Study Guide Mental Health Exam 2 PDF

[Study Guide Mental Health Ch 7, 8, 9, 34, and 6] Chapter 7---The nursing process and standards of care **[ADPIE---]** Assessing Diagnosing Planning Implementing Evaluating **[ADPIE\--Can also look like:]** Assessment Diagnosis Outcome/Identify Planning Implementation Evaluation **OR*...

[Study Guide Mental Health Ch 7, 8, 9, 34, and 6] Chapter 7---The nursing process and standards of care **[ADPIE---]** Assessing Diagnosing Planning Implementing Evaluating **[ADPIE\--Can also look like:]** Assessment Diagnosis Outcome/Identify Planning Implementation Evaluation **OR** Assessing Planning Implementing Evaluation **BOX 7.1** **[Quality and Safety Education for Nurses Competencies]** **Patient-centered care:** Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for the patient's preferences, values, and needs. **Quality improvement:** Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of healthcare systems. **Safety:** Minimize risk of harm to patients and provide optimal healthcare through both system effectiveness and individual performance. **Informatics:** Use information and technology to communicate, manage knowledge, mitigate error, and support decision making. **Teamwork and collaboration:** Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care. **Evidence-based practice (EBP):** Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal healthcare. 1\. Provide patient-centered care **[Standards of Practice Number 1]** **Assessment---(Recognize Cues)** - Collects and synthesizes comprehensive health data pertinent to the healthcare patient's health and situation. - Begins with patient encounter and continues throughout patients stay - Develops a basis for the plan of care and in preparation for discharge - A thorough, formal nursing assessment - Collect data continually and systematically (as patient's condition changes and/or improves) - Primary source is the patient (patient-centered care) When assessing a patient keep in mind the following: **AGE:** **Small children**---consider the developmental age of the child, regression is a hallmark of a psychiatric disorder in children, they are assessed by a combination of interview and observation. **Adolescents---**HEADSSS interview Home environment, Education/Employment, Activities, Drugs/alcohol/tobacco use, Sexuality, Suicide risk, Safety **Older Adults---**as we age we lose our senses, taste, smell, touch, sight, and hearing) do not judge an older adult, an 80 year old can be healthier than a 60 year old. Assess physical deficits and make accommodations for them at onset. **LANGUAGE BARRIERS:** **Interpreter---**is someone who interprets spoken words of a foreign language speaking person or someone who uses American sign language. **Translator---**someone who speaks one or more languages in addition to English and translates written words. **[Steps of assessment in Psychiatric Mental Heal Nursing]** 1. Establish rapport 2. Obtain an understanding of the current problems or chief complaints 3. Review patients' physical status and obtain baseline vitals 4. Assess for risk factors affecting the safety of the patient and others 5. Perform mental status examination (Person, Place, Time) 6. Assess psychosocial status 7. Identify mutual goals for treatment 8. Formulate a plan of care 9. Document data in a retrievable format **[Gathering Data]** 1. Review of systems (baseline vitals, historical and current events, allergies and responses) 2. Laboratory Data---Hypothyroidism may have a clinal appearance of depression 3. Mental Status Examinations---Evaluate current cognitive processes 4. Psychosocial Assessment---How did become necessary 5. Spiritual Assessment---can influence hope and purpose for life - Cardiovascular Disorders - Which term on an assessment is broader? a. Spirituality b. Religion c. Church, Mosque, Temple, Synagogue d. None of the above **[Standards of Practice number 2]** **Diagnose: (Analyze Cues)** - Problem or potential problem---Unmet Needs - Probable Cause---Related to\_\_\_\_\_\_\_\_\_\_\_? - Supporting Data---Signs/Symptoms (reported by patient) / i.e. as evidence by\_\_\_\_\_\_\_\_\_ **[Types of nursing diagnoses]** - Problem focused diagnoses: problem + probable cause + supporting data - Risk---always begin with the phrase at risk for\_\_\_\_\_\_\_\_, followed by the problem **[Standards of Practice number 3]** **Outcomes/Identification: (Prioritize Hypotheses)** - Outcome criteria---expected outcomes realistically achieved through planned nursing interventions **Principles to follow** - Patient reflects a measurable desire to change - Provide direction for continuity of care - Written in positive terms - Realistically achievable **[Standards of Practice number 4]** **Planning: (Generate Solutions)** - Prescribe strategies to assist patient in attaining expected outcomes **Principles to follow** - Safe - Compatible and Appropriate - Realistic and individualized - Evidence based when research is available - **RN Interventions** - Coordination of care - Health teaching and health promotion - Pharmacological, biological, and integrative therapies - Milieu therapy---secure environment, including people, setting, structure and emotional climate to support recovery - **Therapeutic Relationship and Counseling** - Basis of nurse patient interactions - Providing presence and a sounding board - Reinforce healthy behavior - Help patient to recognize maladaptive behavior - Help patient to identify positive coping methods and try out the coping methods - **Advanced Practice Interventions** - Consultation - Prescriptive authority and treatment - Psychotherapy - Systematic - Ongoing - Criteria based **Critical Thinking\--QUIZ** Pedro Gonzales, a 37-year-old Hispanic man, arrived by ambulance from a supermarket, where he had fallen. On his arrival at the emergency department (ED), his breath smelled "fruity." He appeared confused and anxious, saying that "they put the evil eye on me, they want me to die, they are drying out my body... it's draining me dry... they are yelling, they are yelling... no, no, I'm not bad... oh, God, don't let them get me!" When his mother arrived in the ED, she told the staff, through an interpreter, that Pedro has severe diabetes and a diagnosis of paranoid schizophrenia. She says with frustration, "This happens when he doesn't take his medications. In a group or in collaboration with a classmate, respond to the following: 1\. A number of nursing diagnoses are possible in this scenario. Given the provided information, formulate at least two nursing diagnoses and include related to and as evidenced by as appropriate. 2\. For each of your nursing diagnoses, write out one long-term outcome (the problem, what should change, etc.). Include a time frame, desired change, and three criteria that will help you evaluate whether the outcome has been met, not met, or partially met. 3\. What specific needs might you consider when planning nursing care for Mr. Gonzales? 4\. Using the SOAPIE format (see Table 7.3), formulate an initial nurse's note for Mr. Gonzales. **Chapter Review\--QUIZ** 1\. What is the purpose of the Health Insurance Portability and Accountability Act (HIPAA)? Select all that apply. a\. Ensuring that an individual's health information is protected b\. Providing third-party players with access to patient's medical records c\. Facilitating the movement of a patient's medical information to the interested parties d\. Guaranteeing that all those in need of healthcare coverage have options to obtain it e\. Allowing healthcare providers to obtain health information to provide high-quality healthcare. 2\. Which intervention demonstrates a nurse's understanding of the initial action associated with the assessment of a patient's spiritual beliefs? a\. Offering to pray with the patient b\. Providing a consult with the facility's chaplain c\. Asking the patient what role spirituality plays in his daily life d\. Arranging for care to be provided with respect to religious practices 3\. Which nursing interventions best demonstrate an understanding of the Quality and Safety Education in Nursing (QSEN) competences? Select all that apply. a\. Asking the patient what she expects from the treatment she is receiving b\. Seeking recertification for cardiopulmonary resuscitation (CPR) c\. Accessing the internet to monitor social media related to opinions on healthcare d\. Consulting with a dietitian to discuss a patient's cultural food preferences and restrictions e\. Reviewing the literature regarding the best way to monitor the patient for a fluid imbalance 4\. Which disadvantage is inherent to the problem-oriented charting system (SOAPIE)? a\. Does not support a universal organizational system b\. Commonly allows for the inclusion of subjective information c\. Documentation is not listed in chronological order d\. Does not support the nursing process as a format 5\. Which standardized rating scale will the nurse specifically include in the assessment of a newly admitted patient diagnosed with major depressive disorder? a\. Mini-Mental State Examination (MMSE) b\. Body Attitude Test c\. Global Assessment of Functioning Scale (GAF) d\. Beck Inventory 6\. A 13-year-old boy is undergoing a mental health assessment. The nurse practitioner assures him that his medical records are protected and private. The nurse recognizes that this promise cannot be kept when the youth divulges: a\. "I lost my virginity last year." b\. "I am angry with my parents most of the time." c\. "I have thoughts of being in love with boys." d\. "My parents do not know that I hit my grandpa." 7\. During an interview with a non--English-speaking middle-aged woman recently diagnosed with major depressive disorder, the patient's husband states, "She is happy now and doing very well." The patient, however, sits motionless, looking at the floor, and wringing her hands. A professional interpreter would provide better information due to the fact that a family member in the interpreter role may Select all that apply. a\. Be too close to accurately capture the meaning of the patient's mood b\. Censor the patient's thoughts or words c\. Avoid interpretation d\. Leave out unsavory details 8\. A nurse identified a nursing diagnosis of self-mutilation for a female diagnosed with borderline personality disorder. The patient has multiple self-inflicted cuts on her forearms and inner thighs. What is the most important patient outcome for this nursing diagnosis? Patient will a\. Identify triggers to self-mutilation b\. Refrain from self-harm c\. Describe strategies to increase socialization on the unit d\. Describe two strategies to increase self-care 9\. Medical records are considered legal documents. Proper documentation needs to reflect patient condition along with changes. It should also be based on professional standards designated by the state board of nursing, regulatory agencies, and reimbursement requirements. Proper documentation can be enhanced by: a\. Only using objective data b\. Using the nursing process as a guide c\. Using language the specific patient can understand d\. Avoiding legal jargon 10\. Amadi is a 40-year-old African national being treated in a psychiatric outpatient setting due to a court order. Amadi's medical record is limited in scope, so where can Renata, his registered nurse, obtain more data on Amadi's condition within legal parameters? Select all that apply. a\. Emergency department records b\. Police records related to the offense resulting in the court order for treatment c\. Calling his family in Africa for details about Amadi's mental health d. Past medical records in the current facility **ANSWERS** 1\. a, e; 2\. c; 3\. a, b, d, e; 4\. c; 5\. d; 6\. d; 7\. b; 8\. a; 9\. b; 10\. a, b, d **[CHAPTER 8]** **[THERAPEUTIC RELATIONSHIPS]** **Patient centered care---** 1. Dignity and respect 2. Information sharing 3. Patient/ family participation 4. Collaboration in policy and program development 5. Clear and appropriate boundaries 6. Safe, confidential, reliable and consistent 7. Use personality consciously and in full awareness 8. Attempt to establish relatedness 9. Structure nursing interventions **Personal Relationships** Primarily initiated for the purpose of friendship, socialization, enjoyment or accomplishment of a task. (Mutual Needs Are Met) **Therapeutic Relationships** Addressing issues introduced by the patient during the initial assessment or subsequent meeting. This relationship is constantly focused on the patients' problems and needs A close-up of a logo Description automatically generated **Overinvolvement:** 1. Boundary crossing 2. Boundary violations 3. Professional and sexual misconduct 4. Blurring of roles **Advanced Practice RN** Based on psychotherapy changes brain chemistry in much the same way as medication. ***Best treatment for psychiatric problems a combination of medication and psychotherapy.*** 1. Facilitate communication of distressing thoughts and feelings 2. Assist with patient problem solving 3. Help patient examine self-defeating behaviors and test alternatives 4. Promote self-care and independence 5. Provide education about disorders and treatment 6. Promote recovery **Boundaries** The expected and accepted legal, ethical and professional standards that separate nurses from patients. Boundaries provide a safe space for the patient to explore feelings and treatment concerns. **Transference---**Patient unconsciously and inappropriately displaces onto nurse feelings and behaviors related to significant figures in patients past. **Countertransference---**Nurse unconsciously displaces feelings related to significant figures in the nurses past onto the patient. **[Focus on Self-Awareness]** In psychiatric nursing self awareness of nurse and nursing role are the key to forming therapeutic relationships. - Values and beliefs - Reflect on own culture and subculture - Derived from range of choices - Chosen from a variety of influences and role models **[Peplau's Model of Nurse/Patient Relationship]** 1. Preorientation-prepare for assignment, review patient information 2. Orientation-introduction, conversation, establish rapport, specify contract, explain confidentiality. 3. Working-gather data, identify problem solving skills, and self-esteem, provide education, evaluate progress 4. Termination-summarizing the goals and objectives achieved reviewing patient education and providing handouts, discussing ways for patient to incorporate new coping strategies, reviewing situations that occurred during nurse patient relationship. Exchanging memories, which can help validate the experience for both nurse and patient and facilitates closure of that relationship. 1. Research patient history 2. Recognize own thoughts and feelings 3. Set ground rules before first meeting 4. Establish patient rapport 5. Parameters of relationship 6. Formal/informal contract 7. Confidentiality 8. Terms of termination 1. Maintain relationship 2. Gather further data 3. Promote patients problem solving skills, self-esteem, use of language 4. Facilitate behavior change 5. Overcome resistant behaviors 6. Evaluate problems and goals (redefine as necessary) 7. Promote practice and expression of alternative adaptive behaviors 8. Summarize goals and objectives to achieve 9. Discuss ways to implement new coping strategies learned 10. Review situations of relationships 11. Exchange memories **Genuiness-**open, honest, authentic **Empathy-**Attempting to understand from patient perspective **Positive regard-**Respecting and worthy of caring about Attitudes-take nurse patient relationship seriously Actions-attending, suspending value judgements **Critical Thinking** 1\. On your first clinical day, you are assigned to work with an older adult, Ms. Schneider, who is depressed. Your first impression is, "Oh, my, she looks like my rude Aunt Elaine. She even dresses like her." You approach her with a vague feeling of uneasiness and say, "Hello, Ms. Schneider. My name is Alisha. I am a nursing student, and I will be working with you today." She tells you that "a student" could never understand what she is going through. a\. Identify transference and countertransference issues in this situation. What is your most important course of action? b\. What other information will you give Ms. Schneider during this first clinical encounter? Be specific. c\. What are some useful responses you could give Ms. Schneider regarding her concern about whether you could understand what she was going through? 2\. You are interviewing Tom Stone, a 17-year-old who was admitted to a psychiatric unit after a suicide attempt. How would you best respond to each of the following patient requests and behaviors? a\. "I would feel so much better if you would sit closer to me and hold my hand." b\. "I will tell you if I still feel like killing myself, but you have to promise not to tell anyone else. If you do, I can't trust you, ever." c\. "I don't want to talk to you. I have absolutely nothing to say." d\. "I will be going home tomorrow, and you have been so helpful and good to me. I want you to have my watch to remember me by." e\. Tom breaks down and starts sobbing. **Chapter Review** 1\. Which statement made by either the nurse or the patient demonstrates an ineffective patient-nurse relationship? a\. "I've given a lot of thought about what triggers me to be so angry." b\. "Why do you think it's acceptable for you to be so disrespectful to staff?" c\. "Will your spouse be available to attend tomorrow's family group session?" d\. "I wanted you to know that the medication seems to be helping me feel less anxious." 2\. The patient expresses sadness at "being all alone with no one to share my life with." Which response by the nurse demonstrates the existence of a therapeutic relationship? a\. "Loneliness can be a very painful and difficult emotion." b\. "Let's talk and see if you and I have any interests in common." c\. "I use Facebook to find people who share my love of cooking." d\. "Loneliness is managed by getting involved with people." 3\. Which patient outcome is directly associated with the goals of a therapeutic nurse-patient relationship? a\. Patient will be respectful of other patients on the unit. b\. Patient will identify suicidal feelings to staff whenever they occur. c\. Patient will engage in at least one social interaction with the unit population daily. d\. Patient will consume a daily diet to meet both nutritional and hydration needs. 4\. What is the greatest trigger for the development of a patient's nurse-focused transference? a\. The similarity between the nurse and someone the patient already dislikes b\. The nature of the patient's diagnosed mental illness c\. The history the patient has with the patient's parents d\. The degree of authority the nurse has over the patient 5\. Which patient statement demonstrates a value held regarding children? a\. "Nothing is more important to me than the safety of my children." b\. "I believe my spouse wants to leave both me and our children." c\. "I don't think my child's success depends on going to college." d\. "I know my children will help me through my hard times." 6\. Mary is a 39-year-old attending a psychiatric outpatient clinic. Mary believes that her husband, sister, and son cause her problems. Listening to Mary describe the problems, the nurse displays therapeutic communication in which response? a\. "I understand you are in a difficult situation." b\. "Thinking about being wronged repeatedly does more harm than good." c\. "I feel bad about your situation, and I am so sorry it is happening to you and your family." d\. "It must be so difficult to live with uncaring people." 7\. A registered nurse is caring for an older male who reports depressive symptoms since his wife of 54 years died suddenly. He cries, maintains closed body posture, and avoids eye contact. Which nursing action describes attending behavior? a\. Reminding the patient gently that he will "feel better over time" b\. Using a soft tone of voice for questioning c\. Sitting with the patient and taking cues for when to talk or when to remain silent d\. Offering medication and bereavement services 8\. A male patient frequently inquires about the female student nurse's boyfriend, social activities, and school experiences. Which is the best initial response by the student? a\. The student requests assignment to a patient of the same gender as the student. b\. She limits sharing personal information and stresses the patient-centered focus of the conversation. c\. The student shares information to make the therapeutic relationship more equal. d\. She explains that if he persists in focusing on her, she cannot work with him. 9\. Morgan is a third-year nursing student in her psychiatric clinical rotation. She is assigned to an 80-year-old widow admitted for major depressive disorder. The patient describes many losses and sadness. Morgan becomes teary and says meaningfully, "I am so sorry for you." Morgan's instructor overhears the conversation and says, "I understand that getting tearful is a human response. Yet, sympathy isn't helpful in this field." The instructor urges Morgan to focus on: a\. "Adopting the patient's sorrow as your own" b\. "Maintaining pure objectivity" c\. "Using empathy to demonstrate respect and validation of the patient's feelings" d\. "Using touch to let her know that everything is going to be alright" 10\. Emily is a 28-year-old nurse who works on a psychiatric unit. She is assigned to work with Jenna, a 27-year-old who was admitted with major depressive disorder. Emily and Jenna realize that they graduated from the same high school and each has a 2-year-old daughter. Emily and Jenna discuss getting together for a play date with their daughters after Jenna is discharged. This situation reflects: a\. Successful termination b\. Promoting interdependence c\. Boundary blurring a. A strong therapeutic relationship **ANSWERS** 1\. b; 2\. a; 3\. b; 4\. d; 5\. a; 6\. a; 7\. c; 8\. b; 9\. c; 10\. c **[Chapter 9]** **[Therapeutic Communication]** **Therapeutic Communication---**is patient centered, goal directed and scientifically based Saying the wrong thing---helps us to find more useful and effective ways of helping individuals reach their goals. **Therapeutic Communication---**is crucial to the formation of patient centered therapeutic relationships. **[Benefits of Therapeutic Communication]** 1. Feeling safer and protected 2. More satisfied with the care 3. Increased recovery rates 4. Improved adherence to treatment **Theoretical Models of Communication** **Communicator---**they are senders and receivers, makes role more fluid. Communicators are interdependent (i.e. communication is not occurring if the receiver is not listening) **Message---**is the content and ideas that are being exchanged. They are relational and can be communicated nonverbally by such elements as tone and posture. **Channel---**Method by which communication takes place **Feedback---**takes place in a constant feedback being given by both parties, feedback for one is a message for the other. **Encoding/Decoding---**interacting individuals encode, (Develop) messages and send to the other to decode (Determine the meaning) messages received from the other. **Context---**Frames and influences our interactions, more contextual elements 2 people share in common the easier it is to communicate. - Social Context---stated or unstated rules or norms that guide communication - Relational Context---interpersonal history and the type of relationship that is involved, personal is less scripted, therapeutic is more scripted - Cultural context---influence our culture has on communication, gender, race, ethnicity, nationality, sexual orientation, socioeconomic class - Physical Noise (loud units, background music, overhead announcements) - Physiological Noise (biological factors -- Headache, illness, fatigue) - Psychosocial Noise (person not wanting to talk, preoccupied with something else) **Peplau's Interpersonal Theory** **Guiding principles in communication---**clarity ensures that the meaning of the message is accurately understood by both parties **Continuity---**promotes connections among ideas, feelings, events and themes. **Factors that Affect Communication** Personal Depression Cognition Language Cultural Barriers Environmental Factors Background Noise The setting Lack of privacy Uncomfortable seating Relationship Factors Levels of equality with the relationship **Verbal communication** Consist of all the words a person speaks - Communicates-belief, values, perception and meaning - Can Convey---interests and understanding, insult and judgement, clear or conflicting or implied messages, honest or disguised/distorted feelings. **Nonverbal Communication** - Tone of voice - Emphasis on certain words - Physical appearance - Facial expressions - Body posture - Amount of eye contact - Hand gestures - Proximity to another person depends on cultural conventions **Interaction of Verbal and Nonverbal Communication** Spoken words that represent our public selves and can be straight forward or used to distort, conceal, deny, or disguise true feelings - Message can appear to be one thing when in fact they are another - People are often less aware of their nonverbal messages and behavior - Verbal messages can be called the content while the nonverbal behavior is the process - Double bind messages mutually contraindicate messages, usually given by the person in power **Communication skills for nurses** - Using silence - Active listening - Clarifying techniques - Paraphrasing - Restating - Reflecting - Exploring **Therapeutic Communication Questions** - Open ended- experiences, perceptions, and responses - Close ended- give specific information - Projective-"What if" to help patient articulate thoughts and feelings - The miracle question-goal setting, helps patient see future and what it would look like if the problem vanished **Nontherapeutic Communication Techniques** - Excessive questioning - Giving approval or disapproval - Giving advice - Asking "why" questions **[Cultural Considerations]** Use of electronic information and devices and telecommunication technologies to support long distance clinical healthcare. Healthcare professionals need to be familiar with culture of certain verbal and nonverbal communication provide an interpreter. **Technologies** Telehealth Video Health Internet Sources Phone Consultation Image Transmission Interactive Video Sessions **Mobile Applications** Monitor, diagnosed, treat and communicate with patients Mobile phones are used at a high rate Many quickly adaptive apps available More research is needed SAMHSA- free apps for suicide prevention, bullying, prevention, and underage drinking prevention **Concerns of Technology Communication** Privacy / confidentiality Lack of data for efficacy and data Liability issues Research is needed to evaluate risks vs benefits Professional and ethical guideline needed **Preparing for the Clinical Patient Interview** Pace\--let patient set the pace Setting---Security enhances feelings Setting---nurse should be in the same vertical space as patient Introductions---opening questions Initiating the interview **Tactics to avoid** Arguing minimizing or challenging the patient Giving false reassurance Interpreting or speculating Probing into sensitive areas the patient doesn't want to discuss Trying to see the patient on accepting treatment Joining in attacks patients launch at others Participating in criticizing other staff members **Behaviors that support Counseling** Kinesics Communication---nonverbal made by body language Vocal Quality---paralanguage qualities of speech that do not involve language Proxemics---intimate distance, 18 inches apart Personal distance---18 inches to 4 feet Social Distance---18 inches to 12 Public Distance---12 feet or more **Clinical Supervision and Debriefing** Communication and interviewing are acquired skills Fosters professional growth and helps maximize the development of nontherapeutic nurse patient relationships **Process Recording** Written records are a segment of the nurse patient session that reflect as closely that reflect as closely to the verbal or nonverbal behaviors of both patient and nurse. - Written record of segment of sessions - Useful tool to identify communication patters **Critical Thinking** 1\. Keep a written log of a conversation you have with a patient. In your log, identify the therapeutic techniques and types of nontherapeutic communication you noticed yourself using. Rewrite the nontherapeutic communications and replace them with statements that would better facilitate discussion of thoughts and feelings. Share your log and discuss the changes you are working on with one classmate. 2\. Role-play with a classmate at least five nonverbal communications and have your partner identify the message received. 3\. With the other students in your class watching, plan and role-play a nurse-patient conversation that lasts about three minutes. Use both therapeutic and nontherapeutic communication. When you are finished, have your other classmates try to identify the types of communication that you used. 4\. Demonstrate how the nurse would use touch and eye contact when working with patients from three different cultural groups. **Chapter Review** 1\. Which statement made by the nurse demonstrates the best understanding of nonverbal communication? a\. "The patient's verbal and nonverbal communication is often different." b\. "When my patient responds to my question, I check for congruence between verbal and nonverbal communication to help validate the response." c\. "If a patient is slumped in the chair, I can be sure he's angry or depressed." d\. "It's easier to interpret verbal communication than to interpret nonverbal communication." 2\. Which nursing statement is an example of reflection? a\. "I think this feeling will pass." b\. "So you are saying that life has no meaning." c\. "I'm not sure I understand what you mean." d\. "You look sad." 3\. When should a nurse be most alert to the possibility of communication errors resulting in harm to the patient? a\. Change of shift report b\. Admission interviews c\. One-on-one conversations with patients d\. Conversations with patients' families 4\. During an admission assessment and interview, which channels of information communication should the nurse be monitoring? Select all that apply. a\. Auditory b\. Visual c\. Written d\. Tactile e\. Olfactory 5\. What principle about nurse-patient communication should guide a nurse's fear about "saying the wrong thing" to a patient? a\. Patients tend to appreciate a well-meaning person who conveys genuine acceptance, respect, and concern for their situation. b\. The patient is more interested in talking to you than listening to what you have to say and so is not likely to be offended. c\. Considering the patient's history, there is little chance that the comment will do any actual harm. d\. Most people with a mental illness have by necessity developed a high tolerance of forgiveness. 6\. You have been working closely with a patient for the past month. Today, he tells you he is looking forward to meeting with his new psychiatrist but frowns and avoids eye contact while reporting this to you. Which of the following responses would most likely be therapeutic? a\. "A new psychiatrist is a chance to start fresh; I'm sure it will go well for you." b\. "You say you look forward to the meeting, but you appear anxious or unhappy." c\. "I notice that you frowned and avoided eye contact just now. Don't you feel well?" d\. "I get the impression you don't really want to see your psychiatrist---can you tell me why?" 7\. Which student behavior is consistent with therapeutic communication? a\. Offering your opinion when asked to convey support. b\. Summarizing the essence of the patient's comments in your own words. c\. Interrupting periods of silence before they become awkward for the patient. d\. Telling the patient he did well when you approve of his statements or actions. 8\. James is a 42-year-old patient with schizophrenia. He approaches you as you arrive for your day shift and anxiously reports, "Last night, demons came to my room and tried to rape me." Which response would be most therapeutic? a\. "There are no such things as demons. What you saw were hallucinations." b\. "It is not possible for anyone to enter your room at night. You are safe here." c\. "You seem upset. Please tell me more about what you experienced last night." d\. "That must have been frightening, but we'll check on you at night and you'll be safe." 9\. Therapeutic communication is the foundation of a patient-centered interview. Which of the following techniques is not considered therapeutic? a\. Restating b\. Encouraging description of perception c\. Summarizing d\. Asking "why" questions 10\. Carolina is surprised when her patient does not show up for a regularly scheduled appointment. When contacted, the patient states, "I don't need to come see you anymore. I have found a therapy app on my phone that I love." How should Carolina respond to this news? a\. "That sounds exciting, would you be willing to visit and show me the app?" b\. "At this time, there is no real evidence that the app can replace our therapy." c\. "I am not sure that is a good idea right now; we are so close to progress." d\. "Why would you think that is a better option than meeting with me?" **ANSWERS** 1\. b; 2\. d; 3\. a; 4\. a, b, d, e; 5\. a; 6\. b; 7\. b; 8\. c; 9\. d; 10\. a **[Chapter 34 ]** **[Therapeutics Groups]** From Group to Therapeutic group is any group of people who meet for personal development and psychological growth. From Therapeutic group to Group a group is interconnected and independent set of individuals who come together for a shared purpose. **Advantages of therapeutic groups** - Treat multiple members simultaneously - Members benefit from other viewpoints - Safe place to practice new skills - Can promote feelings of cohesiveness **Disadvantages of therapeutic groups** - Privacy concerns - Disruptions - Discouraging group norms hinder personal expression **Concepts common to all groups** Therapeutic factors are aspects for the group experience that leaders and members have identified as curative and crucial for therapeutic change (i.e. a member might recognize that he/she is not different from others in the group. - Curative and crucial for therapeutic change - Group work recognizing what happens on the surface and underneath - Group norms expectations that develop over time - Group themes findings that recur and shar a common thread - Feedback providing group with feedback how they affect one another REMEMBER: conflict --positive conflict resolution is the key to success. **Phases of group development** - **Planning Phase** - The name of the group - Objectives of the group - Types of individuals of the group - Group schedule - Physical Setting - Seating configuration - Description of leader and member responsibilities - Methods or means of evaluating outcomes - **Orientation phase** - The group is forming - **Working phase** - Communication flow of group process and group conduct - **Termination phase** - insurance of each member summarizing personal experiences and accomplishments shares new insight and identifies personal goals. - **Evaluation & follow up phase** - Feedback can be resolicited periodically during the life of the group and also during termination **Roles of Group Members/Group Membership** - Heterogenous Group---range of differences among members - Homogenous Group---members share central traits - Closed Group---new members are added as others leave - Subgroup---Isolated in larger group for specific needs **Group Participation Roles** **ROLE FUNCTION EXAMPLE** +-----------------------+-----------------------+-----------------------+ | Task roles | Elaborator | Gives examples and | | | | follows up the | | | Energizer | meaning of ideas | | | | | | | Information giver | Encourages the group | | | | to make decisions or | | | Opinion giver | act | | | | | | | Orienter | Provides facts or | | | | shares experience as | | | | an authority figure | | | | | | | | Shares opinions, | | | | especially to | | | | influence group | | | | values | | | | | | | | Notes the progress of | | | | the group toward | | | | goals | +=======================+=======================+=======================+ | **Maintenance roles** | Compromiser | During conflict, | | | | yields to preserve | | | Encourager | group harmony | | | | | | | Follower | Praises and seeks | | | | input from others | | | Gatekeeper | | | | | Agrees with the flow | | | Standard setter | of the group | | | | | | | | Monitors the | | | | participation of all | | | | members to keep | | | | communication open | | | | and equal | | | | | | | | Verbalizes standards | | | | for the group | +-----------------------+-----------------------+-----------------------+ | **Individual roles** | Aggressor | Criticizes and | | | | attacks others' ideas | | | Blocker | and feelings | | | | | | | Help seeker | Disagrees with and | | | | halts group issues; | | | Recognition seeker | oppositional | | | | | | | Self-confessor | Excessively seeks | | | | sympathy from the | | | | group | | | | | | | | Seeks attention by | | | | boasting and | | | | discussing | | | | achievements | | | | | | | | Verbalizes feelings | | | | or observations | | | | beyond the scope of | | | | the group topic | +-----------------------+-----------------------+-----------------------+ **Theoretical Framework for Groups** - Humanism- self-actualization, subjective, experience - Cognitive Behavioral- Focuses on maladaptive behavior - Psychodynamic- Resolving, intrapsychic, conflict - Educational- Practical supports - Systems- Social interactions **Virtual Groups** - Most comply with HIPPA - Helpful for online cognitive behavioral therapy groups (CBT) - Possible negative impacts on therapeutic relationships - Feeling of loss of control for clinicians, due to inability to read facial expressions and body language **Nurse Group Leaders** RN's that have a degree and holistic training and educational, and leadership skills, can provide leadership therapeutic groups in a variety of settings RN-activity, educational tasks, and support groups APRN- may also lead specialized group treatments including psychotherapy for which more complex skills are necessary. **Support and self-help groups** **[Support Groups]** - Bereavement - Suicide survivor - National alliance on mental health patient families - Career support - Virtual support - Veterans support - Twelve Step - Gamblers anonymous - Narcotics anonymous - Adult children of alcoholics - Recovery international /mental illness - National mental health consumers self-help clearinghouse **[Styles of Leadership]** - Autocratic leader---exerts control over the group and does not encourage much interaction - Democratic leader---supports extensive group interaction in the process if problem solving - Laissez-Faire leader---allows the group members to behave in any way they choose and does not attempt to control the situation - Crucial feedback - Enhanced professional growth - Help with transference and counter transference - Provides outside perspective - Supports therapeutic goal focus - Provides training - Allows for immediate debriefing - Offers role modeling **[Ethical Issues for Group Therapy]** - Informed consent - Confidentiality and exceptions to confidentiality - Rules about leaving, socializing outside the group - Member removal considerations last resort - Appropriate training or credentialing - ANA's defined scope of practice - Evidence based practice (cognitive behavioral therapy) CBT beneficial for MDD and anxiety disorders. Group for CBT with pharmacotherapy beneficial in reducing symptoms associated with ADHD **[Dealing with Challenging members]** - Monopolizing member---remind entire group to provide equal chances to contribute/ speak directly to member, privately when necessary. - Disruptive Member---listen objectively, ask in private about cause of anger, empathize matter of factly - Silent member---determine cause require response to ease group discomfort provide extra time for member to think about a response and come back to them. **[Expected Outcomes]** - **Medication Groups** Awareness of side effects Awareness of interactions Identification of time and dose for each drug - **Therapy Groups** Insights Behavior changes Reduction in symptoms **Critical Thinking** 1\. You are automatically a part of several groups during nursing education: your large cohort and also your smaller course and clinical practicum groups. Review Table 34.3 and think about your position and ways in which you tend to participate in your current groups at school. a\. Which task role do you assume in your groups? b\. Which maintenance role do you assume? c\. Which individual group role (if any) is yours? d\. In your class groups in general, how would you characterize the norms? 2\. While you were participating in your nursing education groups, you may have noticed that some groups function better than others. Consider your current or a past clinical group and respond to the following questions: a\. How would you describe the dynamics of the group? b\. Which leadership styles have your instructors modeled? c\. Were group members well prepared to participate in group sessions? If no, how did this affect the dynamic of the group? d\. How did the instructor handle group monopolization, silence, complaining, or disruptive actions? **Chapter Review** 1\. Which outcome would be appropriate for a group session on medication education? Select all that apply. a\. Patient will identify three side effects of prescribed medication. b\. Patient will verbalize the purpose of taking the medication. c\. Patient will acknowledge and accept the financial cost of prescribed medications. d\. Patient will correctly identify time of day and dose for each prescribed medication. e\. Patient will list two potential drug--drug and drug--food interactions for prescribed medications. 2\. What question by the nurse leader is helpful in managing a monopolizing member of a group? a\. "You seem angry. Is there something you want to discuss with the group?" b\. "Would it be helpful if you had time to think about the question?" c\. "Would you tell us about experiences that have frightened you?" d\. "Who else would like to share feelings about this issue?" 3\. What advantages does group therapy have over individual therapy? Select all that apply. a\. Groups are less expensive than one-on-one therapy. b\. Groups provide an opportunity to learn from others. c\. Groups are homogeneous in composition. d\. Feedback is available from the group leader and group members. e\. Interpersonal skills can be practiced in a safe environment. 4\. What group would benefit most from a laissez-faire leader? a\. Art group b\. Grief group c\. Social skills group d\. Anger management group 5\. The nurse describes the purpose of psycho-educational groups as providing group members with the knowledge and skills necessary to manage psychiatric symptoms. Which phase of group development is represented? a\. Planning (formation) phase b\. Orientation phase c\. Working phase d\. Termination phase 6\. Group dynamics can vary widely, and sometimes members disrupt the group process. Which of the following participant traits may indicate a need for additional support for a new nurse facilitator? Select all that apply. a\. A member with paranoid delusions b\. A quietly tearful participant expressing suicidal thoughts c\. An angry woman who raises her voice d\. A calm but ineffective communicator 7\. The advanced practice nurse is assigned a group of patients. Which patient would not be appropriate to consider for inpatient group therapy? (Select all that apply.) The patient who a\. Has limited financial and social resources b\. Is experiencing acute mania c\. Has few friends on the unit d\. Is preparing for discharge tomorrow e\. Does not speak up often yet listens to others 8\. Group members are having difficulty deciding what topic to cover in today's session. Which nurse leader response reflects autocratic leadership? a\. "We are talking about fear of rejection today." b\. "Let's go around the room and make suggestions for today's topic." c\. "I will let you come to a conclusion together about what to talk about." d\. "I'll work with you to find a suitable topic for today." 9\. A patient continues to dominate the group conversation despite having been asked to allow others to speak. What is the group leader's most appropriate response? a\. "You are monopolizing the conversation." b\. "When you talk constantly, it makes everyone feel angry." c\. "You are supposed to allow others to speak also." d\. "When you speak out of turn, I am concerned that others will not be able to participate equally." 10\. The nurse is planning the care of patients on her unit, which includes a dual-diagnosis group. Which patient would be appropriate for this group? The patient with a\. Major depression disorder and a history of recurrent suicidal ideation b\. Generalized anxiety disorder and frequent migraine headaches c\. Bipolar disorder and anorexia nervosa d\. Schizophrenia and alcohol use disorder **ANSWERS** 1\. a, b, d, e; 2\. d; 3\. a, b, d, e; 4\. a; 5\. b; 6\. a, b; 7\. b; 8\. a; 9\. d; 10\. d **[Chapter 6]** **[Legal and Ethical Considerations]** **Ethical Concepts---**the study of philosophical beliefs about what is considered right or wrong in a society **Bioethics---**the study of specific ethical questions that arise in healthcare **[6 principles of Bioethics]** 1. Autonomy---respecting the rights of others to make their own decisions 2. Beneficence---the duty to act to benefit or promote the health and well being of others 3. Nonmaleficence---doing no harm to the patient 4. Justice---duty to distribute resources or care equally regardless of personal attributes 5. Fidelity\--maintaining a loyal commitment to the patient and doing no wrong to the patient 6. Veracity---duty to communicate truthfully **[Code of Ethics for Nursing]** 1\. The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems. 2\. The nurse's primary commitment is to the patient, whether an individual, family, group, or community. 3\. The nurse promotes, advocates for, and strives to protect the rights, health, and safety of the patient. 4\. The nurse has authority, accountability, and responsibility for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and provide optimal care. 5\. The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth. 6\. The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality care. 7\. The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy. 8\. The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities. 9\. The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy. **[Evolving Ethical Issues in Psychiatric Care]** **Pharmacogenetic Testing---**genetic testing is not approved by the FDA because there has not been adequate research or clinical evidence. The FDA feels the tests may influence the providers and patients to select or change drugs or doses thereby exposing the patient to harm. **Predictive Psychiatry---**Stigmatization could prevent a person from getting a job. Autonomy (i.e. son wants gene testing for Alzheimer's disease and father does not) which autonomy should be supported. **Genome Testing---**Can cause emotional distress by testing for variants of disease that we don't have cures for like Alzheimer's. Research indicates just knowing you have a disease or are at risk it can alter your physiology. **[Mental Health Laws]** Hospital Admission procedures - Neither voluntary commitment determines a patient's ability to make informed decisions - Care providers establish that a well denied psychiatric problem exists based on DSM 5 - The illness and its symptoms should result in immediate crises situation and other less restrictive alternatives are inadequate or unavailable - There is a reasonable exception that the hospitalization and treatment will improve the presenting problem **Voluntary Admission:** Sought by patient or guardian voluntary patients have the right to obtain a request to leave. **Involuntary:** Is court ordered without the patients consent involuntary admission has to meet certain criteria: - Diagnosed mental illness - Posing a danger to self or others - Gravely disabled unable to provide for basic needs - In need of treatment and the mental illness itself prevents voluntary help seeking **Involuntary Emergency Commitment** Also known as temporary admission or emergency hospitalization - A person is so confused they cannot make decisions on their own - So il they need emergency admission - Primary purpose of emergency admission is for observation diagnosis and treatment of patients who are at risk of hurting themselves or others - It usually takes 24-96 hours - A court hearing is held and a decision is made for discharge, voluntary admission or involuntary commitment **Due Process** Patients who believe they are being unlawfully detained can petition for a [writ of habeous corpus] this is a procedural mechanism used to challenge unlawful detention by the government Patients can also challenge hospitalization through [least restrictive alternate doctrine---]which mandates that care providers take the least drastic action to achieve a specific purpose. **Discharge procedures---** Unconditional release---the termination of the legal patient institution relationship. Release Against Medical Advice---AMA where treatment seems beneficial but there is no compelling reason to seek involuntary continuance of stay. Conditional Release---requires outpatient treatment for a specific time and patient is evaluated for follow through with the medication regimen, ability to meet basic needs and ability to reintegrate into the community. Assisted outpatient treatment---similar to conditional release but this is court ordered outpatient treatment. **[PATIENTS RIGHTS]** - **Right to treatment** - Right to be free from excessive or unnecessary medication - Right to privacy - Right to least restrictive environment - Right to an attorney, clergy and private care providers - Right to not be subjected to lobotomies, ECT and other treatments without an informed consent - **Right to refuse treatment** (only in an emergency situation where a person can cause serious injury to self or others can institutions medicate the patient. The patient must meet all the criteria after a court hearing. - The person must have a serious mental illness - The person's function is deteriorating and if the person is suffering or exhibiting threatening behavior - The benefits of treatment outweigh to harm - The person lacks the capacity to make a reasoned decision about treatment - Less restrictive services have been found inadequate - **Right to informed consent**---the patient has been provided with basic information regarding risks and benefits and patients must be informed of the following: - The nature of the problem or condition - The nature of the proposed treatment - The risks and benefits of that treatment - The alternative treatment options - The probability that the treatment will be successful - The risk of not consenting to treatment - **Rights regarding psychiatric advanced directives**---patients who have experienced severe mental illness have the opportunity to express their treatment preferences. - Designation of physician or therapist - Appointment of someone to make mental health decisions - Preferences regarding medication/ to take or not - Consent or lack of consent for admission to a psychiatric facility - Preferred facilities and unacceptable facilities - Consent or lack of consent for ECT - Individuals who should visit or not visit - **Rights regarding restraints and seclusion**---nurses need to consider the following prior to restraints and seclusion - Verbal interventions - Reducing stimulation - Actively listening - Providing diversion - Offering as needed (PRN) medications **NOTE: Orders are never written as standing or PRN orders for restraints and seclusion.** **Orders and documentation in emergency can place in restraints or seclusion must obtain a written order soon after.** - **Rights regarding confidentiality** - HIPPA - Confidentiality and social media - Confidentiality after death - Confidentiality of professional communications **NOTE: There are exceptions to these rules.** - **Medical staff have the duty to warn and protect third parties** - **Child and elderly abuse reporting statutes** - **Failure to protect patients** **[Laws Relevant to Psychiatric Nursing ]** 1. Tort Law---(Tort) any wrongful act intentional or accidental that results in an injury to another. 2. Intentional Tort---willful and intentional acts that violate another person's rights or property - Assault - Battery - False Imprisonment - Invasion of privacy - Defamation of character 3. Unintentional Tort---unintended acts against another that produce injury or harm - Negligence - Malpractice **There are five elements that a case must have to prove negligence** 1. Duty 2. Breach of Duty 3. Cause in fact 4. Proximate Cause 5. Damages **[Standards for Nursing Care]** Nurses are held to a basic standard of care. The standard is based on what other like nurses who possess the same degree of skill or knowledge in the same or similar situation would do. - State board of nursing - Professional Associations - Institution (mandate policy and procedures) - Custom as a standard of care **[Acting on Questionable Practice]** Negligence, irresponsibility or impairment. As a nurse we have a duty to intervene and a duty to report the following: - Incompetence - Impairment - Criminal activity - Document clearly and accurately - Supervisor should intervene if the supervisor is unavailable you must intervene to protect the patient. **[Documentation of Care]** - Make sure it is accurate and complete - Facilitates the continuity of patient care - Means of interprofessional communication - Patient has the right to review records - The record belongs to the institution **[Medical Records and Quality Improvement]** - Quality improvement is the key goal for the future of nursing and healthcare - Provides valuable information to the facility and to evaluate ways to improve - Can be used as evidence - Can be used for risk management - Used for reimbursement from health insurance **[Medical Records as Evidence]** - Extent of patient's damages and suffering in a lawsuit - Nature and extent of injuries in abuse cases - Nature and extent of physical or mental disabilities in disability cases - Nature and extent of injury and rehabilitation in workers compensation cases **[Guidelines for Electronic Documentation]** - Manages data and communication, reduces errors and facilitates decision - Federal privacy laws on access - Courts assume if it is NOT documented it did NOT happen - Specific rules and time frames for correcting errors---may be dictated by HER system **[Violence in the Psychiatric Setting]** - Nurses participate in setting policies that create and maintain a safe environment - Always document patients' potential for violence - Communicate observations to colleagues - New laws enhance criminal charges and penalties for striking nurses and other members of healthcare in the course of duty.