MH Unit Two Chapters 4-10 Nursing | PDF
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Cynthia Moore
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This document is a guide to mental health nursing, covering topics such as cultural considerations, legal issues, patient rights, and stress management. It presents information on areas such as emergency care, nursing processes, and therapeutic relationships, aiming to help understand the challenges that mental health patients face.
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Mental Health Nursing Unit Two Chapters 4, 5, 6,7,8,9, and 10 Cynthia Moore MSN, RN, PLNC Chapter Four O Seeking and finding treatment for mental health concerns is more difficult than care for physical issues. O Primary care providers O Can be a starting point. O Tend to...
Mental Health Nursing Unit Two Chapters 4, 5, 6,7,8,9, and 10 Cynthia Moore MSN, RN, PLNC Chapter Four O Seeking and finding treatment for mental health concerns is more difficult than care for physical issues. O Primary care providers O Can be a starting point. O Tend to care for people that don’t have serious concerns or complications. O Frequently refer to specialists for care. Specialty Care Providers O APRN O Clinical nurse specialist O Psychiatrist O Psychologist O Social Worker O Variety of therapists O Provide medications, psychotherapy, group therapy, and other treatments. O Patient-centered medical homes/primary care homes O Community Mental Health Centers O Psychiatric Home care O Assertive Community Treatment O In-patient treatment O Other outpatient care O Prevention in the community Biopsychosocial Assessment O What are the patient’s abilities to cope in their environment? O What would be the best option for a treatment facility inpatient or outpatient? O What is their housing situation? O Income and or source of income O Family/support system O Substance abuse history and current use O Physical health O Cultural considerations O Treatment goals and interventions O Case Management O Maintenance of current treatment O Teamwork and collaboration What About Emergency Care? O Comprehensive Emergency Service Model O Hospital Based Consultant Model O Mobile Crisis Team O Observation Units Inpatient O At least 13% of all ER visits pertain to mental health concerns. O US experiences significant wait times to find a mental health placement. O Admission criteria: O Imminent danger of harming self O Imminent danger of harming others O Not able to meet basic needs by self and cannot protect self. O Two types of admission-voluntary or involuntary. O When patients are admitted to inpatient care, they retain their rights. O Please make sure to review the patient’s rights on page 70 in Box 4-2. O We must work as a team O Provide a therapeutic milieu O We want people to feel safe, be welcoming O Want to be safe, be approachable O Manage behavior crisis O Need a plan for managing these behaviors O Always provide safety O Assess, develop goals and interventions O Therapeutic groups O Documentation O Medication management O Need to make sure there is no “cheeking” where they hold the med in their cheek. Make sure people take their ordered meds O Prepare and assist with discharge planning O Help find them shelter, home health services, and maybe assistance with food. Chapter Five O You will need to review chapter five on your own. O Chapter five is regarding cultural implications which is very important, and you have seen this content throughout the program. O The chapter is more review but with a focus on mental health concepts. O You are discussing some of this on the discussion board. O As you read the chapter these are the concepts/definitions I would encourage you to review. O Minority O Race O Ethnicity O Culture and cultural norms O What do persons from Western Tradition value and believe? How do they view mind and body or mentally health versus mental illness. O Same for Eastern Tradition, Indigenous culture, O What is the impact of culture on mental health? O What are some cultural barriers to healthcare? O You will want to be familiar with O Cultural awareness O Cultural knowledge O Cultural encounters O Cultural Skill O Cultural Desire Chapter Six Legal and Ethical Considerations O Ethical Concepts/Principles O Beneficence – Do good O Autonomy – right to choices O Justice – Fair for all O Fidelity – Truthful, loyal O Veracity – To Tell the Truth O Nonmaleficence – Do no harm O Ethical Dilemma O Patient is guaranteed their civil rights as any other person. Pharmacogenetic Testing O DNA profiles used to help determine which medications may work best for a particular patient. O Example – a patient has depression and treatment with medication is indicated. DNA profiles can help the provider to determine the best type. O This can also help predict side effects. O The FDA has NOT approved this practice. O There are many ethical concerns about this and other practices in Mental Health. Admission O Informal-patient desires admission but is free to leave. No formal admission application is made. O Voluntary-patient or parents of a minor can request admission in writing. O The patient can request to leave but needs permission and, in some cases, may turn into involuntary admission. O Temporary admission-doctor does the admission process because patient is a danger to themselves or others or cannot make their own decisions. O This type of admission can (typically) only last 15 days. O The patient will be observed, diagnosed, and treated. O Involuntary admission-without the patient’s consent. O Typically, two physicians must sign indicating that the patient’s mental health currently justifies detention. O Family is also sometimes involved in this process. O For a period of up to 60 days and then must be reviewed by a panel to continue the admission. O Patient can submit a writ of habeas corpus. O Patient feels that they do not need to be there anymore. They fill it out and the facility must deliver it to the court. It will be then reviewed and decided. O A court will then decide this case. Discharge O Conditional Release O They can go home BUT need to go to outpatient therapy or some sort of condition to leave, O If they don’t do it, they can be readmitted O Unconditional Release O Can leave and have no obligations to uphold O Release against medical advice O Physician wants them to stay but there isn’t any immediate danger or anything they can hold them on. O Allowed to go but must sign a form that it is against medical advice Patient Rights O Right to treatment O Right to refuse treatment O Right to informed consent O Involuntary admission and advance directives O Restraint and seclusion O Last thing we do. Read the policy on this!! O Need to try other things FIRST. O Confidentiality and HIPPA O Confidentiality after death O Duty to warn O Child and Elder Abuse Legal Concerns O Failure to protect patients in our care O Intentional torts O Threats, abuse O Unintentional torts O Negligence, Malpractice O Breech of Duty O You were assigned to this person, and you didn’t give them their meds, or wrong meds O Negligence O Have to prove duty, foreseeability, did harm happen O Documentation O Violence O Staff, patients Chapter 7 Nursing process O Just as nurses use the nursing process to deliver physical care, we also need to use the nursing process in mental health nursing. O The assessment should include the following but may vary from facility to facility: O Review of body systems O Lab data O MSE=Mental status exam O Psychosocial assessment O Spiritual/religious assessment O Cultural and social assessment O Use of scales as appropriate O When assessment is concluded need to verify and validate all information gathered. O Remember that the assessment portion must be geared to the age group you are working with. O Physical disease can manifest itself to appear as a mental health disorder. O Mental health disease can also produce physical symptoms. O Patient’s being treated for either physical or mental disease must be screened for both to rule out other causes or contributing factors. O Once assessment data is validated nursing diagnoses can be formulated. O Goals and or plans will be identified that are patient centered and culturally appropriate. O Interventions will be utilized that involve the entire team working towards the client goals. O Evaluation will need to be completed to realize the goal is met, will not be met, or the goal/plan needs to be updated or changed. Interventions O Basic Level O Coordination of Care O Health Teaching and Health Promotion O Milieu Therapy O Pharmacological, Biological, and Integrative Therapies O Therapeutic Relationship and Counseling O Advanced Practice Level O Prescriptions O Psychotherapy O Consultation O Documentation O Documentation of Nonadherence Chapter Eight and Chapter Nine Therapeutic Relationship and Therapeutic Communication O Basis of all psychiatric nursing treatment approaches. O To establish an understanding in the client that the nurse-client relationship is O Safe O Confidential O Reliable O With clear boundaries O The nurse must remember that some client’s with mental health disease have issues with relationships. O The client may not have contact with their family and may have lost their friends. O The nurse might be the one person in their life that they can communicate with and establish a relationship. O Therapeutic use of self-using your personality to relate to others and effectively help others. Social versus therapeutic O Must involve at least two people to be considered a true relationship. O Relationships are termed either: O Intimate O Social O Therapeutic Social Relationships O Initiated for the purpose of friendship or meeting a goal. O Individuals have an emotional commitment at some level but not as striking as in intimate relationships. O The communication can be superficial in these types of relationships or can be further developed. Therapeutic Relationships O Relationship consistently focused on the client's problems and needs O Potential solutions to problems discussed O Solution of client's choice implemented by client O New coping skills develop O Behavioral change encouraged O Nurses must utilize the following behaviors: accountable, focus on the client, clinical competence, do not judge, and supervision by a supervisor or team to establish therapeutic relationships. Detrimental Nurse-Client Relationship O Nurse tries to get his or her own needs met O Nurse tries to solve the client's problems O Nurse takes the role of a friend or family member of the client O Lack of boundaries in the relationship Personal Characteristics of the Nurse that Help Promote Change and Growth in Clients O Trust O Respect O Rapport O A bond between the nurse and the client. O Genuineness O Self-awareness of one's feelings Positive self regard O Non-judgmental focus on clients O Empathy O Feelings and ideas of client accurately perceived Boundaries of the Nurse-Client Relationship O Client's needs are separated from the nurse's needs O Client's role is different from that of the nurse Boundaries Blurred O When nurses are O Overly helpful O Controlling O Narcissistic-selfish, focused on self, elated image of self Boundaries Blurred: Transference O Person unconsciously displaces onto individual in current life, emotions and behaviors from childhood that originated in relationships with significant persons in their life. O Transference intensified with person in authority in current life. O If negative transference occurs it can create problems with the relationship. O In other words, if the client transfers their negative memories to the nurse this can impede progress. Boundaries Blurred: Countertransference O Nurse displaces onto client feelings related to people in nurse's past O Clients transference to nurse often results in countertransference in nurse O Common sign of countertransference in nurse is over identification with the client O If nurses allow this to happen will limit our ability to empower clients to change, to get better, and to enjoy autonomy in their own care. Phases of Nurse-Client Relationship O In 1952 Hildegard Peplau introduced this concept to nursing regarding establishing a nurse-patient relationship. O Pre- Orientation-nurse prepares for the orientation phase prior to the first meeting with the client. O Orientation phase-the interview is conducted, goals, limits, etc. are clarified. O Working phase-maintain, gather more data, facilitate change, evaluate, promote alternative behaviors. O Termination phase-summarize goals achieved, how to continue work that was accomplished, exchanging memories, moving towards the end of the relationship as in discharge preparation. Factors Beneficial to Nurse- Client Relationships O Consistent, regular, and private interactions with client O Being honest and congruent O Letting client set the pace Factors Hampering Nurse-Client Relationship O Lack of nurse availability or lack of contact O Lack of nurse self-awareness O Nurse's negative feelings about client The Communication Process O Stimulus for information, comfort, or advice O Sender – initiates contact O Message – sent or expressed O Variety of media – hearing, visual, touch, smell O Feedback received Berol’s Model of Communication O Stimulus – reason for communication O Sender- initiates the interpersonal contact O Message- information sent O Media- how the message is sent ( auditory- tactile, smell or combination) O Receiver- response to the message O Feedback- receiver’s response Communication: Verbal O All words a person speaks O Communicates O Beliefs and values O Perceptions and meaning O Communication: Non-verbal -65%-95% sent message -Body Behavior - Facial expression - Personal appearance Therapeutic Communication Techniques O Tools for enhancing communication O Using silence O Active listening O Listening with empathy Clarifying Techniques O Paraphrasing O Restating O Reflecting O Exploring O Use both open ended and close ended questions to elicit patient response. Nontherapeutic Communication Techniques O Excessive questioning O Giving approval or disapproval O Giving advice O Asking “why” questions Cultural Communication Barriers O Areas problematic for interpreting messages O Communication styles O Use of eye contact O Perception of touch O Cultural filters-cultural bias or prejudices Preparing for the Interview O Pace-client should set the pace of the interview. O Setting-do you feel safe in the chosen environment and does the client feel safe and comfortable? O Seating O Introductions O Initiating the interview: O Where should we start? O Tell me what some of the stresses you have had recently? O Tell me about the difficulties you have been experiencing. O Tell me what brings you here? Attending Behaviors O Culturally and individually appropriate O Eye contact O Body language O Distance O Intimate ( 0-18 inches) O Personal ( 18-40 inches) O Social ( 4-12 feet) O Vocal qualities- loud or soft, pitch, rate, and fluency. O Verbal tracking-neutral feedback to what the client is saying. The Clinical Interview O Content and direction of the clinical interview are decided by the client O The client leads Helpful Guidelines O Speak briefly – “ how should we start today?” O When you do not know what to say, say nothing O When in doubt focus on feelings O Avoid giving advice or argue O Do not rely on asking questions O Pay attention to nonverbal clues O Focus on the client Common Client Behaviors O Cries O Asks nurse to keep a secret O Asks the nurse a personal question O Interrupted by another client O Communicates thoughts of suicide Process Recording O Written record of a segment of the nurse- patient session that reflects as closely as possible the verbal and nonverbal behaviors of both patient and nurse O Useful tool for identifying communication patterns Chapter 10 Responses to Stress O Severe stress is not healthy and can increase the risk of mental illness. O Stress can be identified in a variety of settings and each person reacts and copes with stress in different ways. O Nursing has a responsibility to help patients adapt and cope with stress. O Tri-fold approach-create an atmosphere that promotes healing, help patients with coping strategies, and help them find future ways to improve or develop new coping strategies. O This approach is not just for patients who have mental health disorders but for all patients, residents, and or clients we serve. Theory O Walter Cannon O Fight-or-flight response O Body prepares for situation that individual perceives as threat to survival O New research indicates that men and women have different neural responses to stress O Some new research indicates that estrogen may reduce stress response in women. O Physically the changes that occur such as blood flow and the release of salivary cortisol can clearly be documented that there is a different response between male and female genders. O Hans Selye O General Adaptation Syndrome (GAS) O Three stages O Alarm or acute stress stage O Resistance or adaptation stage O Exhaustion stage O Psychological reactions (Lazarus) O Distress – reacts to something and continues to stress O Eustress – reacts to stress and then moves on Neurotransmitter Stress Responses O Serotonin synthesis more active during stress response. O May impair serotonin receptor sites and brain’s ability to use serotonin as corticosteroids are released. O There is no conclusive evidence, but this is felt to be a part of why serotonin availability decreases which can lead to depression/less available serotonin/ increased risk of depression. Immune Stress Responses O Interaction between nervous system and immune system during alarm phase of GAS O Negatively affects body’s ability to produce protective factors Again, this is theory but more and more evidence suggests there is a link between stress, the immune system, and the development of disease. Many people have hypotheses that indicate this is why some people develop cancers and others do not. Mediators of the Stress Response O Stressors – what is causing the stress O Perception – How do you perceive it, is it that important? O Personality – How does the personality assist with coping O Social support Nursing Management of Stress Response O Measuring stress O Social Readjustment Rating Scale (Holmes and Rahe; 1967, 1978, 1997) O Measures level of positive and negative stressful life events over a 1-year period O There have been changes in what causes stress over the years and the impact it has on society. O There is a tool in your book on page 165 to measure your level of stress. O Self-help groups O Low- and high-quality support O Culture O Spirituality and religious beliefs Assessing Coping Styles O Positive Stress Responses: O Problem solving O Using social support O Reframing O Negative Stress Responses: O Avoidance O Self-blame O Wishful thinking Coping Styles O Health-sustaining habits O Life satisfactions O Social supports O Effective and healthy responses to stress Behavior Stress-Management Techniques O Benson’s relaxation techniques O Meditation O Guided imagery O Breathing exercises O Physical exercise O Progressive muscle relaxation O Biofeedback Cognitive Approaches to Stress Management O Cognitive reframing O Mindfulness O Journaling O Humor