Understanding Mental Health

• Mental health is about coping with the normal stresses of life
• Self-awareness involves conscious knowledge of one's character, feelings, desires, and motivations.
• Self-awareness includes a deeper understanding of your emotions, strengths, weaknesses, drive, and thought process.
• Empathy and compassion are important qualities to have towards everyone.
• Mental illness is a condition that affects thinking, feeling, and mood.
• Mental illness may affect someone's ability to relate to others and function each day.
• Stigma is a mark of disgrace that sets someone apart from others.
• Stigma labels mental illness, creates negative attitudes leading to discrimination and can stem from lack of education, cultural factors, and fear of difference.
• The continuum of mental health and mental illness includes well-being, emotional problems/concerns, and mental illness.
• Well-being involves occasional stress to mild distress without impairment.
• Emotional problems/concerns involve mild to moderate distress with mild or temporary impairment.
• Mental illness involves marked distress, moderate to disabling chronic impairment.
• Resilience is closely associated with adapting to change and trauma.
• Role of resilience allows people to secure resources to support well-being.
• Mental illness is culturally defined and based on interpretations of effective functioning according to societal norms.
• The mentally ill may often behave in a way that is socially unacceptable.
• For centuries, symptoms of mental illness were believed to be attributed to demonic forces.
• Later psychological theories focused on the science of the mind and behavior.
• Theories explained mental illness origins as faulty psychological processes correctable via increased personal insight and understanding.
• These theories were challenged after medications effectively controlled mood disorders and calmed uncontrollable patients.

Social Influences

• NAMI is the National Alliance on Mental Illness
• NAMI Started in the 1970s
• In the US the interrogation of equality for all become a priority
• Groups began to advocate for their rights and to fight stigma

Decade of the Brain

• US initiative stimulated a worldwide growth of scientific research
• A lot of progress was made during this time in the areas of neural development, gene mapping and other aspects of neuroscience and brain research
• DSM-5 provides criteria for psychiatric disorders and a basis for comprehensive and appropriate interventions.
• DSM-5 criteria includes impatient, outpatient, partial hospitalization, consultation-liaison, clinics, private practice, primary care, and community populations.
• Nurses advocate for psychiatric patients through direct and indirect action.
• Nurses uphold patient confidentiality
• Nurses may choose to be active in consumer mental health on an indirect level.
• Care settings change to best address a patient's individual needs at any given moment.
• Partial hospitalization programs offer intensive, short-term treatment similar to inpatient care.
• Patients in partial hospitalization are able to return home each day as programs offers 5-6 hours per day of individual and group psychotherapy treatment.
• Assertive community treatment is for clients with mental illness who are non-compliant with traditional treatment with the goal to reduce recurrence of hospitalization.

Levels of Prevention

• Primary prevention promotes health and prevents mental health problems from occurring by teaching stress reduction techniques.
• Secondary prevention focuses on early detection of mental illness, such as screening older adults for depression.
• Tertiary prevention is aimed at individuals who already have a psychiatric condition, and focuses on rehabilitation and preventing problems from recurring by leading a support group who have completed a substance abuse program.

Types of Holds (Adults)

• Requires a psychiatrist to put patients on hold
• 5150 is a 72-hour hold due to danger to others, danger to themselves, and being gravely disabled
• 5250: 14-day hold where one can get out of the hold by having a probable cause hearing or a WRIT of Habeas Corpus where a judge determines if the hold is valid and interpret the law
• Conservatorship is a legal relationship by court appointment, where the guardian acts in the best interest of a severely disabled person and is more for 30-day holds
• Advisement forms explain why the patient is on a 72-hour hold including the date and time of expiration
• Request for hearing for relief prevents the patient from having or purchasing firearms for 5 years if placed on a 72-hour hold

Patient Rights

• Right to be treated with dignity, right to be involved in treatment, right to legal counsel, right to informed consent, right to request to leave the hospital, right to a timely evaluation and right to communicate privately.
• Patients must be provided with all essential information required to make an informed decision whether or not to accept treatment as A patient needs to consent to psychiatric medications.
• If a patient is continuing to violate other people consent is not needed for the medications.

Reise Hearing

• Arose from a psychiatric patient who had adverse reactions to medication that affected urinating and was not allowed to deny the medication
• The prescriber/petitioner bears the burden of proving the patient's incapacity to refuse medications by clear and convincing evidence.
• If the patient does not want medication, but it is beneficial, it goes to court, and if the physician's medication order is valid, medication can be given without consent (benefits rather than risk).
• there must be a good reason to deny patients their rights, as they may cause injury to others, serious infringement or damage to the facility.
• Must document date and time, specific right, good cause for denial of right, and a review if the denial was extended beyond 30 days.
• Working as a Team in Inpatient Care' nursing leadership reflects the holistic nature of nursing and safety is priority
• Protecting the patient is essential, but staff and other patients have equal importance, as many patients try to commit suicide.
• Property and clothing are checked to prevent any potential harmful items, risk assessments are made, and intimate relationships are discouraged or prohibited.
• Tracking patient activity should be done routinely based on risk where safety checks must be done every 15 minutes.

Schizophrenia

• 1% of the world has schizophrenia
• Average onset differs between genders where it is later 20s to early 30s for women and in late adolescence to early adulthood (17-early 20s) for men
• Schizophrenia is seen in post-menopausal women

Diagnosis

• Should not be made until the age of 7, as ADHD needs to be ruled out first
• Predisposing factors include genetics (most common reason), biochemical factors (high levels of dopamine, norepinephrine, low levels of serotonin, acetylcholine, GABA), viral infection, anatomical abnormalities, electrophysiology, physical and psychological conditions, and environmental influences.

Course of Illness

• Premorbid signs occur before there is clear evidence of disorder
• Premorbid signs include distinct personality traits or behaviors, such as being shy/withdrawn, having poor peer relationships, doing poorly in school, demonstrating asocial behavior, or not having close friends
• In the prodromal phase, symptoms more clearly manifest as signs developing as schizophrenia with an average length of 2-5 years, including social withdrawal, depression, sudden onset of obsessive controlling behaviors.
• The active psychotic phase includes manifestations of acute symptoms of schizophrenia which is psychosis.
• The residual phase is a period of remission and exacerbation.
• The paradigm of thirds includes significant and lasting improvement, some improvement with intermittent relapses and residual disability, and severe and permanent incapacity.

Other Schizophrenia Spectrum and Psychotic Disorders

• Delusional disorder includes patients presenting delusions for at least 1 month including fixed false beliefs, bizarre, and not derived by ordinary life experiences.
• Brief psychotic disorder occurs with the onset of psychotic symptoms lasting for a day but less than 1 month including hallucinations, delusions, or just hallucinations.
• Schizophreniform disorder lasts for at least 1 month but less than 6 months including hallucinations/delusions.
• Schizophrenia Disorder lasts more than 6 months.
• Schizoaffective Disorder shows signs and symptoms of schizophrenia, along with depression symptoms or mania symptoms.
• Psychosis NOS (not specified) occurs if an individuals is not able to have conversations and there is a waiting for a full psychiatric history.

Positive Symptoms

• Disturbances in perception includes hallucinations
• Hallucinations are false sensory perceptions associated with real external stimuli
• Auditory hallucinations are the most common
• Always ask patients what the voices are saying
• Command hallucinations are deemed the most dangerous as the voice gives them a command.
• Illusions are misinterpretations or misperceptions of a real stimuli
• Echopraxia is when someone is mimicking the movement of others
• Disturbances in thought content includes delusions which are fixed false beliefs.
• Delusions of persecution are the most common type, where an individual believes that they are being persecuted/plotted against or followed, poisoned, or drugged.
• Delusions of grandiosity is when a patient associate with a famous person or believes their they have some kind of superpower.
• Referential delusions is the belief that the radio, commercial, and newspaper is sending them a message or that people are talking bad about them.
• Religiosity is the belief that one was sent by god.
• Somatic delusions are unrealistic beliefs that something is happening with their health or bodily function
• Nihilistic delusions is the belief that part of themselves are non-existence, or believes the whole world no longer exists.
• Erotomania is falsely believing someone usually in a higher position is in love with them
• Jealous delusions is centering of ideas that the person's sexual partner is unfaithful.

Speech Disturbances

• Loose association: thought disorder where there is a lack of logical connection between ideas
• May jump from one topic to another without apparent reason, making speech difficult to follow where one should respond with, "I do not understand you."
• Neologism is invented words that are not in the dictionary
• Clang associations are random words that could rhyme
• Word salad is random words that do not flow together
• Circumstantiality delays individual from reaching a point of communication due to unnecessary details.
• Perseveration (echolalia) is when a person echoes a word, or repeats it over and over
• Negative symptoms includes disturbances in affect.
• Flat/bland affect includes no emotional tone.
• Restrictive affect has reduced emotional expression
• Inappropriate affect displays a discrepancy between emotional expression and the content of their speech, thoughts, or situation
• Apathy is indifference or lack of interest
• Avolition is lack of motivation.
• Anosognosia affects a lack of awareness of having an illness or disorder, most common for non adhering to medication regimen and have higher rates of relapse with their conditions.
• Anhedonia is the inability to experience pleasure, can put one at risk for suicide
• Concrete thinkers have a lack of abstract thinking ability
• Waxy flexibility is a condition in which the client allows their body parts to be placed in a bizarre or uncomfortable conditions.
• Medication is neuroleptic medication.
• Conventional medications are the first generation, typical medications that was invented in the early 50s and 60s.

Conventional medication

• Therapeutic effect noticeable within a few days
• Highly protein bound
• Long half life allows it to being give it once a day.
• Targets only positive symptoms of schizophrenia
• Lowers dopamine resulting in a lot of extra pyramidal side effects that can be reversed.
• Parkinsonism includes Parkinson's symptoms without having the disease such as a shuffling gait, tremors, drooling, and muscle rigidity with symptoms that may appear 1-5 days after administration of meds, and occurs a lot w/women and dehydrated clients.
• Akinesia includes absences/impairment in voluntary movements
• Akathisia includes continuous restlessness/fidgeting (50-60 days after therapy) mostly in women.
• Dystonia includes involuntary muscle spasms of the face, arms, legs, and neck where it is dangerous on the neck because it disrupts one's respiratory system and occurs more in men and those younger than 25 years old.
• Tardive dyskinesia is irreversible (late signs)
• Affects involuntary movements affecting the lower face, facilitating tongue movements (smacking of lips, blinking)
• Valbenazine can be used to help treat it
• AIMS scale measures involuntary movements to monitor the effects of long term treatment with medication.
• The AIMS scale is given every 3-6 months and monitor for the development of Tardive dyskinesia (it can develop within 1 month of meds)

NMS (Neuroleptic Malignant Syndrome)

• Rare and life threatening.
• Manifestations of sudden high fever, changes in blood pressure, dysrhythmias, changes in level of consciousness
• Can occur in the first two weeks of drug administration

Common First Generation Medications

• Chlorpromazine was created first
• Fluphenazine
• Thioridazine
• Thiothixene
• Trifluoperazine
• Dopamine Receptor Blockers (Lowers Dopamine)
• Reduces Symptoms
• Administered Once A Day
• Targets Positive Symptoms of Schizophrenia
• Unconventional, Second Generation, Atypical Medications
• Highly Protein Bound
• Lowers dopamine
• Reduced Risk of EPS (Extrapyramidal Symptoms)
• Targets Positive and Negative Symptoms as First Line of Treatment
• ASBCLIOPQRZ
• Aripiprazole, Asenapine, Brexpiprazole, Caripiprazine, Lurasidone, Iloperidone, Olanzapine, Paliperidone, Quetiapine, Risperidone, Ziprasidone
• Clozapine
• Given As Last Resort
• Needs To Be Verified In A Database To Ensure Which Patients Are Taking The Medication
• Suppresses Bone Marrow Production
• Induces Agranulocytosis That Lowers WBC
• Wear A Mask As Patients Are Prone To Infection
• Side Effects

Common Side Effects

• Cholinergic Blockade causing dry mouth, constipation, tachycardia, blurred vision, urinary hesitancy / retention
• Weight Gain which is the MOST common side effect
• Hyperglycemia which may cause high lipids and cholesterol which can result in type 2 diabetes.

Mental Status Examination: ASEPTIC

• Appearance/Behavior
• Speech Content (Slow, Fast?)
• Emotion/Mood (How Are They Expressing Themselves W/Facial Expressions and How They Are Feeling)
  • Flat, Blunted, Restricted, Inappropriate
• Inquiry type of Assessment
• Perception (Assess For Hallucinations)
  • Are They Hearing Voices? What are the Voices Telling The Patient?
  • Encourage Patient To Listen To Music / Distract Themselves From Voices Or Hallucinations
  • Voice Dismissal: If Hearing Voices, Tell Patient To Say Go Away And Leave Them Alone.
  • Effective Because It Is A Conscious Method That Helps Them Dismiss Those Hallucinations / Voices
  • A Voicing Doubt / Reasoning Doubt Therapeutic Technique
  • This is For Delusions

Additional Notes

• Do not agree/disagree with them, just let them know you understand it, but find it hard to accept it.
• Deny The Realness of It
• Thought Content
  • Are They Using Circumstantiality/Suicidal Ideation?
• Insight/Judgement
  • Inquiring About Their Diagnosis
  • Seeing If They Know What Is Morally Right Or Wrong
• Cognition
  • Assess Alertness and Orientation x4
  • Assess Attention and Concentration Span
  • Assessing Short and Long Term Memory Recall
• Aggression: A Behavioral Response When Someone Is Angry
• Intended To Threaten Or Injure The Victim's Security Or Self Esteem.
• Anger: Emotional State That Varies In Intensity From Mild Irritation To Intense Fury And Range
  • A Normal Human Emotion, Negative Expression
  • Psychological Changes:
  • Increased Heart Rate
  • Increased Blood Pressure
  • Increased Body Temperature
  • Increased Skin Perspires

Nursing Actions For Aggression

• Remain Calm
• Set Verbal Limits: Expresses The Consequences of Inappropriate Expression of Anger
• Encourage To Keep A Diary Of Anger Thoughts
• Avoid Touching Patient
• Help To Determine The Real Source Of Anger
• Help To Find Alternative Ways of Releasing Tension
• Role Model
• De-Escalation Technique
  • Observe For Escalation of Anger
  • Ensure There Is Enough Staff To Help
  • Talking Down → "Let's Sit Down and Talk About It."
  • Physical Outlets → Suggest Walking/Exercising To Release Tension
• Medication
• Call For Assistance
• Seclusion and Restraints (Observe and Document)