates life without their disorder

Clarifying Techniques

• Restating: Repeat client's words.
• Reflecting: Encourage client to examine feelings.
• Paraphrasing: Summarize client's message.
• Exploring: Encourage deeper discussion.
• Focusing: Keep the conversation on key issues.
• Giving Information: Provide relevant facts.
• Presenting Reality: Helps clients distinguish delusions from reality.
• Summarizing: Reinforces important points.
• Offering Self: Shows availability and support.

Barriers to Effective Communication

• Asking irrelevant personal questions or Offering personal opinions
• Giving advice instead of letting clients explore solutions.
• Providing false reassurance or Minimizing feelings
• Changing the topic or Asking "why” questions due to the accusatory nature
• Offering value judgments or Using excessive questioning.
• Giving approval or disapproval which can influence behavior.

Communication Adaptations for Different Age Groups

Children

• Use simple language and Be at eye level.
• Use play to encourage communication.

Adolescents

• Consider peer relationships & identity concerns.
• Determine risk for treatment refusal.

Older Adults

• Minimize distractions and Speak slowly & clearly.
• Allow extra time for responses.
• Seek input from family or caregivers if needed.

Chapter 4: Creating and Maintaining a Therapeutic and Safe Environment

Therapeutic Nurse-Client Relationship

• Purposeful and goal-directed.
• Requires well-defined with clear boundaries.
• Structured to meet client's needs.
• Safe, confidential, reliable, and consistent.

Milieu Therapy

• Creates a structured, supportive, and safe environment for clients.
• Goal: Help clients learn adaptive coping, interaction skills, and relationship-building for recovery.

Nurse's Role

• Ensure client and staff safety.
• Manage behaviors to reduce stress.
• Encourage self-responsibility and recovery skills.
• Facilitate group/community meetings.

Characteristics of the Therapeutic Milieu

Physical Setting

• Clean, orderly, and well-furnished to promote relaxation.
• Has areas for solitude and group interactions.
• Needs safe furniture, good lighting, and low noise levels.
• The traffic flow should minimize client agitation.

Health Care Team Responsibilities

• Promote independence and self-care.
• Treat clients with fairness and respect.
• Model good social behavior.
• Set clear professional boundaries.
• Encourage self-worth and hope.

Emotional Climate

• Clients should feel safe from harm (self-harm or others).
• Clients should feel cared for and accepted.

Roles of the Nurse in a Therapeutic Relationship

• Maintain self-awareness of personal values and beliefs.
• Focus on the client's thoughts, feelings, and experiences.
• Identify client needs and encourage problem-solving.
• Promote autonomy and self-reliance.
• Educate the client and family on mental health topics.
• Encourage positive behavior change.
• Establish a trauma-informed, nonjudgmental environment.

Benefits of the Therapeutic Relationship

• Promotes well-being for clients with mental illnesses.
• Creates positive impact on treatment outcomes.
• Collaboration with the interdisciplinary team strengthens care.

Factors that enhance therapeutic relationships

• Consistent approach to interactions.
• Active listening and attentiveness.
• Build trust and professional boundaries.

Establishing Boundaries in the Nurse-Client Relationship

• Blurred Boundaries occur when the nurse's needs are met rather than the client's.
• The relationship becomes social instead of therapeutic.

Types of Relationships

• Social Relationship: Focuses on mutual needs (e.g., friendship).
• Therapeutic Relationship: Focuses on client's problems to support recovery.

Transference & Countertransference

Transference

• Client projects feelings about someone else onto the nurse.
• Example: "You remind me of my father."
• Nursing Implication: Address transference therapeutically.

Countertransference

• Nurse projects their personal feelings onto the client.
• Example: The client reminds the nurse of a friend, affecting objectivity.
• Nursing Implication: Seek peer or supervisor support if countertransference occurs.

Phases of Therapeutic Relationships

Orientation Phase (Establishing Trust)

• Introduce yourself, establish boundaries.
• Discuss confidentiality.
• Explore client's thoughts, feelings, and needs.
• Identify testing behaviors and trust issues.

Working Phase (Encouraging Change)

• Maintain relationship & evaluate client's progress.
• Encourage problem-solving and self-esteem.
• Address resistance and transference issues.
• Revise plans as needed.

Termination Phase (Ending Relationship)

• Summarize progress and discuss future plans.
• Review coping strategies and prepare for independence.

Client Safety in the Milieu

• Prevents harm: no access to sharp objects or harmful items.
• Involves restricting visitors and monitor client behaviors with limited substance access (alcohol, drugs).
• Prevents elopement (escaping the facility).
• Uses de-escalation techniques for agitation.

Room Assignments

• Considers mental health diagnoses.
• Be mindful of nighttime disruptions.
• Avoid pairing paranoid clients together.

Activities Within the Therapeutic Milieu

• Community Meetings encourage participation, decision-making, and self-worth.
• Individual Therapy are One-on-one sessions with a provider.
• Group Therapy are Peer support sessions for mental health concerns.
• Psychoeducational Groups that Teach coping strategies and mental health education
• Recreational Therapy providesExercise, games, community outings
• Unstructured Time allows for client observation.

Chapter 5, Diverse Practice Settings

Overview of Mental Health Nursing

• Occurs across acute care, community settings, and forensic nursing.
• Advocacy and referrals support individuals with mental illnesses.

Settings for Mental Health Care

Acute Care

• Intensive treatment provided in locked units for clients posing a danger to themselves or others.
• Goal: Stabilize symptoms for a quick return to the community.
• Care provided by interprofessional teams.
• Can be privately owned, state-run, or part of general hospitals.
• Has forensic units in correctional facilities
• Case management eases the transition to community settings.

Community Settings

• Includes clinics, schools, partial hospitalization programs, crisis centers, and home health care.

The Nurse’s Role

-Stabilizes clients for community integration, providing referrals, and promoting social activities.

• Focuses on all levels of prevention for optimal outcomes.

Forensic Nursing

• Consists of nursing, biophysical and forensic science.
• Assists with evidence collection, trauma analysis and treatment of victims of violence, abuse, and trauma.

Rehabilitation

• Provided in structured environments for clients with substance use disorders, self-harm, anxiety, and PTSD.
• Offers medication support, daily living assistance and has varied treatment durations.

History of Mental Health Care in the U.S.

Early care

• Occurred in institutional facilities prior to the 20th century.

Mid-1900s

• Congress enacted laws to improve conditions and promote deinstitutionalization.

1970s-1990s

• Case management introduced which reduced hospital stays.

1999

• Mental illness was recognized as a disability under the Americans with Disabilities Act.

Acute Mental Health Care Settings Admission Criteria

• Danger to self/others
• Inability to meet basic needs
• Failure of community treatments
• Coexisting mental illness and medical needs

Goals

• Preventing harm, stabilizing mental health crises and transition to community setting.

Community-Based Mental Health Programs

Partial Hospitalization Programs

• Intense, short-term treatment which includes detox programs when appropriate.

Assertive Community Treatment (ACT)

• Reduces hospitalizations with crisis intervention and support in clients’ homes.

Community Mental Health Centers

• Education groups, and access to medication programs and counseling opportunities.

Psychosocial Rehabilitation Programs:

• Residential and day programming with specific programming for older adults when needs require.

Home-Based Services

• Provided mental health care to children, older adults, and medically frail clients

Telehealth

• Expands access for those unable to attend in person therapy through virtual meetings.

Levels of Prevention

Primary Prevention:

• Prevents mental illness before it starts (i.e., stress management training).

Secondary Prevention:

• Early detection and intervention (i.e., screenings).

Tertiary Prevention:

• Rehab and relapse prevention (i.e., support groups).

Roles of Nurses in Mental Health Practice

Registered Nurse (RN)

• Requires a degree and offers medication, nursing interventions, and facilitates care management.

Advanced Practice Nurse (APN)

• Requires a master's or doctorate in behavioral health, can prescribe medication and conduct original research.

Chapter 6, Psychoanalysis, Psychotherapy, and Behavioral Therapies

• These address mental health issues using different approaches.
• Nurses collect data, identify needs, evaluate therapy, advocate for client’s right to treatment, and psychoeducation

Psychoanalysis

Classical Psychoanalysis

• Long-term, resolves conflicts with unconscious thoughts.
• Developed by Sigmund Freud and focuses on early childhood experiences.
• Rarely used now due to time demand and/or insurance restrictions.

Psychoanalysis Techniques

Transference

• Clients redirect feelings to the therapist.

Countertransference

• Therapists unconsciously get reactions toward the patient.

Psychoanalysis Tools

Free Association

• Spontaneous, uncensored thought sharing.

Dream Analysis

• Dreams are reflective of urges.

Using Defense Mechanisms

• Helps client cope with anxiety.

Psychotherapy

• More interactive with client-therapist trust which is key to problem-solving.

Types of Psychotherapy

Psychodynamic Therapy

• Similar to psychoanalysis but focuses on current issues and takes less time.

Interpersonal Psychotherapy (IPT)

• Addresses issues and is triggered by their stressors.

Cognitive Therapy

• Based on changing feelings, has shown to be effective for depression, anxiety, and trauma disorders.

Behavioral Therapy

• Behaviors is based on behaviorism, rooted in learning, to treat mental illness .

Desensitization and Reprocessing (EMDR)

• Processing traumatic memories in a structured environment.
• Effective for PTSD and anxiety.

Cognitive-Behavioral Therapy (CBT)

• CBT is a mix of cognitive, behavioral therapy, used for anxiety, depression, and stress.

Dialectical Behavior Therapy (DBT)

• Helps a subset of clients with personality issues, focuses on gradual changes, is emotionally informed.

Cognitive Therapy Implementation

Cognitive Reframing

• Challenges negative thoughts to help develop healthier thinking patterns.

Priority Restructuring

• Focuses on healthy, enjoyable activities.

Journal Keeping

• Encourages processing the experience.

Monitoring

• Recognizes challenges to change negative thinking.

Behavioral Therapy Types and Uses

Modeling

• Therapists show clients proper behaviors to imitate good social skills. Operant Conditioning is Positive reinforcement for desirable behavior.

Other Behavior Therapies

Systematic Desensitization

• Gradually exposes the client to anxiety provoking stimuli with relaxation techniques to manage anxiety.

Aversion Therapy

• Pairing a maladaptive with bad enforcement.
• Example: using something bad tasting to avert the interest in alcohol.

Relaxation

• Involves meditation and biofeedback

Flooding

• Exposes a client to triggers to decrease fear.

Response Prevention

• Prevents compulsions to break the behaviors.

Thought Stopping

• Teaches to interrupt thoughts with verbal commands such as “STOP”.

Trauma-Focused CBT

• Uses coping mechanisms for the client to reframe memories.

Validation Therapy

• Used for neurocognitive disorders and creates validation.

Virtual Exposure

• Creates safe environment for them to treat with less risk phobias or other disorders.

Chapter 7, Group and Family Therapy

• Group and family participation provides a therapeutic method of expressing feelings.
• Leadership provides a supportive influence.

Leadership Styles

Democratic leadership

• Encourages interaction for decision making.

Lazzaire Fair

• Promotes autonomy. Autocratic - The leader controls the structure without allowing much group input.

Examples of Group Therapy

• Therapy is used in Stress management, Substance abuse recovery, Understanding mental illness, and Dual diagnosis.

Key Concepts in Group Therapy

• Group Process is the interaction between members of a group in sessions.
• Group Norms is expected behaviors within the group, such as raising hands before speaking in assigned seats.

Hidden Agenda

• Unstated personal goals that disrupt group process.
• Example: a member embarrassing someone.

Group Dynamics

• A group can be open (new members join) and closed (membership is exclusive).

Group Homogeneity

• Members share a characteristic, such as gender, ethnicity, or diagnosis

Group Heterogeneity

• Members differ in mixed variables, such as gender

Subgroups

• Smaller groups that work separately.

Components of Therapy Sessions

• Components offer cohesion and clear communication of guidelines toward a therapeutic objective. "

Focuses and Goals for Each Type of Therapy

• Individual Therapy focuses on the needs of the client, developing self awareness. The Goals are for self development, improved decision making.
• Family Therapy* Focuses on family dynamics, improves understating and positive interactions.
• Group Therapy* Helps members develop self awareness, encouraging behavior changes and improving relationships.

What are The Goals in Group Therapy?

• To encourage sharing of emotions and healing, in addition to a therapeutic advantage over individual therapy.

Key Concerns in Group Therapy

• Privacy issues
• Unequal attention
• Disruptive behaviors

Phases of Group Development

Planning phase

• Characterized in defining structures of membership to select leadership.

Orientation phase

• Involves defining goals of trust and structure as well developing termination policies.

Working Phase

• Involves problem solving while communicating and working towards goals.

Termination Phase

• Characterized in reflection in group growth.

Roles in Group Therapy

Maintenance Roles

• Focused on keeping the group focused on its main objectives.

Task Roles

• Involve organizing group activities.

Individual Roles

• Can disrupt the process by prioritizing personal agendas.

Examples of Group Therapy Settings

Acute Mental Health Setting

• Involves immediate relief, in which leaders provide structure daily.

Outpatient Setting

• Longer therapy with attendance, members help shape the group for long term goals. "

Virtual Groups

• Remote therapy sessions in the age of technology

Challenges include

• Access to technology
• Difficulty with nonverbal
• Lack of presence in discussions.

Family and Therapy

• Healthy families promote clear communication and emotional support Families & Family Therapy

Types of Families

• Nuclear has married parents with children.
• Single parents are the parent raising the child.
• Adoptive families are parents through adoption.
• Blended families have stepparents.
• Cohabitating families are not married and still raising families.
• Extended families such as extended parents.

Functional Families

• Support flexibility for a healthy communication and emotional environment.

Dysfunctional Families

• Employ negative copying mechanisms by poor communication.

Family Boundaries

• Healthy boundaries provide mutual understanding while roles are defined.
• Dysfunctional families may employ boundary enmeshment, causing the members to loose their sense of individuality, and be isolated.

Family Dysfunction Concepts

Scapegoating

• A family member will attempt to take the blame of all external problems to themselves (usually targeting a child).

Triangulation

• Drawing the member into conflict (example being the child caught into the parents issues).

Multigenerational Issue

• Cycle of repeating problems in the over generations (usually trauma related).

Families with Discipline have varying functions.

• Healthily families can maintains safety and security by providing age support in a controlled manner.

Family Therapy

• Defines families who use assessment for evaluation of boundaries and communication.

Nurses’ Role in Family Therapy is to

• Educate families on management, providing administration guidance and resourceful access.

Multi-Family Therapy

• Where similar families are in group dynamics to share support (example being families shairing schizophrenia concerns). "

Chapter 8, Brain Stimulation Therapies

Overview: Treating Mental Health

• Non-pharmacological interventions include Electroconvulsive (ECT), * Repetitive Transcranial, and Vagus nerve, and Deep brain stimulation (DBS) therapies.

Electroconvulsive Therapy (ECT)

Indications (Potential Diagnoses)

• Applies electricity to induce seizure activity in anesthesia.
• Intended to enhance neurotransmitters (Serotonin, dopamine and norepinephrine).
• Used for depressive and schizophrenia-like disorders.
• Patients who are homicidal can see effect results.
• Patients with schizoaffective like the catatonic schizophrenia.

Contraindications

• No absolute with heart attacks, hypertension and stroke.
• Ineffective with substance and personality disorders

Considerations & Procedural Care

• Patients will be in the treatment schedule 2-3 weeks with informed consent.
• An Xray and ECG will be taken prior.

Medication Management

• 30 minutes before ECT: Injection of atropine sulfate to reduce secretions in bradycardia.
• Propofol will be anesthesized and muscle relaxant to prevent injuries.

Monitering

Repetitive Transcranial Magnetic Stimulation (rTMS)

• Blood pressure, oxygen levels and cardiac rhythm is a must.

Complications

• Short-term memory loss
• confusion
• Reactions to Cardio issues can occur at 100 percent in most patients.

Relapse

• ECT may not work long-term.

Treat depression with less harmful risks to the procedure.

• Does not cause seizures.

Approve with less harm than electrocutions, especially with those facing depression or needing medication.

Considerations

• Is a noninvasive electrocution used for non responsive depression.
• Can be effective with pain.
• Is a outpatient with pulsing devices, and effects take weeks to take action so it must be external used.

Complications

• Patients may experience dysphoria from the surge.
• And can have episodes.

DBS or deep treatments.

• Requires surgical treatments.
• In which less treatments can be taken to alleviate the pain.

FDA and used is for more Parkinson related issues.

Side effects

• Headache
• Seizures and confusion

Chapter 9 Communication & Therapeutic Relationships

Communication

Therapeutic Relationship

• Client-Centered Care, Client Participation: Active involvement in treatment plan & goals.
• Nurse Role: Empathetic listening, fostering a supportive environment, holistic approach.

Therapeutic Communication Techniques

• Open-ended questions (Encourage discussion)
• Clarification (Ensuring understanding)
• Closed-ended questions (For specific information)
• Summarizing (Confirming information)

Assessment & Recognizing Cues

• Identify symptoms & patterns related to the patient.

3. Client History Assessment

• Physiological: Ability to participate

Cultural to the patient Psychosocial Assessment

Mental Status Exam (MSE)

Risk for violence, suicide, aggression

Work, education, family history

Dementia care & validation therapy

Nursing Process

• Prioritizing nursing care, team collaboration.
• Focus on clients.

Implementation

• Client & Family Teaching
• Condition, medications, relapse warning signs, follow-ups.

5. Evaluation of Outcomes

• Review effectiveness of care plan

Cognitive Therapy Techniques

• Focus on priorities.
• Expressing stressful thoughts.
• Expressing emotions non-aggressively. Identifying negative thoughts

6. Phases of the Nurse-Client Relationship" orientation to the patient with set plans.
7. Identification from their plans.
8. Resolution that shows their current plan.

Professionalism & Communication Strategies

• Qualities that build trust from honesty.

9. Barriers to trust: Education, language, socioeconomic standing.

• Avoid boundary blurring. Stay professional & therapeutic